Overview of Gender Identity

This first section briefly outlines key terms related to gender. This term is culturally and emotionally laden; it may evoke images related to femininity and masculinity, pink and blue, different types of clothing, or a figure above a restroom door. Gender is a complex and important term informed by biology, social structures, and identity. It is commonly conflated with biological sex and thought of as an inherent, fixed aspect of a person’s life. Yet psychiatry’s conceptualizations of gender have become more complex and affirming in recent years. In order to provide a more nuanced understanding of gender, we define relevant terms below.

Sex

Historically, the terms “sex” and “gender” have been used interchangeably. These concepts, however, are distinct. The term “sex” typically refers to one’s biology: chromosomes, genitalia, hormones, and secondary sex characteristics such as breasts, distribution of body hair, or an Adam’s apple. Such physiological traits typically lead to sex assignment by a doctor, even before a baby is born. Babies with two X chromosomes are called “female.” Those with one X and one Y chromosome are called “male.” Most often, of course, doctors assign an individual’s sex prior to birth through a process of prenatal sex discernment: a process of testing to determine the sex of a fetus. Moments after an individual is born, their sex is codified on their birth certificate – as female or male – and a complex process of socialization is set into motion.

Because of this medical tradition of assigning a baby the label of “girl” or “boy,” sex is typically thought of as a binary paradigm, with each person fitting the label of either “female” or “male.” Sex, however, is not binary. Approximately 1.5 percent of babies are born with genitalia, hormones, or secondary sex characteristics that do not fit into either category. These babies are typically referred to as having intersex traits. This concept is discussed further throughout this chapter and highlights that sex is not exclusively biologically determined, but also socially and medically ascribed.

Gender

Gender is a term describing the behavioral, cultural, and psychological traits associated with masculinity and femininity. Whereas sex is primarily biological, gender is primarily social. Gender is mutable and culturally dependent; it varies across culture, ideology, race/ethnicity, and time. The World Health Organization defines gender as “the socially constructed characteristics of women and men, such as norms, roles, and relationships of and between groups of women and men. It varies from society to society and can be changed.” Every person’s gender is informed by a complex interplay between their body, identity, and expression and role. Multiple concepts are discussed below that may sound similar though describe discrete constructs. For example, gender identity, expression, and roles inform each other though are different processes. For clarity, it may be helpful to think of examples and/or consider how these concepts manifest differently in your life.

Gender identity is a person’s inner sense of being a girl/woman, boy/man, something else in terms of gender, having multiple gender identities, or having no gender identity at all. Gender identity refers to a person’s feelings about themselves in terms of how they relate to masculinity, femininity, and a blend of similar traits. Although studies demonstrate a wide spectrum of gender identities, society reinforces a notion that gender is a binary phenomenon consisting of only two genders, girl/woman or boy/man. Gender identity is often thought of as internal, whereas gender expression is considered more external.

Gender expression refers to the behavioral manifestations of one’s gender. It is the way we show our gender identity to the world around us. This includes behaviors and rituals we may take for granted: wearing pants rather than a skirt, using the women’s bathroom, speaking with a bass rather than falsetto voice, and responding to particular pronouns such as “he,” “she,” or “they.” Gender expression is defined by clothing, mannerisms, vocal patterns, and behaviors. Feminist and queer theorists typically define gender expression as a “performance” rather than something biologically predestined (Butler, 1990). Gender expression is informed by one’s personal preferences and cultural experiences. For example, men are socialized to be strong, unemotional, ambitious, and competitive. Women are socialized to be softer: to take care of others, support families, and to acquiesce to men. Yet many people defy or transcend these expectations of gender expression and express their gender in diverse ways.

Gender roles are the social demands deemed appropriate, legal, and productive based on each person’s gender. They are specific, gendered behaviors and expectations. Think about the ways you assume men and women behave in society; the professions, relational expectations, and political positions you may imagine differently for men versus women are examples of gender roles. A demonstrative illustration is the competitive world of business and economics. When we envision the key players working on Wall Street to influence the global marketplace, we may imagine white men in powerful positions aggressively negotiating deals and asserting their dominance in sleek, often colorless board rooms. When we think about women in this world, we think of administrative assistants or wives. These gender roles are informed by sexist and often racial ideologies and political structures that have a real impact on access to political power. Many people defy gender roles, though there are often social consequences for doing so.

Gender roles assign predetermined tasks, behaviors, and social expectations for individuals based on their assigned sex. They also have profound social, economic, and psychological impacts. To put this in context, a 2017 study by Fortune magazine analyzing the leadership of the 1,000 American companies with the largest annual revenue found that only 54 companies were run by women; among these companies, only 5.4 percent had a female CEO. This disparity can be understood in the context of gender roles. Women are generally not socialized to run businesses or compete in the global marketplace. Certainly, this gender gap has social, economic, and political causes and effects. The predominance of men in business may seem like a “given,” considering this patriarchal system has persisted in Western civilizations for generations. It is important to consider the impact of gender roles in creating and perpetuating such a disparity.

Transgender

Transgender (often abbreviated to “trans”) is an umbrella term for people whose gender identity or expression does not align in a traditional way with the sex they were assigned at birth. A transgender man is a person who was assigned female sex at birth and identifies as a man. Other common terms include trans man, female-to-male, FtM, and man of trans experience. A transgender woman is a person who was assigned male at birth and identifies as a woman. Other common terms include trans woman, male-to-female, MtF, and woman of trans experience. Many, though not all, transgender people pursue psychotherapy, surgery, and other biomedical interventions to assure their gender presentation aligns with their gender identity.

The term cisgender (often abbreviated to “cis”) refers to a person whose gender identity and expression aligns in a traditional way with the sex they were assigned at birth. For example, a cisgender man is a person who was assigned male sex at birth and continues to identify as a man. Some scholars prefer the term “non-transgender” or “non-trans” because this language is easier to understand and may intentionally normalize the transgender experience. The terms cissexism and transphobia refer to sociopolitical and personal systems of norms, behaviors, and laws that privilege cisgender people.

Resilience and oppression play a significant role in the lives of transgender people. According to recent studies by the Centers for Disease Control and numerous community samples, transgender people experience numerous adverse health outcomes in comparison to non-transgender people, including elevated HIV/STI risk, incidence, and prevalence (particularly among transgender women of color); and psychiatric disorders, such as depressive disorders, anxiety disorders, and substance use disorders, and increased incidence and prevalence of suicidal ideation and attempts. Transgender people also face numerous barriers to care, including high costs, lack of access, and discrimination in health care settings. There is a vicious cycle of anti-transgender discrimination, lack of access to culturally sensitive health care, and health disparities (Reback, Clark, Holloway, & Fletcher, 2018), exacerbating what scholars see as a crisis in transgender health. Transgender people have a critical need for culturally sensitive, gender-affirming health care.

Transgender people also demonstrate remarkable resilience: individual- and group-level factors that buffer against the deleterious effects of stigma and adversity. Particular strategies for resilience may include the cultivation of self-acceptance, gender and racial identity pride, personal mastery, self-esteem, and emotion regulation skills. Transgender people also engage in group-level factors such as social support and collective action for transgender rights, both of which have been shown to improve health outcomes and reduce levels of risk and pathology.

People Born with Intersex Traits

Intersex is an umbrella term used to describe a wide range of natural bodily variations. It is often used when referring to individuals born with some combination of sex characteristics (e.g., chromosomes, genitalia, internal reproductive organs, or hormones) that defy binary notions of female and male sex. Although this definition may make such an occurrence sound rare, somewhere between approximately 0.05 to 1.7 percent of the world population is born with intersex traits. To put that number into context, babies born with red hair make up less than 2 percent of the population, as do babies with green eyes. For some people, their intersex traits are visible to doctors and parents at birth; for others, these traits may not emerge until puberty, adolescence, or even adulthood. Intersex traits tend to carry stigma, and it is critical to be mindful of judgments or knee-jerk reactions to want to “fix” a person’s body that may, in fact, simply be different than your own.

According to many vocal intersex communities, doctors and medical professionals have historically subjected intersex babies to unnecessary surgeries and other medical interventions (e.g., repeated genital examinations, genital surgery in the first days of life, forced dilation) in order to address bodily differences. Intersex advocates argue against such surgical and medical interventions, which have been shown in many studies to be associated with emotional and physical trauma, identity diffusion, and elevated rates of suicidal ideation and attempts in this population (for a review, see Davis, 2013). Few data exist supporting the claim that surgery is necessary to correct these differences in sex development.

Many intersex advocates argue the majority of medical interventions may pose significant harm and recommend instead that collaborative care practices be followed, including shared decision-making and psychoeducation. In 2015, an advocacy group named InterACT: Advocates for Intersex Youth released a brochure outlining “What We Wish Our Doctors Knew.” Suggestions for intersex-affirming care include: providing emotional support, encouraging peer and community affiliation, communicating honestly, avoiding stigmatizing terms such as “normal” or “transvestite,” not taking photos of patient’s genitalia, and allowing patients and their families to make informed decisions about which medical interventions (if any) to pursue.

Nonbinary/Gender Expansive and Other Fluid Categories

Gender identities and expressions are rapidly evolving. Given the recent shifts in acceptance for gender variation and creativity in gendered expression, many people identify as nonbinary: neither girl/woman nor boy/man or possessing a combination of traits or behaviors that may be a hybrid, combination, or even frank rejection of femininity, masculinity, and androgyny. The term “nonbinary” emerged from transgender communities who were eager to dispel notions that even transgender people must adhere to a strictly binary gender paradigm. Other common terms include genderqueer, gender-diverse, and gender expansive, among others. People with nonbinary gender identities are receiving increased attention and care within psychiatry. In 2015, for example, the American Psychological Association’s Division 44 (Society for the Psychology of Sexual and Gender Diversity) released a fact sheet on nonbinary identities (Webb, Matsuno, Budge, Krisnan, & Balsam, 2015), calling for increased scientific and clinical focus for this unique population. Recent studies have demonstrated that nonbinary people, in addition to facing issues common among binary transgender people, also report higher levels of physical violence, sexual abuse, and economic/employment discrimination than both their binary transgender and cisgender counterparts (Harrison et al., 2012; Richards et al., 2016).

There are also many fluid categories of gender that transcend primarily white, Western, binary notions. Many societies explicitly incorporate and celebrate people in more fluid gender categories. For example, many Indigenous American cultures have long revered people who identify as two-spirit: embodying both feminine and masculinity spirits within one person (Wilson, 1996). Many South Asian countries similarly celebrate hijra: a respected community including eunuchs, intersex people, and transgender people. The Supreme Court in India, for example, formally recognized a “third gender” in 2014. These nuances of gender identity and expression remind us that Western, binary myths of gender are exactly that. We have a responsibility as clinicians – often on the front lines serving race- and gender-diverse communities – to respect patients’ identities and provide affirming advocacy and care.

Overview of Sexual Orientation

This section briefly outlines key terms related to sexuality and sexual orientation. Similar to gender, sexuality is a construct that has been recently understood to be fluid, mutable, and socially determined. Conceding that sexuality is a social construction, of course, does not deny that it is core to the human experience and thus has important psychiatric implications. Sexuality involves processes of pleasure, intimacy, reproduction, and health: elemental drives and aspects of the human experience. It is also impacted by legal, cultural, moral, and religious aspects of life. In order to provide sexuality-affirming care, this section briefly explores the key concepts and terms, followed by a discussion of the psychiatric implications of sexual orientation.

Sexual Orientation

Sexual orientation, behavior, and attraction are historically conflated constructs. However, it is important to tease them apart. A common taxonomy organizes sexual orientation into three intersecting components: (1) sexual orientation identity, or who I am; (2) sexual behavior, or what I do; and (3) sexual attraction, whom I desire. These distinctions are important because they do not always line up for many people. When patients explore each process, they may experience curiosity and confusion, dissonance and integration, and a critical process of identity development. Sexual orientation is typically determined by the gender(s) of the person or people someone is attracted to. Data suggest that people’s sexual orientations are typically more fluid than we may think; attraction, behavior, and identity exist more on a continuum of identity and desire rather than in discrete and cleanly categorical ways (Vrangalova & Williams, 2012).

Sexual orientation identity – who I am – describes how a person self-identifies their emotional, romantic, and physical attractions and behaviors. Typical examples of terms and communities related to sexual orientation identity include straight/heterosexual, lesbian, gay, bisexual, queer, pansexual, and asexual. The term “sexual orientation” connotes that a person is oriented in a particular way, such as a man with a primary desire for men. People typically prefer this term over “sexual preference,” which connotes that individuals prefer – or choose – their sexual, emotional, romantic, and physical attractions.

Sexual behavior – what I do – is the manner in which a person engages in sexual activities. People engage in a variety of sexual acts, ranging from acts performed alone (e.g., masturbation) to acts with others (e.g., oral sex, vaginal intercourse, and other behaviors). When working with patients, it is important to explore both the potential risks and benefits of specific sexual behaviors.

Sexual attraction – whom I desire – is a person’s emotional, romantic, and physical attractions. Why tease these apart? For many individuals, these three processes may be in tension. Think, for example, about a hypothetical man who is married to a non-transgender woman, has sex with men, and is sexually attracted to transgender women. For this individual, his sexual orientation identity, sexual behavior, and sexual attraction may not fit cohesively within a restrictive social environment. He may experience identity diffusion, shame, and stigma, and he may benefit from nuanced resilience strategies to manage these complex components of self.

Diversity of Sexual Orientations

A person who is heterosexual (i.e., straight) feels primary emotional, romantic, and/or physical attractions to people of a different gender. Examples include men primarily attracted to women and women primarily attracted to men. The term heteronormativity refers to the social and political system in which heterosexuality is privileged and other identities are marginalized.

A person who is lesbian, gay, or homosexual feels primary emotional, romantic, and/or physical attractions to people of the same gender. Lesbian is a sexual orientation referring to women with a primary attraction to other women. Gay is a sexual orientation referring to primary attraction to people of the same gender; this term is used to describe people of all genders, whereas lesbian is typically reserved for women. The term homosexual was historically used as a psychiatric diagnosis, so people who identify as lesbian and gay typically do not use this term to describe themselves.

A person who is bisexual experiences primary emotional, romantic, and/or physical attractions to more than one gender. Psychiatric research into clinical issues faced by bisexual individuals reveals themes of exclusion (i.e., feeling excluded both from straight and gay or lesbian communities) as well as bicultural self-efficacy (i.e., being able to participate in gay/queer and straight cultural practices and spaces).

Queer is an umbrella term for gender and sexual minorities. Originally a pejorative term, “queer” has been reclaimed by sexual and gender minority people to describe a sexual orientation, gender identity, or similar identity or expression that does not conform to dominant social norms of gender and sexuality. Many young people have adopted the term queer as an identity term to defy binary notions of gender and sexuality.

Pansexual is a similar term referring to a person with emotional, romantic, and physical attractions to people regardless of (rather than because of) genders. A person who is asexual typically denies significant sexual attraction to others or reports minimal desire to engage in sexual activity.

Monogamy is the practice of engaging in an emotional, romantic, or physical relationship with only one partner. Compulsory monogamy refers to the cultural expectation that people marry one person and engage in an exclusive relationship with that one person. Conversely, consensual non-monogamy (CNM) describes the practice of engaging in emotional, romantic, or physical relationships with multiple partners. It is important to distinguish CNM from cheating, the practice of engaging in multiple relationships without the consent of one’s spouse or partner. CNM is a separate practice in which one or more partners consensually engage in multiple relationships. People of all gender identities and sexual orientations may practice both monogamy and CNM. A recent meta-analysis revealed that people who engage in CNM report similar or higher rates of relational satisfaction and psychological well-being compared to people who engage in monogamy (Brewster et al., 2017). Many people engage in kink behaviors, an umbrella term describing a broad range of sexual behavior typically considered to be unconventional. Examples include spanking, dripping candle wax, cross-dressing (wearing clothing typically considered normative for a person of a different gender), and engaging in sexual role play. Again, despite carrying stigma, engaging in kink does not pose significant implications for psychiatric functioning or well-being and is often considered a normative expression of sexual and romantic desire.

Gender and Sexual Identity Development

Throughout the evolution of the field of psychiatry, multiple models have dominated thought about how and why people develop particular gender identities and sexual orientations. Psychiatry has long been curious about what drives and motivations lead to particular sexual attractions, behaviors, and identities. There has long been a discrepancy between those who believed gender and sexuality were produced by “nature,” or a child’s genetic and biological influences, versus those who argued that gender and sexuality are due to “nurture,” or the environment in which a child is raised. For psychiatrists seeking to understand the reasons humans have particular experiences related to gender and sexuality, this has been a vital question. The current state of psychiatric science posits that both play a role, suggesting a dual nature-nurture understanding of how gender identity and sexual orientation develop.

There are several arguments within the field of psychiatry that sexuality and gender are determined by nature: one’s chromosomes, genes, and natal development. Within these frameworks, sex is fundamentally biological in nature, determined by variations in a single chromosome: the 23rd pair of 23 along the cell nucleus. Human sex chromosomes, a typical pair of mammal allosomes, determine the sex of an individual. Most females have two X chromosomes in their 23rd pair and most males, rather, have an X chromosome and a Y chromosome. Knowledge about sex chromosomes dates back to 1905, when geneticist Nettie Stevens published a study on the chromosomal makeup of sperm and egg cells produced by mealworms.

These findings were applied and extended in research with human biology and psychiatry: the widespread understanding in medicine for decades to come was that sex and gender were determined by biology alone. Indeed, Charles Darwin and other early, eminent scholars, including Francis Galton and Edward L. Thorndike, wrote about gender-as-nature: arguing that women were naturally passive, intellectually inferior, and motivated by evolutionary instinct to nurture.

Discourse on the development of sexual identity emerged around this time as well, beginning largely with works by Sigmund Freud. In Three Essays on the Theory of Sexuality, Freud (1905) commented that young infants (0–5 years old) have, in analytic terms, polymorphous perversity: driven to seek pleasure from any object, person, or being, regardless of gender. Before children are educated in the social, legal, and political norms of their culture, Freud wrote, they simply turn to various bodily parts for sexual gratification. Throughout childhood development, however, their desires are circumscribed by education, social norms, and their parents or caregiving. This leads to repression: an amnesia or subjugation of primitive, polymorphous sexual desires. Freud wrote that heterosexual adults retain some homosexual desires, which are sublimated due to pressure from society. Although Freud lay a foundation of pathologizing theories about the development and persistence of queerness (i.e., positing it occurs due to arrests in sexual development), he later argued against an analytic “cure” or repudiation of people with same-sex desire. Indeed, the majority of contemporary psychoanalytic organizations (including the prominent American Psychoanalytic Association) have denounced early theories and may advocate for sexual and gender minority communities.

Throughout the mid-1900s, psychiatry and medical interventions were developed to “treat” gender and sexual diversity. These interventions were based on a belief that gender and sexual minority people had stunted or “inverted” identity development. They were often subjected to medically unnecessary and often harmful interventions, including electroconvulsive therapy, psychosurgery (e.g., lobotomy), supposedly reparative psychoanalysis, and chemical castration. It was due to early advocates within the field of psychiatry and sex research that marginalized communities were later de-pathologized and treated with more respect and care by the field. In contemporary practice, so-called “conversion therapy” (the pseudoscientific practice of attempting to change a patient’s gender identity and/or sexual orientation) has been debunked and criminalized due to its harmful effects and lack of empirical validity.

More recent psychiatric conceptualizations of gender and sexuality are dominated by a belief that identity development is determined by an interaction of nature and nurture. According to a recent review (Eagly & Wood, 2013), psychiatry has shifted dramatically toward a less pathologizing, more integrated (nature and nurture) understanding of the roles of both biological factors and socialization. A prominent recent conceptualization of sexual identity development is the multiple continua model posited by Hammack (2005). Proponents of this model argue that sexuality is best understood as “a matrix of mental-emotional-behavioral experiences occurring across a wide range of contexts” (Moe, Reicherzer, & Dupuy, 2011, p. 230). This concept transcends the nature-nurture debate by integrating both sides of the date into its understanding of sexuality.

It has been well-documented in the literature that lesbian, gay, bisexual, transgender and queer (LGBTQ) people have unique developmental milestones in terms of how they may develop awareness, social expression, and integration of their sexual and/or gender minority status. Cass (1979), for example, posited a six-stage gay and lesbian identity development model, beginning at Stage 1 (Identity Confusion) and resolving in Stage 6 (Identity Synthesis). Similar models have been established among bisexual people, transgender people and gender nonbinary people, though models incorporating intersecting identities in their conceptualization (i.e., the influence of racial minority status on sexual orientation identity development) continue to be underresearched.