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Sexual Orientation Matters in Sexual

Eusebio Rubio-Aurioles, MD, PHD,* and Kevan Wylie, MD, FRCP, FRCPsych† *Asociacion Mexicana para la Salud Sexual A.C. (AMSSAC), Mexico City, Mexico; †Porterbrook Clinic, Sheffield, UK

ABSTRACT

Introduction. is a topic that needs to be integrated into the knowledge base of the practitioner of sexual medicine. Aim. To present to the reader a summary of the current literature on homosexuality and and address specifically issues that pertain to the relationship sexual orientation and sexual medicine practice. Main Outcome Measures. The information is presented in a continued medical education format, with a series of evaluation questions at the end of the activity. Methods. A review of the literature is presented and organized according to the authors’ judgment of the value of the information as to provide the reader with an inclusive panorama of the issues covered. Results. Current concepts, debates, and need for further research are presented. Conclusions. The professional of sexual medicine needs to be aware of the various topics reviewed in this article as his or her involvement in the area of sexuality can create the expectation on the part of the patients of knowingness of all aspects of . Sexual orientation is a complex area but considerable understanding has fortunately been achieved in many issues in reference to homosexuality and . Rubio-Aurioles E, and Wylie K. Sexual orientation matters in sexual medicine. J Sex Med 2008;5:1521–1533. Key Words. Sexual Orientation; Homosexuality; ; Determinants of Orientation

Introduction tation to the sexual medicine specialist. Homo- sexuality has a long history of debated issues in exual medicine is a multidisciplinary field that medicine and some of the debates have not S has come to exist with the integration of pro- reached a conclusion; a substantial part of this fessionals trained in several specialties of medicine article intends to familiarize the professional with and other health-related professions. Homosexu- the state of the art of those debates. ality, as a scientific topic, has traditionally been A review of the literature is presented. The more studied and discussed by and sources consulted include manuscripts that clinical psychology. The emergence of the new appeared in the literature in recent years but field of sexual medicine creates the need for edu- also include a number of classical references to cational activities that bring up to date profession- illustrate the development of concepts. The als whose “field of origin” is not related to certain process of the literature review followed areas of human sexuality. When such a profes- an educational criteria and not a systematic sional becomes involved in sexual medicine, their procedure. day-to-day clinical practice will inevitably expose the clinician to these topics, which are probably Basic Concepts in Sexual Orientation not included in their “original” specialty training. The objective of this presentation is precisely to Homosexuality is one of the possible arrangements offer in a brief and short format a summary of what of sexual orientation. Usually, it is agreed that has been occurring with the area of sexual orien- sexual orientation can be heterosexual, homo-

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sexual, bisexual, and in some individuals who deny In more recent years, the fact that many male any sexual interest, asexual. These categories refer individuals do not identify themselves as gay to the preferred gender of and also or homosexual but have sexual interaction with include an increased likelihood of establishing other men has prompted clinicians, especially romantic ties with a person with the same gender those working in the prevention of HIV and other as the one preferred for sexual interaction. sexual transmitted , to use an even more Although most of the time there is a correspon- descriptive term that avoids issues of self- dence between the behavioral level and the inner identification: men who have sex with men. The experience, fantasies, and desires, sexual orienta- main reason for the emergence of this new term is tion refers basically to the internal experience that the relative low reliability of self-labeling in clini- might be congruent or not with the explicit sexual cal settings when patients are interrogated about behavior of the individual. their sexual orientation or preference [5]. The fol- The Pan American Health Organization, which lowing quote is from the Joint United Nations is the regional office of the World Health Organi- Program on HIV/AIDS: “The term ‘men who zation for the Americas, in a report of a consulta- have sex with men’—frequently shortened to tion on sexual health promotion with a group of MSM—describes a behavior rather than a specific experts convened by this organization and the group of people. It includes self-identified gay, World Association for Sexual Health, defines bisexual, transgendered, or heterosexual men. sexual orientation as “the organization of an indi- Many men who have sex with men do not con- vidual’s eroticism and/or emotional attachment sider themselves gay or bisexual. They are often with reference to the sex and gender of the partner married, particularly where discriminatory laws or involved in sexual activity. Sexual orientation may social stigma of male sexual relations exist. Largely be manifested in any one or a combination of because of the taboo, the female partners of men sexual behavior, thoughts, fantasies, or desire [1]. who have sex with men are often unaware of their Sexual behavior is commonly coherent with partner’s other liaisons, and the threat posed to sexual orientation, but it has become clear that themselves. Forced sex among men is not uncom- sexual behavior is much more variable than sexual mon, especially in men-only environments such as orientation. For example, an individual can expe- prisons. Men who have sex with men are found in rience homosexual behavior, with his or her basic all societies, yet are largely invisible in many sexual orientation being heterosexual. The discor- places” [6]. dance in the other direction is also possible. In a less formal way, the English term gay has However, it is assumed that most individuals on gained acceptance among a large number of audi- the long-term maintain a concordance between ences to denominate individuals who identify sexual orientation and sexual behavior. themselves as homosexuals. Initially, the term A brief note on the previously used terminol- applied only to men, but it has extended its ogy is in order. Sexual orientation has followed a meaning to include both men and women in many relatively large number of terms that denote the areas of the world. The term lesbian has also same human characteristic but that have been gained acceptability to denominate the homo- abandoned because of multiple connotations that sexual women. In contrast to the term gay, lesbian erroneously portrayed the reality of homosexual applies only to female individuals who identify men and women. A partial list includes: sexual themselves as homosexuals. inversion and perverted tendency [2], sexual deviation, [3] and more recently, sexual prefer- Frequency of Gay and Lesbian Orientations ence [4]. Most of the former terms have been abandoned because of their pejorative connota- The question of how prevalent the homosexual tions. Sexual preference, although not pejorative, and bisexual orientation is has been a subject of has acquired the connotation of free choice and debate. A number of problems have prevented a scholars agree that a characteristic of sexual ori- straightforward answer to the question: first, the entation is that it is not chosen by the individual, way in which the assessment is made can influence and for this reason, the term sexual preference is the conclusion of the particular study, especially being substituted by the more neutral term in cultures and moments in history when homo- “sexual orientation.” sexuality was concealed; second, the frequency of

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homosexual behavior apparently is much higher cousins but not from fathers or paternal relatives. that the prevalence of self-identified gay, lesbian, This suggested the possibility of sex link transmis- or bisexual individuals; third, in some areas of sion in a portion of the population. DNA linkage the world where gay activism has advanced, the analysis revealed a correlation between homo- reported frequency of gay, lesbian, and bisexual sexual orientation and the inheritance of polymor- individuals seems to be higher. phic markers on the X chromosome in 64% of For example, the Kinsey reports showed that the pairs tested, linkage being on a patch of DNA 37% of men have had at least one as a called Xq28. Hu et al. [12] corroborated previous result of sexual interaction with other man, 13% of reported linkage of Xq28 and male homosexuality females had at least some overt homosexual expe- in selected families but not in women. rience to orgasm; furthermore, 10% of males were A review by Bocklandt and Hamer [13] found more or less exclusively homosexual and 8% of no evidence that physiologically occurring varia- males were exclusively homosexual for at least tions in androgen exposure influenced differences three years between the ages of 16 and 55. These in sexual orientation. Instead, the authors hypo- figures include only behavior, and not the self- thesized that genomic imprinting may regulate identification of the individual. The Kinsey report sex-specific expression of genes of sexual dimor- included a very large number of interviews but phic traits, including sexual orientation. failed to obtain a representative sample of the The study by Otis and Skinner [14] in a rural population [7,8]. state of the mid-south United States investigated In general, the reports of the frequency of respondent thoughts on what may affect sexual homosexual orientation vary from 1% to 10% of orientation, looking at issues of , relation- the adult population for male estimates, and in a ship between parents, relationship with parents, consistent way, numbers are reportedly lower for birth order, peers, growing up in a dysfunctional females. Researchers attempting to evaluate the family, growing up in a single parent family, nega- frequency of homosexual orientation in different tive experiences with the opposite sex, and positive populations usually agree that a fair estimate for experiences with the same sex. The results fol- male homosexual orientation in the general popu- lowed similar results of studies of heterosexual lation is around 4–5% of the adult male population men and women with gay men more likely to view and around 2–3% of the female adult population sexual orientation as a result of genetics than [9,10]. lesbian responders. The lesbian group was more likely to view positive relationships with the same sex to have a great influence on sexual orientation. Why Does Sexual Orientation Differ in People? The first genome screen for normal variation in The debate continues about the role of factors the behavioral trait of sexual orientation in males resulting in same sex preference and sexual orien- was reported by Mustanski et al. [15]. Of interest, tation. Among the proposed ones we can see: full linkage to Xq28 was not found in all of the genetic and biological influences, environmental samples. More recent studies have found that the influences with exposure to various stimuli, and number of women with extreme skewing of X socially learned factors leading to personal choice. chromosome inactivation was significantly higher The role of genetic influences has been investi- in mothers of gay men (13%) compared to con- gated with some vigor. Discouraging investigation trols (4%) and an increase in mothers of two or into biological origins has been advocated by many more gay sons (23%). This further supports the in the fear that should a cause be found, the reclas- role for the X chromosome in regulation of sexual sification of sexual orientation as a disease state orientation in a subgroup of gay men [16]. would lead to attempts to remove such sexual pre- A study from Italy [17] found that women with ference by conservative and religious scientists. gay family members have more children than The role of genetics was investigated and re- women with all straight relatives. Mothers of gay ported by Hammer et al. [11] in a study that men had an average of 2.7 children compared to claimed to show a partial genetic influence. Ex- mothers of straight men who averaged 2.3. This tensive interviews with 76 pairs of gay brothers study confirmed previous reports that gay men and their families identified homosexuality to be have more maternal than paternal male homo- inherited through the maternal uncles and male sexual relatives, that homosexual males are often

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later born than firstborn, and that they have more dictated by its genetic code under various environ- older brothers than older sisters. mental conditions [22]. Developmental instability Genes are not the only biological factor that is frequently measured indirectly using fluctuating influences sexual orientation. Environmental asymmetry, which refers to small, non-directional factors experienced within the uterus are impor- deviations from perfect symmetry in the develop- tant. Having an older brother increased the odds ment of bilateral traits. An increase in develop- of homosexuality in right-handers only; in non- mental instability as measured by elevated right-handers, having older brothers did not affect fluctuating asymmetry in gay men and lesbians the odds of homosexuality [18]. This study utilized compared to heterosexual men and women was information complied from Alfred Kinsey’s work identified in a recent study [23]. in the 1940s. Whether genes, hormones, immunological, or An important study from Bogaert [19] identi- some other environmental factor results in same- fied that only biological older brothers and not any sex orientation “the changes” within the brain other sibling characteristic predicted men’s sexual structure still remain elusive. Interest remains in orientation and confirming the importance of fra- looking at an area of the anterior hypothalamus, ternal birth order. This study allowed comparison particularly with the interstitial nuclei of the from gay and heterosexual men who grew up in human anterior hypothalamus (INAH). The non-biological families (usually adopted). The INAH 3 region had been reported as smaller in conclusion being that it was not by having and homosexual men compared to heterosexual men. living with the older brother that the younger man However, a study by Byne et al. found no differ- identified as gay, but more likely to be the envi- ence in the number of neurons within the nucleus ronment and having shared the same womb of the based upon presumed sexual orientation [24]. In mother. It has been hypothesized that the mother this line of inquiry, the group of Roselli et al. [25] may develop immunity to certain male specific reported a cell group within the medial preoptic molecules in the Y chromosome, which with sub- area (MPOA)/anterior hypothalamus of eight sequent births leads to some immunological effect matched adult sheep was found to be significantly on the male brain. larger than in adult rams than in ewes. In addition, Bocklandt and Vilain [20] have argued that the volume was two times greater in female orien- genetic factors play some role in sexually dimor- tated rams than in male orientated rams. There phic traits and that sex differences in the brain and were also significantly greater levels of messenger behavior are an end point of that sex determina- ribose nucleic acid (mRNA) in female orientated tion. They suggest that the number of dopamin- rams than in ewes, while male orientated rams ergic cells in the mesencephalon may influence exhibited intermediate levels of expression. As sexual orientation independently of gonadal hor- the MPOA/anterior hypothalamus is known to mones (such as testosterone secreted from the control the expression of male sexual behaviors, testes). the suggestion from the authors was that naturally In a recent report by Ellis et al., heterosexual occurring variations in sexual partner preferences males and females exhibited statistically identical may be related to differences in both brain frequencies of blood type A whereas gay men anatomy and capacity for estrogen synthesis. exhibited a relatively low incidence and lesbians a relatively high incidence to significant values. An unusually high proportion of homosexuals of both Why Homosexual Orientation Is Not Considered sexes were rhesus negative compared to hetero- sexuals, suggesting a connection may exist between In most of today’s clinical world, it is common sexual orientation and genes on both chromosome knowledge that homosexuality is not considered 9 (where blood type is determined) and chromo- a pathological condition. The American Psychiat- some 1 (where rhesus factor is regulated) [21]. ric Association removed homosexuality from its Recently, studies investigating sexual orienta- official Diagnostic and Statistical Manual of tion have provided support for the role of another Mental Disorders in 1973 [26]. factor: developmental instability. The term devel- This decision occurred in the context of very opmental stability refers to an individual organ- important cultural changes in the United States ism’s capacity to produce the specific phenotype as brought on by the social protest movements of the

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Table 1 Incidence of sexual techniques in the year previous to interview reported by participants who identified themselves as homosexuals in the Bell and Weinberg Study [28]

White homosexual Black homosexual White homosexual Black homosexual Technique men (N = 575) (%) men (N = 111) (%) women (N = 228) (%) women (N = 63) (%) Body rubbing 41 53 46 77 Masturbating partner 83 91 79 88 Being masturbated by partner 85 88 82 89 Performing oral–genital 95 89 78 80 Receiving oral–genital 94 96 75 84 Performing anal intercourse 78 90 NA NA Receiving anal intercourse 67 78 NA NA

1960s and 1970s, beginning with the civil rights comparing variations among ethnic and cultural movement, and evolving on to the women’s and groups. A classic example of this is the investigation gay rights movements. conducted by Bell and Weinberg in the 1970s [28], The decision was in fact an indirect result of the who interviewed 686 males and 293 females who pressure exerted by gay activists, but what the identified themselves as homosexuals recruited political pressure did was to force a review of avail- from the San Francisco Bay Area in the United able scientific evidence that severely questioned States. These authors present a detailed report on the assumption that homosexuality was pathologi- the frequency of sexual techniques used by the cal. A very active scientist, psychiatrist, and het- respondent in the year previous to the interview. erosexual who participated in those discussions These are summarized in Table 1. As it can be and processes writes some years later: “Countless observed, there is a wide range of sexual techniques objective psychological test have been done by used by persons with homosexual orientations, and now on nonpatient groups of homosexuals with contrary to somehow simplistic assumptions, there matched groups of heterosexual, beginning with is a substantial number of homosexual persons who Evelyn Hooker’s classic study (1957). With sur- perform homosexual techniques equivalent to het- prising uniformity, the vast majority of these erosexual vaginal intercourse. Also of interest is the studies have shown few, if any, significant differ- information presented in Table 2 with data gath- ences in personality structure between the two ered from the same Bell and Weinberg Study [28], groups and no greater psychopathology among where the favorite sexual technique of homosexual non patients homosexuals than among matched males and females are recorded. There is no par- heterosexual controls” [26, p. 400]. Psychologist ticular technique that is favored by all homosexual Evelyn Hooker’s groundbreaking study compared men and women. In particular, the assumption that the projective test results from 30 non-patient anal intercourse is the favorite sexual technique of homosexual men with those of 30 non-patient het- homosexual men is not sustained by this empirical erosexual men. The study found that experienced information. psychologists, unaware of whose test results they The figures reported by the Bell and Weinberg were interpreting, could not distinguish between Study [28] are, however, from a sample obtained in the two groups [27]. the U.S. and with some time elapsed. There has The World Health Organization removed been discussion in the literature pointing to pos- homosexuality from the International Classifica- sible differences in the preferences of sexual tech- tion of Disease (ICD)-10 in 1992. niques of men from other cultures, especially the Latino culture where the link between masculinity and sexual behavior is reported to be more related Sexual Orientation and Sexual Behavior to the inserter role in anal intercourse than the The particularities of sexual techniques preferred gender of the partner. In a recent report by Jeffries by homosexually identified individuals have been [29], who used a U.S. national probability sample the subject of attention by researchers. Investiga- of 4,928 men, found that non-Mexican Latino, but tions performed some 30 years ago tended to focus not Mexican men, had increased likelihoods of on the differences of techniques used by individuals ever having than non-Latino whites and that identified themselves as homosexuals and than non-Latino blacks. Latino men pre-

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Table 2 Rating of sexual techniques as favorite reported by participants who identified themselves as homosexuals in the Bell and Weinberg Study [28]

White homosexual Black homosexual White homosexual Black homosexual Technique men (N = 575) (%) men (N = 111) (%) women (N = 228) (%) women (N = 63) (%) Body rubbing 3 2 12 24 Masturbating partner 0 0 0 2 Being masturbated by partner 1 0 16 5 Mutual 2 1 13 7 Performing oral–genital 2 3 6 0 Receiving oral–genital 27 18 20 29 Performing anal intercourse 26 44 NA NA Receiving anal intercourse 5 11 NA NA

ferred insertive or receptive sex in comparison to misuse was reported to be increasingly prevalent non-Latino blacks and whites, but the difference among men who have sex with men and is associ- disappeared after education was controlled for. ated with the practice of unprotected oral or anal sex with multiple partners and a potential increase in HIV transmission rates. Additionally, concerns HIV Transmission in High-Risk Sexual Behavior on the use in conjunction with inhalant nitrates The emergence of the HIV epidemic has renewed (poppers) or with certain antiretroviral drugs were the interest of documenting the prevalence of the addressed. Overall, there was a strong consensus on various sexual practices. This interest has been the need for additional short and long-term studies fueled by the need to identify the factors that on possible links of PDE5i use to changes in sexual determine risk behaviors that increase the chances behavior and lifestyle factors. On the medical use of of transmission. Accordingly, the sexual behaviors PDE5i on individuals with HIV-positive status, the investigated focus on the ones that favor HIV group of experts endorsed the applicability of the transmission. For example, a recent survey con- recently issued recommendations on erectile dys- ducted among 1,996 men who had sex with men function management [32] with additional areas in the San Francisco Bay Area [30] found that of emphasis: the need for safer sex counseling, between 3 and 19% of the participants reported a comprehensive sexually transmitted infections form of sexual risk behavior including unprotected screening and follow-up, avoidance of potentially insertive anal intercourse (18.9%) or unprotected dangerous drug interactions, and the potential receptive anal intercourse with a partner of the benefit of testosterone replacement for HIV- same HIV serostatus (14.2%). When the risk positive men with decreased androgen. factors for unprotected insertive anal intercourse with a serodiscordant partner were investigated Homophobia and Internalized Homophobia the use of sildenafil and a greater number of part- ners in the last 12 months were identified. The concept of homophobia has emerged as a The concerns raised by reports that linked the clinically usable tool to explain several phenomena use of phosphodiesterase type 5 inhibitors (PDE- in relation to sexual orientation. As commented 5i) to an increased risk rate of high risk sexual earlier, homosexuality was classified and declassi- behavior were addressed in a multidisciplinary fied as a mental illness in the past century; the conference founded by the National Institute reasons for its classification as a mental problem or of Mental Health (USA) known as the Bolger “pathology” are rooted in the cultural foundations Conference [31]. Leading investigators in several of occidental culture where systematic condemna- disciplines gathered for 2 days to make recom- tion and equation of homosexuality with sin and mendations. Reports highlighting the potential crime have been consistent, in the years 1150 to misuse of PDE-5i as recreational drugs, often in 1350, homosexual behavior had changed from association with drugs of abuse such as metham- something between the curious and the worth of phetamines, methylenedioxymethamphetamine celebrating to something that merits persecution, (MDMA) (known as ecstasy), , and other and in many places of Europe, the death penalty stimulant drugs were discussed. The pattern of [33].

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With the declassification of homosexuality as a accepting environment. Homophobia, conse- disease, and the dissemination of scientific studies quently, can be the subject matter of psychothera- that showed the lack of validity of cultural asser- peutic work. This is a critical element in the case of tions of what it means to have a homosexual persons with homosexual orientation who seek orientation, the culturally held ideas on homo- clinical help but can also be a focus of psycho- sexuality have not vanished. Interestingly, the for heterosexual persons that for reasons judgment of homosexuality was part of a greater of professional interest, clinical work, or parent- condemnation that included any form of non- ing, realize that they need to get rid of their irra- procreational sex: masturbation and other forms of tional reactions. “unrestrained” sexual lust, among which homo- sexuality was included. Psychologist George Weinberg coined the Are Homosexual Persons Good Parents? term homophobia to denote the irrational aver- sion to homosexuality and homosexual people Somehow in the frontier of the discussions to con- (quoted in [33]). It is important to note that sider individuals with homosexual orientation in homophobia does not mean disliking of homo- exactly the same terms as the individuals with het- sexuals. Not feeling particularly prone to under- erosexual orientation is the debate on the fitness stand and be friendly with homosexual persons is for parenthood that people with homosexual ori- generally rooted in the social condemnation of entation have. homosexuality that is highly prevalent in many The debate on this matter has been centered on cultures. Homophobia implies, as Friedman and the eventual consequences on the development of Downey [33] comment, a much more active the children involved. There have been a consid- aggression toward the homosexual possibility in erable number of studies that have dispelled pre- humans, homophobic reactions usually involve viously held ideas. The psychological health of the much more than the reactions typically seen in children is not damaged by the parent’s sexual other phobias: “phobic people do not devalue or orientation, regardless if they are biological sons ragefully attack phobic objects” (p. 175) as people or daughters, adopted, or if the parent lives in a with homophobia often do with homosexual homosexual union ( or de facto). Having a people. People with homophobia tend to be homosexual parent does not make it impossible to authoritarian, conservative, come from religious develop as a heterosexual, as some previously held backgrounds in which homosexuality is viewed ideas suggested. negatively, and tend to have little or no contact A review by Patterson [35] concluded that more with homosexual persons [34]. than two decades of research demonstrate that Homophobia has been described as the most there are no important differences in the develop- influential factor in symptoms that cause distress ment or the level of adjustment in the children of and disability in gay and lesbian people. homosexual couples compared to the children Homophobic attitudes can come from parents, of heterosexual couples. Results indicate that the peers, society at large, and most importantly for outcome is much more a result of the quality of the the purposes of this manuscript, the health-care family interactions than the sexual orientation of professional. When homophobic attitudes come parents. from the patient himself, they become a very dis- On the other hand, a number of studies have ruptive and destructive force that creates impor- shown that the likelihood of becoming homo- tant health risks and that needs to be addressed in sexual does not increase dramatically by the fact a proper manner by the clinician. A homophobic that one parent is homosexual [36,37]. reaction on the part of the clinician to a behavior These and other research reports have been the rooted in internalized homophobia of a patient can basis of changes in some countries’ law systems be an authentic trigger to self-destruction. that recently have granted rights to Homophobia can be rooted in complex un- homosexual people and couples. It is clear that resolved psychological issues. When this is the homosexuality does not guarantee good , case, the simple availability of information can be in about the same degree that heterosexuality does unsuccessful in resolving those issues and in the either. However, restricting the right of people creating of a more rational, supportive, and with homosexual orientation to raise children

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seems, from the perspective of these studies, it seems likely that the promotion of change thera- unjustified. pies reinforces stereotypes and contributes to a negative climate for lesbian, gay, and bisexual persons. This appears to be especially likely for How Should Gay Men and Women Be Supported lesbian, gay, and bisexual individuals who grow up by Clinicians? in more conservative religious settings” [42]. Many ethical and dubious treatments, including The move away from reparative therapy (con- aversion therapy, apomorphine therapy, electric version therapy) to affirmative therapy and gay shock therapy, and covert sensitization have been sensitive therapy by therapists who are well- used in the past to change “gay orientation” and informed of the issues facing gay and bisexual this has led to marked criticism of psychiatrists in men from living within cultures and religious encouraging and supporting the stereotypes and orders where there is social homophobia will be social construction of gay and lesbian sex as a beneficial. mental disorder. Assumptions were made in psy- choanalysis as well as in the behavioral treatments that sexuality could be altered, which lead to unsci- Special Clinical Needs of People with Homosexual and Bisexual Orientation entific therapy and practice. Homosexuality was considered the product of modern urban life and It is necessary in all clinical consultations to not masturbation by Ammon (1879–1942) and could assume the sexual orientation of presenting be prevented by sports, “respect for ,” and patients to be heterosexual. Using open questions a natural living [38]. A recent review by Murphy such as “are you single or married” and “are you [39] has suggested that the recommendations of living with someone” are a useful way forward to including bicycling, hypnosis (150 ses- allow the patient to disclose some information. sions), large quantities of alcohol followed by visits Asking them to “tell me about your relationship” to brothels, cocaine, castration, testicle implants, and whether there are “any difficulties in the more and manipulating sex hormones during intimate parts of that relationship” can allow should all be regarded with great concern. A the patient to disclose homosexual practice or review by King and Bartlett [40] concludes that orientation. mental health professionals should be aware of For some, it is important to give continued reas- mistakes of the past. surance with statements such as “I realize that Despite this, a study described over 200 partici- dealing with your own sexuality can be difficult pants (self-selective) who reported some minimal and that’s the case for many people whether they change from homosexual to heterosexual orienta- are heterosexual, gay, lesbian, bisexual, or trans- tion that lasted at least 5 years [41]. Virtually all of gendered.” By going on and encouraging them to the participants reported substantial changes in respond to “how do you feel about your own sexu- core aspects of sexual orientation, and for some, ality? Have you ever encountered any difficulties the change of self-identity also brought about in your or around your issues relating to change to overt sexual behavior. The study pro- your sexuality?” is facilitating. However the ques- poses that changes in core features of sexual ori- tions are raised, it is important to give individuals entation are possible although complete change and couples permission to bring up their anxieties was uncommon. and concerns. Clinicians must avoid being dis- The official position of the American Psycho- tracted or embarrassed by the responses and for logical Association on the issue of therapeutic those areas where it is difficult to understand or approaches that attempt to change sexual orienta- appreciate because of the professional’s own life tion is, however, very clear against the approach: experiences, it is helpful to encourage the patient “All major national mental health organizations to talk and describe the issues to the clinician have officially expressed concerns about therapies rather than assume “all knowingness” and thereby promoted to modify sexual orientation. To date, getting it wrong. there has been no scientifically adequate research An article that is directed particularly toward to show that therapy aimed at changing sexual human sexuality education professionals provides orientation (sometimes called reparative or con- some useful identification of factors to allow sys- version therapy) is safe or effective. Furthermore, temic change within both organizations and at

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ground floor worker level to dismantle heterosex- around social isolation, feeling isolated and stig- ism and to move from the rhetoric of inclusion matized, and poor self-esteem and shamefulness, into actual inclusion. Shared leadership, inclusive which can affect social relationships. polices, practices and pedagogy, resources, a plan, When dealing with individuals and couples and ongoing and inclusive communication allows with sexual problems, it is important to establish systemic transformation and culture change. This early on whether the presenting issue is indeed a may be useful in both team development and in the problem. When genital touching and function is supervision setting to allow change to be made not of primacy within many relationships, it may possible particularly for those clinicians who are be necessary to look beyond the stated problem uncomfortable or find difficulties in working with to establish potential issues that could be worthy of gay or lesbian individuals [43]. exploration. In lesbian women, it has been sug- It is important to remember that the assump- gested that some women may be reluctant to be tion that problems that are brought to consulta- seen as taking on the more dominant or lead role tion should not be assumed as necessarily directly or to be seen as the sexually dominant partner. associated with sexual orientation. Where orienta- Issues around equality and intimacy may be much tion issues are part of the presenting complaint, stronger issues that need exploration. In men, the clinical problems often arise from either there is often a need to demonstrate either the attempting to develop or to live within a hostile macho aggressive male character with hard firm culture or from attempting to develop and sustain , and so issues of erectile instability, rapid relationships with other people of the same gender , or concerns about penile size or girth where socialization has been focused on hetero- can bring about substantial distress. Likewise, con- sexual relationships [44]. cerns about , particularly in secondary or The lack of support or recognition for the exist- casual relationships, can result in problem areas ence of lesbian women or gay men within educa- within the primary relationship. Established forms tional facilities, including universities, can bring of intervention are effective with gay couples about a sense of isolation and self-destructive, self- although the specific needs of gay and lesbian negating behaviors including substance misuse and people may need to be addressed by the therapist self-harming behavior. These in turn are often [45]. assumed by the individual as confirming the inher- A study by Means-Christensen et al. [46] found ent truth that all of the issues are because of their that psychometric profiles of cohabiting same mental health [44]. Some of the reasons for gender and opposite gender couples were more seeking counseling and therapy may be very much similar to nondistressed married heterosexual around developing and maintaining intimate rela- couples from the general community than to tionships, dealing with emotional satisfaction from couples in therapy when using the marital satisfac- several relationships at one time; accepting sexual tion inventory-revised. attraction to others beyond the primary partner, Although gay male and lesbian couples are and exploring the morality issues around acting more similar than different from heterosexual upon such attraction, potentially destroying the couples, the impact of homophobia and hetero- primary relationship. Issues of self-hatred within sexism on gay and lesbian couples must be internalized homophobia preventing healthy psy- acknowledged separately from external legal and chosexual development and especially issues social sanctions. Many gay men and lesbian involving the disclosure of homosexual orientation women have unfounded negative views regarding with friends, peers, and family can bring people their own potential for enduring and fulfilling into therapy. intimate relationships because of their own Patients may present with any of the sexual socialization experiences. In addition, it is impor- problems or relationship issues that bring hetero- tant to remember that stereotypic gender role sexual patients and couples to our clinics. There is attitudes and cognitive emotional and interper- often great anxiety as to whether the clinical inter- sonal styles reflecting feminization or masculinity ventions and interactions will be different with warrant examination in any couple regardless of same-sex couples or gay or lesbian individuals. sexual orientation. Since sexuality affects general health, it may be There is epidemiological evidence that indi- necessary to spend more time looking at issues viduals who identify themselves as homosexual

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have an increased use of mental health-care ser- Subsequent reports followed the line put vices. Cochran and Mays [47] compared data from forward by . These reports a U.S. National Household Survey of Drug Use were characteristically expert opinion-based. For and compared sexually active individuals who had instance, McWhirter and Mattison, in 1980 [50], a heterosexual partner with individuals having echoed the views of Masters and Johnson when a homosexual partner during the last 12 months. they consider that with homosexual Six psychiatric syndromes were investigated (major couples and individuals is not significantly dif- depression, generalized anxiety disorder, panic ferent from therapy for heterosexuals; however, attacks, agoraphobia, and drug and/or alcohol they comment that a critical issue for the proper dependency) as well as the use of mental health management of sexual problems is the lack of services. Although nearly three-quarters of homo- homophobia in the part of the professional. sexually active individuals did not meet the criteria In a more recent appraisal on the subject, for any of the six syndromes assessed, the authors Nichols [51], while maintaining the basic assertion found an increased risk in homosexual men to have that sex therapy with people with homosexual ori- major depression and panic attacks, and in the case entation is not so different from sex therapy with of lesbians, an increased risk of alcohol or substance heterosexual clients, except insofar the former dependence syndromes. While it is likely that these usually involved specific issues such as sexual iden- associations are the result of social factors, the tity, alternative lifestyles, and the nature of some of clinician should take special care to identify and the sexual practices that become focus of treatment. properly address these issues. The prevalence of among It is particularly important to examine issues homosexual individuals has not been properly of gender role with gay male and lesbian couples. investigated. Using a convenience sample of 197 Dealing with men’s socialization with competi- homosexual men who attended a health seminar, tiveness, assertiveness, autonomy, self-confidence, Rosser et al. [52] found sexual dysfunction and instrumentality, and the tendency not to express concerns to be a common problem; almost all men intimate feelings in comparison to women’s social- reported some degree of sexual difficulty in their ization with an emphasis on nurturance, emotional lifetime. Interestingly, a common complaint in this expressiveness, verbal exploration of emotions, sample was the presence of painful receptive anal and warmth means that since both partners within intercourse. the couple are likely to share similar socialization In contrast, the frequency of sexual dysfunction histories, same gender partners may initially have on HIV-positive homosexual or bisexual men has greater familiarity for their partners’ gender- been investigated in several reports. Lallemand linked emotional and interpersonal styles [48]. et al. studied a group of 156 ambulatory HIV- infected homosexual and bisexual men to assess the prevalence of sexual dysfunction using the Sexual Dysfunction and Homosexual Orientation International Index of Erectile Function and five Compared to the amount of information available sections of the Derogatis Sexual Functioning on a variety of sexual dysfunctions among the Inventory [53]. A total of 71% of the patients heterosexual population, the scarcity of literature reported some degree of sexual dysfunction. Of addressing sexual dysfunction issues among the these, 89% reported decrease or loss of , homosexual population is notable. Masters and 68% orgasmic problems, 86% erectile dysfunc- Johnson published their observations on their tion, and 79% ejaculation problems. effort to treat sexual dysfunction on homosexual There is a clear lack of evidence-based knowl- couples in a report in 1979 [49]. They state that edge when it comes to assessing the prevalence and according to their observations, the sexual capaci- treatment effectiveness of sexual dysfunction ties of the body “function in identical ways, among the homosexual patients. The initial sys- whether we are interacting heterosexually or tematic exclusion of homosexual behavior in the homosexually” (pp. 404–405). Therefore, they measures to assess treatment effectiveness as well supported the concept that “sexual dysfunction be as the exclusion of homosexual persons from trials treated with the same therapeutic principles and investigating the modern pharmacological treat- techniques regardless of the sexual orientation of ments for needs to be the distressed individual” (p. 406). acknowledged and corrected. The same holds true

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for other sexual dysfunctions. As sexual medicine Organization (PAHO) World Health Organization continues to broaden its perspectives, the need for (WHO) In collaboration with the World Associa- understanding the similarities and differences of tion for (WAS) in Antigua Guatemala, special populations continues to increase. Guatemala May 19–22, 2000. 2 Ellis H. Studies in the psychology of sex. Volume 1. New York: Random House; 1936. Conclusions 3 Leitenberg H. Handbook of behavior modification and behavior therapy. Englewood Cliffs: Prentice- The professional of sexual medicine needs to be Hall; 1976. aware of the various topics reviewed in this article as 4 Bell AP, Weinberg MS, Hammersmith SK. Sexual his or her involvement in the area of sexuality can preference: Its development in men and women. create the expectation on the part of the patients of Bloomington: Indiana University Press; 1981. knowingness of all aspects of human sexuality. 5 Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Sexual orientation is a complex area but con- Mostashari F. Discordance between sexual behavior siderable understanding has fortunately been and self-reported sexual identity: A population- achieved in many issues in reference to homo- based survey of New York city men. Ann Intern Med sexuality and heterosexuality. Clinicians should be 2006;145:416–25. 6 UNAIDS Joint United Nations Programme on aware of the current state of knowledge so their HIV/AIDS. Men who have sex with men. Available interventions maximize the opportunities for at: http://www.unaids.org/en/PolicyandPractice/ health promotion in all patients, regardless of KeyPopulations/MenSexMen/ (accessed January patient sexual orientation. 26, 2008). 7 Kinsey AC, Pomeroy WB, Martin CE. Sexual Corresponding Author: Eusebio Rubio-Aurioles, behavior in the human male. Philadelphia and MD, PHD, Asociacion Mexicana para la Salud Sexual London: Saunders and Co.; 1948. A.C. (AMSSAC), Mexico City, Mexico. Tel: +52 55 8 Kinsey AC, Pomeroy WB, Martin CE, Genhard 5573; Fax: +52 55 1065; E-mail: [email protected] PH. Sexual behavior in the human female. Philadel- Conflict of Interest: None declared. phia and London: Saunders and Co.; 1953. 9 Bailey JM, Pillard RC. Genetics of human sexual orientation. Annu Rev Sex Res 1995;6:126–50. Statement of Authorship 10 Bailey JM, Pillard RC, Neale C, Agyei Y. Heritable Category 1 factors influence sexual orientation in women. Arch Gen Psychiatry 1993;50:217–23. (a) Conception and Design 11 Hamer DH, Hu S, Magnuson VL, Hu N, Pattatucci Eusebio Rubio-Aurioles; Kevan Wylie AML. A linkage between DNA markers on the X (b) Acquisition of Data chromosome and male sexual orientation. Science Eusebio Rubio-Aurioles; Kevan Wylie 1993;261:320–6. (c) Analysis and Interpretation of Data 12 Hu S, Pattatucci AM, Patterson C, Li L, Fulker Eusebio Rubio-Aurioles; Kevan Wylie DW, Cherny SS, Kruglyak L, Hamer DH. Linkage between sexual orientation and chromosome Xq28 Category 2 in males but not in females. Nat Genet 1995;11: (a) Drafting the Article 248–56. Eusebio Rubio-Aurioles; Kevan Wylie 13 Brocklandt S, Hamer DH. Beyond hormones: A (b) Revising It for Intellectual Content novel hypothesis for the biological basis of male Eusebio Rubio-Aurioles; Kevan Wylie sexual orientation. J Endocrinol Invest 2003;26(3 suppl):8–12. Category 3 14 Otis MS, Skinner WF. An exploratory study of dif- (a) Final Approval of the Completed Article ferences in views of factors affecting sexual orienta- Eusebio Rubio-Aurioles; Kevan Wylie tion for a sample of lesbians and gay men. Psychol Rep 2004;94(3 pt 2):1173–9. 15 Mustanski BS, Dupree MG, Nievergelt CM, Bock- References landt S, Schork NJ, Hamer DH. A genomewide 1 Pan American Health Organization-World Health scan of male sexual orientation. Hum Genet 2005; Organization. Promotion sexual health of recom- 116:272–8. mendations for action. Proceedings of a regional 16 Bocklandt S, Horvath S, Vilain E, Hamer DH. consultation convened by Pan American Health Extreme skewing of X chromosome inactivation in

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