Few topics are as complex and controversial as human sexual orientation and gender identity. These matters touch upon our most intimate thoughts and feelings, and help to define us as both individuals and social beings. Discussions of the ethical questions raised by sexual orientation and gender identity can become heated and personal, and the associated policy issues sometimes provoke intense controversies. The disputants, journalists, and lawmakers in these debates often invoke the authority of science, and in our news and social media and our broader popular culture we hear claims about what “science says” on these matters.
This report offers a careful summary and an up-to-date explanation of many of the most rigorous findings produced by the biological, psychological, and social sciences related to sexual orientation and gender identity. We examine a vast body of scientific literature from several disciplines. We try to acknowledge the limitations of the research and to avoid premature conclusions that would result in over-interpretation of scientific findings. Since the relevant literature is rife with inconsistent and ambiguous definitions, we not only examine the empirical evidence but also delve into underlying conceptual problems. This report does not, however, discuss matters of morality or policy; our focus is on the scientific evidence — what it shows and what it does not show.
We begin in Part One by critically examining whether concepts such as heterosexuality, homosexuality, and bisexuality represent distinct, fixed, and biologically determined properties of human beings. As part of this discussion, we look at the popular “born that way” hypothesis, which posits that human sexual orientation is biologically innate; we examine the evidence for this claim across several subspecialties of the biological sciences. We explore the developmental origins of sexual attractions, the degree to which such attractions may change over time, and the complexities inherent in the incorporation of these attractions into one’s sexual identity. Drawing on evidence from twin studies and other types of research, we explore genetic, environmental, and hormonal factors. We also explore some of the scientific evidence relating brain science to sexual orientation.
In Part Two we examine research on health outcomes as they relate to sexual orientation and gender identity. There is a consistently observed higher risk of poor physical and mental health outcomes for lesbian, gay, bisexual, and transgender subpopulations compared to the general population. These outcomes include depression, anxiety, substance abuse, and most alarmingly, suicide. For example, among the transgender subpopulation in the United States, the rate of attempted suicide is estimated to be as high as 41%, ten times higher than in the general population. As physicians, academics, and scientists, we believe all of the subsequent discussions in this report must be cast in the light of this public health issue.
We also examine some ideas proposed to explain these differential health outcomes, including the “social stress model.” This hypothesis — which holds that stressors like stigma and prejudice account for much of the additional suffering observed in these subpopulations — does not seem to offer a complete explanation for the disparities in the outcomes.
Much as Part One investigates the conjecture that sexual orientation is fixed with a causal biological basis, a portion of Part Three examines similar issues with respect to gender identity. Biological sex (the binary categories of male and female) is a fixed aspect of human nature, even though some individuals affected by disorders of sex development may exhibit ambiguous sex characteristics. By contrast, gender identity is a social and psychological concept that is not well defined, and there is little scientific evidence that it is an innate, fixed biological property.
Part Three also examines sex-reassignment procedures and the evidence for their effectiveness at alleviating the poor mental health outcomes experienced by many people who identify as transgender. Compared to the general population, postoperative transgender individuals continue to be at high risk of poor mental health outcomes.
An area of particular concern involves medical interventions for gender-nonconforming youth. They are increasingly receiving therapies that affirm their felt genders, and even hormone treatments or surgical modifications at young ages. But the majority of children who identify as a gender that does not conform to their biological sex will no longer do so by the time they reach adulthood. We are disturbed and alarmed by the severity and irreversibility of some interventions being publicly discussed and employed for children.
Sexual orientation and gender identity resist explanation by simple theories. There is a large gap between the certainty with which beliefs are held about these matters and what a sober assessment of the science reveals. In the face of this complexity and uncertainty, we need to be humble about what we know and do not know. We readily acknowledge that this report is neither an exhaustive analysis of the subjects it addresses nor the last word on them. Science is by no means the only avenue for understanding these astoundingly complex, multifaceted topics; there are other sources of wisdom and knowledge — including art, religion, philosophy, and lived human experience. And much of our scientific knowledge in this area remains unsettled. However, we offer this overview of the scientific literature in the hope that it can provide a shared framework for intelligent, enlightened discourse in political, professional, and scientific exchanges — and may add to our capacity as concerned citizens to alleviate suffering and promote human health and flourishing.