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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

Special Article
         Richard C. Friedman, M.D., and Jennifer I. Downey, M.D.


Information Provider: Victoria Edwards 
From: bo415@FreeNet.Carleton.CA (Rob Nisbet)
There are many discussions on homosexuality.  I found this paper 
particularly useful to glean more of the facts and less of the 
presumptions.  My apologies for not quoting the 136 references  listed 
in this article.  Reprints may be obtained by writing Dr. Friedman at 
225 Central Park West, Apt. 103, New York, NY 10024.  
This article is 10 pages in all.

This article is taken from the New England Journal of Medicine, October, 

1994 Vol. 331 No.14

  The deletion of homosexuality from the Diagnostic and Statistical Manual
of the American Psychiatric Association in 1980 marked a dramatic reversal 
of the judgment that homosexuality is a behavioral disorder.  In the 
practice of medicine, especially psychiatry, it is important to distinguish 
between that which is abnormal and that which is not.  Reviewing the present
state of knowledge about homosexuality is of interest not only for medical 
and historical reasons, but also because of the central role of this sexual 
orientation in the adaptive psychological functioning of countless people.
  The studies reviewed here are largely studies of white, middle-class 
people.  Space does not allow for a discussion of cultural and ethnic 
diversity with regard to sexual orientation.


  The term homosexual entered common usage in 1869.  The word gay, used to 
signify "homosexual", took on that meaning over the past 25 years in the 
context of the gay-rights movement.  In common parlance, gay refers to males
and sometimes to females, whereas lesbian is reserved exclusively for 
females.  Sexual fantasy, in contrast to sexual activity, refers to private 
psychological imagery associated with feelings that are explicitly erotic 
or lustful and with physiologic responses of sexual arousal.  The term 
sexual orientation refers to a person's potential to respond to persons of 
the same sex, the opposite sex, or both.  Ego identity refers to the sense 
of connection between a person and a particular social group whose values 
that person shares.  Identity is formed during adolescence and early 
adulthood from experiences earlier in development.  The sense of being gay 
or lesbian is a facet of ego identity.  It may be entirely private, or it 
may be communicated to others, in which case it becomes part of one's 
social role.      
                          Sexual Behavior

  About half a century ago, Kinsey et al. collected sexual histories from 
thousands of Americans who, though diverse, were not a representative sample
of the general population.  Kinsey reported that 8 percent of men and 4 
percent of women were exclusively homosexual for a period of at least three 
years during adulthood.  Four percent of men and 2 percent of women were 
exclusively homosexual after adolescence.  Thirty-seven percent of men and 
20 percent of women reported at least one homosexual experience that 
resulted in orgasm.
  Subsequent studies of subjects more representative of the general 
population have yielded lower estimates of homosexual behavior.  Fay et al. 
compared data obtained from national surveys of male sexual behavior carried
out in 1970 and 1988 with the data originally collected by Kinsey.  In 1970,
according to Fay et al., 20 percent of men had at least one homosexual 
experience resulting in orgasm but only 7 percent had such experiences after
the age of 19.  Only 3 percent of the adult male population studied had 
homosexual contacts either occasionally or more often.  In both the 1970 and
1988 studies, the proportion of men with homosexual contact during the 
preceding year was approximately 2 percent.  In a recent review of studies 
conducted in the United States on sexual behavior, Seidman and Rieder 
estimated that 2 percent of men are currently exclusively homosexual and 
that an additional 3 percent are bisexual.
  Data on the current prevalence of homosexual behavior among women are 
scant.  In a review of the literature on male and female homosexuality and 
bisexuality throughout the world, however, Diamond concluded that 
approximately 6 percent of men and 3 percent of women have engaged in 
same-sex behavior since adolescence.
  Homosexuality may be underreported because of social prejudice.  Also, 
many homosexually arousable women may be included in the population reported
as heterosexual, since women may engage in sexual intercourse without sexual
arousal.  Studies that assess the frequency of intercourse but not sexual 
fantasy may therefore be misleading in this regard.
  By the age of 18 or 19 years, three quarters of American youth, regardless
of their sexual orientation, have had sexual relations with another person.
Gay males are more likely than heterosexual males to become sexually active 
at a younger age (12.7 vs. 15.7 years) and to have had multiple sexual 
partners.  The ages at the time of the first sexual experience with another 
person are closer for lesbians and heterosexual females (15.4 vs. 16.2 
  Of heterosexually active adults in the general population, about 20 
percent of men have had 1 sexual partner during their lives, 55 percent have
had up to 20 partners, and about 25 percent have had 20 or more partners.  
Some older studies conducted before the epidemic of the acquired 
immunodeficiency syndrome (AIDS)  indicated that homosexual men were more 
likely than heterosexual men to have had a very large number of sexual 
partners.  More recent population-based studies have found this to be 
relatively uncommon.  For instance, Fay et al. found that of men, who had 
homosexual contact after the age of twenty, almost all had 20 or fewer 
homosexual partners in their lifetimes.  Of 1450 men in the sample, only 
2 were reported to have had 100 or more same-sex partners.
  The inconsistency in the data on the number of sexual partners of 
homosexual men probably reflects flaws in the sampling techniques of the 
earlier studies (e.g., recruiting subjects in gay bars) and their completion
before the human immunodeficiency virus (HIV) epidemic.  The overlap between
gay and heterosexual men with respect to the number of partners is 
considerable, although a small subgroup of gay men have had sex with a great
many more partners than almost any heterosexual men.  Women have been 
studied less than men, but the existing data show that lesbians resemble 
heterosexual women more than gay men in their sexual behavior.  For 
instance, women of any sexual orientation are more likely to view sexual 
desire as a function of emotional intimacy and to value romantic love and 
monogamy.  Almost all married women are sexually active only with their 
husbands, and unmarried women are very unlikely to have more than one 
partner in a given three-month period.  Blumstein and Schwartz reported that
women in lesbian couples had fewer partners than women in heterosexual 
couples.  Lesbian couples generally have less sexual activity than their 
heterosexual counterparts but report higher levels of intimacy and as much 
or more satisfaction with the sexual relationship.
  A substantial minority of adults in the United states abstain from sex, 
regardless of sexual orientation.  In one study, 13 percent of homosexual 
and bisexual men reported having no sexual partner in the previous year, and
in another 43 percent of lesbians had been abstinent for a year or more.  
Among unmarried heterosexual adults, women are also more likely to be 
abstinent than men.
  Diverse sexual practices occur in different groups regardless of sexual 
orientation, although with variable frequency.  Thus, recent studies suggest
that the majority (over 75 percent) of heterosexual and homosexual adults in
the United States engage in oral-genital sex.  Homosexual couples may do so 
more frequently, however.  Kanouse et al. reported that about 55 percent of 
homosexual men and 26 percent of heterosexual men and women had engaged in 
oral sex in the month before the survey.
  Although anal sex is practiced by 10 percent of heterosexual couples at 
least occasionally, male homosexual couples engage in it more frequently.  
A recent study in Los Angeles reported episodes of anal sex in the four 
weeks before the survey to be six times more frequent among homosexual men
than among heterosexual men studied at the same time.
  The high risk of contracting HIV among homosexual men is usually 
attributed to contact with semen during unprotected receptive anal 
intercourse or other practices associated with the exchange of bodily fluids.  
Efforts to educate gay men in safe-sex practices to prevent HIV infection 
have been only partially effective in changing behavior.  Those who continue
to engage in unprotected anal intercourse with multiple partners tend to be 
younger, to belong to minority groups, to engage in sexual acts more 
frequently, to use drugs or alcohol in connection with sex, to have 
psychiatric disorders, and if previously tested for HIV, to be seronegative.
Such men may have adequate cognitive information about HIV transmission but 
may entertain a false notion that they personally are "safe" when they 
engage in high-risk sexual behavior.  Lapses in safe-sex precautions in men 
who ordinarily do practice safe sex are also common - in 45 percent over the
previous six months in one study.
  A small number of lesbians have been reported to be HIV-positive, almost 
always as a result of exposure to risk factors other than contact with a 
partner of the same sex.  However, since vaginal secretions and menstrual 
blood are known to be implicated in female-to-male transmission of the 
virus, lesbians in relationships with seropositive women or who have 
multiple partners, including men or women of unknown HIV status, are 
routinely advised to use safe-sex practices.  Nonetheless, no medically 
tested strategy for women to avoid contact with bodily fluids of same-sex 
partners has been developed that adequately addresses the particular issues
presented by female anatomy and physiology.
  Homosexual males have an increased risk of a variety of sexually 
transmitted diseases other than HIV infection.  These include gonorrhea, 
syphilis, and human papillomavirus infection, as well as hepatitis B.  
Perianal carcinomas also occur more frequently in this group.  Lesbians do
not have a higher risk of any sexually transmitted diseases than 
heterosexual women.


  The term homophobia was coined in 1967 to signify a negative attitude 
toward homosexual people.  In the United states, two particularly prominent
influences fostering antihomosexual attitudes have been religious 
fundamentalism and heterosexism, the belief in the moral superiority of 
institutions and practices associated with heterosexuality.
  A widespread tendency to view homosexuality as a stigma and to depict 
homosexual people in terms of negative stereotypes has only recently begun
to lessen.  A majority of respondents in a national poll in 1987 indicated 
that they would prefer not to work around homosexual people.  Studies of 
homophobic people indicate that they are likely to be authoritarian, 
conservative, and religious; to have resided in areas where negative 
attitudes toward homosexuals are viewed as normal; and not to have had 
personal contact with gay or lesbian people.  Most gays and lesbians have 
been harassed or threatened because of their sexual orientation, and a 
sizable minority have been assaulted.  Many negative beliefs about 
homosexual people are similar to those associated with other prejudices, 
such as racism.
  In some respects, however, irrationally negative attitudes toward 
homosexual people are different from other forms of prejudice.  For example,
a young gay or lesbian person may grow up passing as heterosexual in an 
environment in which his or her friends are all heterosexual and homophobic.
A recent national survey of gay men and lesbians revealed that the average 
time between a person's recognition of his or her own sexual orientation and
its disclosure to someone else was more than four years.  Many gay and 
lesbian people never reveal their sexual orientation, even to family members.
  Antihomosexual attitudes are prominent in many sectors of the American 
medical community, and numerous physicians find it necessary to hide their 
sexual orientation from colleagues and patients.  There are no accurate data
on the frequency of such "closeting", but it is undoubtedly common.  
Homophobic attitudes have been reported among physicians, medical students, 
nurses, social workers, and mental health practitioners.
  It is likely that many students enter professional schools with 
antihomosexual attitudes that go unchallenged during their education.  A 
recent survey of medical schools, for example, found that on average only
3.5 hours were devoted to the topic of homosexuality during the four year 
curriculum.  This is notable, since there is evidence that experience with 
gay and lesbian faculty members and participation in educational activities 
such as small-group discussions may influence students to develop more 
favorable attitudes toward homosexual people.


  By December 1993, the number of cases of AIDS diagnosed in adolescents and
adults in the United States totaled 355,936.  Among the 311,578 men with 
AIDS, 62 percent had as their primary risk factor sex with other men, 
whereas only 2 percent contracted AIDS from heterosexual activity.  Women 
accounted for a much smaller number of AIDS cases (44,357). When AIDS in 
women was related to sexual activity, it was most often associated with 
heterosexual contact with an HIV-positive man (35 percent of cases).
  Like the deadliest epidemics and wars, the AIDS crisis affects all members
of society, not just those immediately at risk.  Although it is not confined
to homosexual men, the epidemic has increased their degree of stigmatization.
Lesbians are at no increased risk of AIDS, but they are also stigmatized, 
because the public often wrongly assumes that all homosexual people are at 
high risk.  Gay patients with AIDS are exposed to antihomosexual bias from 
employers, social service agencies, insurance carriers, and health care 
providers.  Because of bias and fear of contagion, some persons and 
organizations may be reluctant to provide entitlements or carry out 
indicated medical procedures.
  Undergoing a serologic test for HIV is often deeply frightening.  Despite 
this, rates of psychiatric symptoms and syndromes have not been shown to be 
generally increased among HIV-positive patients as compared with those who 
are HIV-negative.  Vulnerable subgroups, however, may have psychiatric 
symptoms and disorders, triggered by HIV testing or other vicissitudes of 
HIV infection.  HIV itself and the opportunistic infections and cancers 
associated with it may directly cause a variety of neurologic syndromes 
(e.g., AIDS encephalopathy) that affect cognition, motivation, social 
judgment, and mood.
  Homophobia and the tendency to stigmatize the chronically ill may lead to 
deleterious social isolation by influencing those in the patient's support 
system to shun him or her.  When internalized, these attitudes may motivate 
the HIV-positive person to avoid others.  That person must decide whom to 
tell and may again experience conflicts about coming out as a gay person.  
The nuclear family sometimes first learns that a person was HIV-positive or 
even that the person was gay when they are notified of his or her death.
  Seropositive gay patients are likely to live in a community of the 
bereaved.  In the AIDS epidemic, many people endure serial losses.  Those
who have lost lovers often try to establish intimate sexual relationships 
with others while they are still grieving.  The new partners may also be 
seropositive.  HIV-positive partners who become involved with each other 
when asymptomatic experience mutual apprehension about when one or both will
become ill.  An HIV-positive person who has an HIV-negative partner often 
fears that he or she will infect the partner, and this fear may be 
reciprocated.  The vitality of a sexual relationship can be compromised by 
the constant vigilance needed to engage in sexual practices that are 
reasonably safe.
  People who die of AIDS are often cared for by their lovers, and the strain
placed on intimate and sexual relationships is substantial.  Losing the 
sexual dimension of a partnership may be associated with shame at the loss 
of bodily functions, attractiveness, and sexual interest.  The partner who 
remains well must sometimes cope with choices regarding celibacy or 
infidelity in situations in which the sexual activity of the couple is 
curtailed.  There is no specific social niche for lovers, as there is for 
husbands and wives.  For example, there is no English word comparable to 
"widower", for one who has survived the loss of a same-sex lover.
  Many of these issues also pertain to bisexual men, particularly those who 
present themselves as heterosexual while they are secretly involved with 
other men.  A wife's first awareness that her husband has been homosexually 
active may come when she learns that he is HIV-positive or has AIDS.
  One study showed an increased frequency of completed suicide among 
homosexual men with AIDS.  Studies of suicidality in patients with AIDS and 
those tested for HIV have not found an increased incidence, however.  The 
population at risk for suicide seems to be composed of those whose history 
and psychiatric status had already increased their risk of suicide before 
the development of AIDS.  The complex topic of rational suicide is beyond 
the scope of this article.
Helpful medical and psychological interventions for seropositive people and 
their affected family members and friends include self-help groups, 
counseling and psychotherapy, and pharmacotherapy.  For many, coping with 
being HIV-positive includes maintaining involvement in life's activities, 
connectedness to others, and hope.

                          Psychopathologic Issues

  Independent studies with diverse designs have failed to find any increased
frequency of various forms of psychopathology among homosexual people as 
compared with heterosexual people.  If identifying data on projective tests 
are deleted, it is impossible to distinguish homosexual from heterosexual 
people.  This finding is compatible with clinical reports that emphasize 
similarities in psychodynamic motivations despite differences in sexual 
orientation.  Studies testing the hypothesis that homosexual people have 
phobic anxiety about heterosexuality have had negative results.  Research on
 specific disorders, such as sexual abuse of children, has not revealed an 
increased frequency of homosexual perpetrators.  These data, in conjunction 
with research on the family, have invalidated the once popular theory that 
castrating mothers and detached or hostile fathers are necessary and 
sufficient causes of male homosexuality.  The origins of sexual orientation 
appear to be multifactorial and diverse.

Internalized Homophobia

  Developmental issues pertaining to sexual orientation are somewhat 
different in the two sexes.  Usually boys follow and orderly sequence in 
which sexual feelings occur during childhood, followed by masturbation with
sexual fantasies during early adolescence, sexual activity with others in 
mid-to-late adolescence, and a sense of identity as heterosexual, 
homosexual, or (in rare cases) bisexual during late adolescence or early 
adulthood.  Those who are on a development path toward predominant or 
exclusive homosexuality often feel homosexual attraction during childhood 
even though they may have never met a homosexual person and do not actually
know what homosexuality is.  The developmental pathways leading to a 
homosexual orientation are more varied in girls and women, although in one 
subgroup the pathway is similar to that described for boys and men.
  Gay adults often describe themselves as having felt "different" from other
children.  The factors leading to a sense of difference are diverse and 
include both homosexual feelings and cross-gender interests and traits.  In
boys these tend to be aesthetic and intellectual; in girls, they are 
athletic.  Beginning in childhood, many gay and lesbian people have feelings
of shame at being considered deviant, as well as feelings of self-hatred 
because they identify with those who devalue them.  Such feelings arise from
identification with the aggressor, a mental mechanism experienced by many 
victims of abuse.
  Many gay and lesbian people have had painful childhoods.  Perhaps for this
reason, lifetimes rates of major depression and abuse or dependence on 
alcohol and other drugs have reported to be increased among homosexual men,
although their current rates of psychiatric disorders are not.  The 
disparity between the current and the past incidence of psychopathology 
awaits explanation.  One hypothesis is that homosexual men ultimately 
develop effective ways of coping with stressors.

Suicide and Gay Youth

  Three psychological postmortem studies conducted in different areas of the
United States have not demonstrated an increased frequency of people 
identified as homosexual among those who committed suicide.  On the other 
hand, some studies of youths who have attempted suicide have revealed a 
disproportionately high number of homosexual persons.  In a study of 137 
homosexual youths, Remafedi et al. found that 41 had attempted suicide.  
More than half the attempts were of moderate-to-severe lethality and 
involved inaccessibility to the rescue - variables associated with completed
suicide.  The literature suggests that conflicts about the disclosure of 
sexual orientation (coming out) may influence young people to attempt 
suicide if they are otherwise predisposed.  Many of those who attempt 
suicide have not yet disclosed their sexual orientation to anyone.  Some 
people who have committed suicide and have not been identified as homosexual
may have taken their lives because of conflict about a homosexual 
orientation that had been hidden from others.
  Suicide attempts in all young people, regardless of sexual orientation, 
are associated with a common set of predisposing influences.  Among 
vulnerable gay and lesbian young people, the physician should be 
particularly sensitive to self-hatred arising in response to homosexual 
feelings, conflicts about coming out, and homophobia among those in the 
patient's social support system.  A dysfunctional family often scapegoats a
young person who is identified as unacceptable and attempts to recruit 
medical authorities to make that person conform to the family's norms.

Alcoholism and Substance Abuse

  An increased frequency of alcoholism among lesbians as compared with 
heterosexual women has been reported in some studies.  Some researchers 
have reported a trend toward an increase in alcoholism or problem drinking 
among homosexual men.  The use of illicit drugs, at least occasionally, has
also been reported to be more frequent among homosexual women than among 
heterosexual women, and a similar trend has been observed among men.  
Because such data are sparse and the studies have been confounded by the 
inclusion of subjects recruited in gay bars, it is impossible at this time 
to reach definitive conclusions about the frequencies of alcoholism and 
substance abuse in relation to sexual orientation.

                 Normal Development in Homosexuals

  By the time of adolescence, some people's erotic feelings and attractions 
are predominantly or exclusively homosexual.  The American Academy of 
Pediatrics has developed guidelines for physicians treating such patients.  
Ideally, complex developmental processes culminate in positive gay or 
lesbian identity and self-acceptance.  Although gay and lesbian groups are 
diverse and no single developmental line can summarize developmental issues,
pathways leading to durable, loving sexual partnerships are common among 
lesbians and gay men.
  Confusion about sexual orientation is common during adolescence, however,
and most adolescents who participate in homosexual activity or have 
homosexual feelings do not become gay or lesbian adults.  Careful history 
taking often makes it impossible to identify patients with predominant or 
exclusive homosexual responsivity and to support those who need assistance 
in establishing a gay identity.  These patients must be distinguished from 
the many others who are confused by concurrent homosexual and heterosexual 
feelings.  Here, the physician can often assist the patient in  avoiding the
premature foreclosure of homosexual or heterosexual identity until further 
development has occurred.
  A sizable minority of lesbians and gay men are married, or once were, and 
many are parents.  Conservative estimates exceed 1 million each for lesbian 
mothers and gay fathers.  At least 6 million children have gay or lesbian 
parents.  The literature on children of lesbian mothers indicates no adverse
effects of a homosexual orientation, as evidenced by psychiatric symptoms, 
peer relationships, and overall functioning of the offspring.  The frequency
of a homosexual orientation has not been greater in such children than in 
children of heterosexual mothers.  The data on children of gay fathers are 
more scant.  No evidence has emerged, however, to indicate an adverse effect
of sexual orientation on the quality of fathering.  Enough information has 
accumulated to warrant the recommendation that sexual orientation should not
in itself be the basis for psychiatric and legal decisions about parenting 
or planned parenting.
  Ever-increasing numbers of homosexual persons and couples are requesting 
medical assistance in achieving parenthood through new reproductive 
techniques, including the Alternative Treatments of gametes (both egg and sperm) and the 
use of gestational surrogates.  The data reviewed above support the judgment
that medical decisions about the use of such techniques should not be based 
on sexual orientation alone.

                 Change in Sexual Orientation

  Most people who seek to alter their sexual orientation consider themselves 
homosexual and wish to become heterosexual.  Studies of changes in sexual 
orientation have varied in quality, and there are no adequate long term 
outcome data.  Many men who view themselves as homosexual have actually been
attracted to women at some time during their lives.  In this group, the 
homosexual-heterosexual mental balance may sometimes shift during therapy.  
The meaning attributed to sexual fantasies in determining the sense of 
identity may also change, so that the person may come to believe that his or
her sexual orientation has changed.  Homosexual fantasies often persist, 
however, or recur.  Among homosexual men who have never experienced sexual 
attraction to women, there is little evidence that permanent replacement of 
homosexual fantasies by heterosexual ones is possible.
  The data on women, though extremely sparse, suggest that there is more 
variation with respect to the plasticity of sexual fantasies than with men.
Many women seem to be able to experience bisexual fantasies or to 
participate in bisexual activity without necessarily constructing an 
identity or a social role as bisexual or lesbian.  A subgroup has been 
described, however, whose pattern of psychosexual development is similar to
that of many men.  In these women, exclusive homosexual fantasies have been 
present since childhood, and their total replacement by heterosexual 
fantasies is unlikely.
  Patients who seek a change in their sexual orientation are diverse with 
respect to sexual attitudes, values, and psychopathological features.  Some 
are motivated by homophobia, and the wish to change subsides as this is 
addressed.  Others reject their homosexual orientation for other reasons, 
often religious.  Sometimes the incompatibility between sexual desires and 
personal values cannot be resolved by therapeutic interventions.  Those who 
deliver health care have a continuing role in helping such people preserve 
self-esteem and avoid anxiety and depression as much as possible.

                          Psychobiologic Aspects

  In a recent study using DNA linkage analysis, Hamer et al. concluded that 
a gene that influences homosexual orientation in males is contained on the 
X chromosome.  Thirty-three of 40 homosexual pairs of siblings were found to
be concordant for five markers in the distal region of the X chromosome, 
and the remaining 7 were discordant at one or more of these loci.  Since 
certain types of families in which homosexuality was aggregated were 
selectively studied, no inference about the frequency of X-linked males 
homosexuality in the general population was possible.
  Bailey et al. reported increased concordance for homosexuality among male 
and female monozygotic twins, as compared with dizygotic twins.  Their data 
were consistent with results from a number of other studies of sexual 
orientation in twins and of familial aggregation of homosexuality.  One 
recent study found no difference in rates of concordance for homosexuality 
between monozygotic and dizygotic male and female twins, but the zygosity 
and sexual orientation of the co-twin were determined from the index 
subject's self-report.  A genetic influence on homosexual orientation is 
also suggested by a few cases of identical twins concordant for 
homosexuality who were separated early in life and reared apart.

Sex Hormones and Psychosexual Development

  Neither plasma hormone values nor other endocrine tests reliably 
distinguish groups with regard to sexual orientation.  Studies of mammalian 
sexual behavior led to the hypothesis that a prenatal androgen deficit 
results in male homosexuality and that prenatal androgen excess results in 
female homosexuality.
  Another reason for hypothesizing that prenatal sex-steroid hormones may 
influence sexual orientation derives from behavioral antecedents of 
homosexuality.  During the childhood of gay men, aversion to play that 
involves fighting and rough-and-tumble team sports is common.  The opposite 
pattern - vigorous tomboyishness - is common among girls who later become 
lesbians.  In humans and many other mammals, prenatal sex-steroid hormones 
influence prepubertal nonsexual behavior, including rough-and-tumble play.  
This raises the question whether a childhood predilection for or aversion to
rough-and-tumble activities could be related to differences in prenatal 
androgen secretion.
  Homosexual men and women report more "cross-gender" behavior (often 
considered to be nonconformity with sex roles) during childhood than 
heterosexual men and women.  Most boys with psychiatric disorders of gender 
identity who have been followed become homosexual as adolescents or adults, 
although most homosexual adults have not had this syndrome as children.  No 
follow-up studies of females have been carried out.  However, childhood 
gender-identity disorder has not been demonstrated to be influenced directly
by biologic factors.

Further Implication of Intersex Studies

  Important general principles of psychosexual development have been derived
from studies of patients with unusual intersex disorders.  Although each 
syndrome is of interest, studies of females with congenital adrenal 
hyperplasia treated early in life illustrate a point of general relevance.  
Whereas the evidence for an effect on prenatal androgens on childhood 
sex-role behavior is robust in these patients and in others exposed to 
masculinizing hormones during gestation, the evidence for an effect on 
later-occuring sexual orientation is modest.  Although homosexual 
responsivity develops in more of these patients than in controls, most 
report exclusively heterosexual behavior as adults.

Brain Differences Associated with Sexual Orientation

  Unreplicated reports have been published of the increased size of the 
superchiasmic nucleus of the hypothalmus, decreased size of the third 
anterior interstitial nucleus, and increased size of the anterior commissure
in homosexual men.  Studies of left- and right-sided dominance and of 
cognitive functioing have not been conclusive.  Finally, a number of studies
indicate that homosexual men tend to be born later in groups of siblings 
than do heterosexual men.  Neither the reason for this nor its importance is
yet apparent.
  Preliminary evidence suggests that to some extent sexual orientation is 
influenced by biologic factors, although the intermediate mechanisms remain 
to be described.  Since sex differences in behavior appear to be influenced 
by prenatal sex hormones, the hypothesis that complex changes in prenatal 
androgen secretion influence sexual orientation remains viable, although 
  Some prenatal hormonal events may be under genetic influence , whereas 
others may occur as a result of environmental factors.  An example is 
prenatal stress, which inhibits the secretion of testosterone, influences 
the sexual behavior of rats, and may influence the sexual orientation in 
humans (although it has not been proved to do so).  In some people neither 
genetic nor prenatal hormonal influences may determine the sexual 
orientation.  Diverse lines of psychosexual development could lead to the 
same behavioral end point with regard to sexual orientation.


Although there has been rapid growth recently in our knowledge about sexual 
orientation, fundamental questions remain.  Enough data have accumulated to 
warrant the dismissal of incorrect ideas once widely accepted about 
homosexual people.  Many areas of law and public policy are still influenced
by views disregarded by behavioral scientists.  Thus, homosexual acts are 
still considered criminal in many states.  Decisions about custody, 
visitation, and adoption are frequently made on the basis of sexual 
orientation.  Homosexual partners are not afforded the same protection as 
marital couples.  In addition, homosexual people receive unequal treatment 
in the military.  There are no data from scientific studies to justify the 
unequal treatment of homosexual people or their exclusion from any group.