what is actually known from research:
Conclusions from the biological, psychological and social sciences

Dr. Paul McHugh, MD - Head of the Department of Psychiatry at Johns Hopkins University, an outstanding psychiatrist of recent decades, researcher, professor and teacher.
 Dr. Lawrence Meyer, MB, MS, Ph.D. - Scientist in the Department of Psychiatry at Johns Hopkins University, professor at Arizona State University, statistician, epidemiologist, expert in the development, analysis and interpretation of complex experimental and observational data in the field of health and medicine.

Summary

In 2016, two leading scientists from Johns Hopkins Research University published a paper summarizing all available biological, psychological and sociological research in the field of sexual orientation and gender identity. The authors, who strongly support equality and oppose discrimination against LGBT people, hope that the information provided will empower doctors, scientists and citizens - all of us - to address the health problems faced by LGBT populations in our society. 

Some key findings of the report:

PART I. SEXUAL ORIENTATION 

• Understanding of sexual orientation as an innate, biologically defined and fixed trait - the idea that people are “born that way” - does not find confirmation in science. 

• Despite the evidence that biological factors such as genes and hormones are associated with sexual behavior and desire, there is no convincing explanation of the biological causes of a person’s sexual orientation. Despite the insignificant differences in brain structures and activity between homosexual and heterosexual individuals identified as a result of research, such neurobiological data do not show whether these differences are innate or are the result of environmental and psychological factors. 

• Longitudinal studies of adolescents suggest that sexual orientation can be quite variable during the life of some people; as one study showed, about 80% of young men reporting same-sex drives did not repeat this when they became adults. 

• Compared to heterosexuals, heterosexuals are two to three times more likely to experience childhood sexual abuse.

PART II SEXUALITY, MENTAL HEALTH AND SOCIAL STRESS 

• Compared to the general population, non-heterosexual subpopulations are at increased risk of a variety of deleterious effects on general and mental health. 

• The risk of anxiety disorders in members of a non-heterosexual population is estimated to be approximately 1,5 times higher than in members of a heterosexual population; the risk of developing depression is about 2 times, the risk of substance abuse is 1,5 times and the risk of suicide is almost 2,5 times. 

• Members of a transgender population are also at higher risk for a variety of mental health problems than members of a non-transgender population. Particularly alarming data were obtained on the level of suicide attempts throughout the life of transgender people of all ages, which is 41% compared to less than 5% of the total US population. 

• According to available, albeit limited, evidence, social stressors, including discrimination and stigmatization, increase the risk of adverse mental health outcomes among non-heterosexual and transgender populations. Additional high-quality longitudinal research is needed to make the “model of social stress” a useful tool for understanding public health problems.

PART III GENDER IDENTITY 

• The hypothesis that gender identity is an innate, fixed trait of a person that does not depend on the biological sex (that a person can be “a man stuck in a woman’s body” or “a woman stuck in a man’s body”) has no scientific evidence. 

• According to recent estimates, about 0,6% of US adults identify with a gender that does not match their biological gender. 

• Comparative studies of brain structures of transgender and non-transgender people have shown weak correlations between brain structure and cross-gender identification. These correlations do not suggest that cross-gender identification is to some extent dependent on neurobiological factors. 

• Compared with the general population, adults who have undergone sex-correcting surgery still have an increased risk of mental health problems. As one study showed, compared with the control group, people who changed sex had a tendency to suicide attempt at about 5 times, and the likelihood of dying as a result of suicide was about 19 times. 

• Children are a special case in the topic of gender. Only a minority of children with cross-gender identity will adhere to it in adolescence and adulthood. 

• There is little scientific evidence of the therapeutic value of interventions that delay puberty or alter secondary sexual characteristics of adolescents, although some children may improve their psychological state, provided that they receive encouragement and support in their cross-gender identification. There is no evidence that transgender people with gender-atypical thoughts or behaviors should be encouraged.

Introduction

It is unlikely that there will be many topics comparable in complexity and inconsistency with questions about sexual orientation and gender identity of a person. These questions affect our most secret thoughts and feelings and help to define everyone as a person and as a member of society. The debate over ethical issues related to sexual orientation and gender identity is hot, and their participants tend to become personal, and the corresponding problems at the state level cause serious disagreement. Discussion participants, journalists, and lawmakers often cite authoritative scientific evidence, and in the news, social media, and wider media circles, we often hear statements that “science says” about this.

This paper presents a carefully compiled review of modern explanations of a large number of the most accurate results of scientific biological, psychological and social studies regarding sexual orientation and gender identity. We consider a large amount of scientific literature in various disciplines. We try to take into account the limitations of research and not draw premature conclusions that could lead to a hyperinterpretation of scientific data. Due to the abundance of conflicting and inaccurate definitions in the literature, we not only examine empirical data, but also examine the underlying conceptual problems. This report, however, does not address issues of morality and ethics; our focus is on scientific research and on what they show or not show.

In Part I, we begin with a critical analysis of concepts such as heterosexuality, homosexuality, and bisexuality, and consider how much they reflect individual, unchanging, and biologically related characteristics of a person. Along with other questions in this part, we turn to the widespread hypothesis “such are born”, according to which a person has an inherent sexual orientation; We analyze the confirmation of this hypothesis in various branches of biological sciences. We examine the origins of sex drive formation, the degree to which sex drive can change over time, and the difficulties associated with including sex drive in sexual identity. Based on the results of twin and other studies, we analyze genetic, environmental and hormonal factors. We also analyze some scientific findings linking brain science with sexual orientation.

Part II presents an analysis of the study of the dependence of health problems on sexual orientation and gender identity. Among lesbians, gays, bisexuals and transgender people, there is always a higher risk of weakened physical and mental health compared to the general population. Such health problems include depression, anxiety, substance abuse and, most dangerous, increase the risk of suicide. For example, in the United States, 41% of transgender populations attempted suicide, which is ten times higher than that of the general population. We - doctors, teachers and scientists - believe that all further discussions in this work should be conducted in the light of public health problems.

We also analyze some of the ideas put forward to explain these differences in health status, including a model of social stress. This hypothesis, according to which stressors such as stigma and prejudice are the causes of additional suffering characteristic of these subpopulations, does not fully explain the difference in risk levels.

If part I presents an analysis of the assumption that sexual orientation is invariably due to biological reasons, then one of the sections of part III discusses similar issues regarding gender identity. Biological gender (binary categories of male and female) is a stable aspect of human nature, even considering that some individuals suffering from sexual development disorders exhibit dual sexual characteristics. On the contrary, gender identity is a socio-psychological concept that does not have an exact definition, and only a small amount of scientific data indicates that this is an innate, unchanging biological quality.

Part III also analyzes gender correction and data on its effectiveness to alleviate the mental health problems that affect many individuals who are identified as transgender people. Compared to the general population, transgender people who have sexually altered by surgery have a high risk of weakening mental health.

Of particular concern is the issue of medical intervention for gender reassignment among young gender nonconformists. More and more patients undergo procedures that help them accept the gender that they feel, and even hormone therapy and surgery at an early age. However, most children whose gender identity does not match their biological gender will change this identity as they grow older. We are concerned and worried about the cruelty and irreversibility of certain interventions that are openly discussed in society and apply to children.

Sexual orientation and gender identity do not lend themselves to a simple theoretical explanation. There is a huge gap between the confidence with which ideas about these concepts are supported, and what opens up with a sober scientific approach. Faced with such complexity and uncertainty, we must more modestly assess what we know and what not. We readily acknowledge that this work is neither an exhaustive analysis of the issues it addresses, nor is it ultimate truth. In no way is science the only way to understand these incredibly complex and multifaceted problems - there are other sources of wisdom and knowledge, including art, religion, philosophy and life experience. In addition, many scientific knowledge in this area has not yet been streamlined. Despite everything, we hope that this review of the scientific literature will help build a common framework for a reasonable and enlightened discourse in the political, professional and scientific environment, and that with its help we, as conscious citizens, can do more to alleviate suffering and promote health and the prosperity of mankind.

PART I - Sexual orientation

Despite the widespread belief that sexual orientation is an innate, unchanging, and biological trait of a person, that everyone — heterosexuals, homosexuals, and bisexuals — are “born that way,” this statement is not supported by sufficient scientific evidence. In fact, the very concept of sexual orientation is extremely ambiguous; it can relate to behavioral characteristics, to feelings of attraction and to a sense of identity. As a result of epidemiological studies, a very insignificant relationship was found between genetic factors and sexual drives and behaviors, but no significant data were obtained that indicated specific genes. There are also confirmations of other hypotheses about the biological causes of homosexual behavior, attraction and identity, for example, about the effect of hormones on intrauterine development, however, these data are very limited. As a result of brain studies, some differences between homosexuals and heterosexuals were found, but it was not possible to prove that these differences are innate, and not formed under the influence of external environmental factors on psychological and neurobiological characteristics. A correlation was found between hetero-sexuality and one of the external factors, namely victimization as a result of childhood sexual abuse, the effect of which can also be seen in the higher prevalence of detrimental effects on mental health in non-heterosexual subpopulations compared to the general population. In general, the obtained data suggest a certain degree of variability in the models of sexual desire and behavior - as opposed to the opinion that “such are born”, which unnecessarily simplifies the complexity of the phenomenon of human sexuality. 

read PART I (PDF, 50 pages)

PART II - Sexuality, Mental Health and Social Stress

Compared to the general population, non-heterosexual and transgender groups have an increased rate of mental health problems such as anxiety disorder, depression and suicide, as well as behavioral and social problems, including substance abuse and violence against a sexual partner. The most common explanation of this phenomenon in the scientific literature is the model of social stress, according to which the social stressors to which members of these subpopulations are subjected - stigma and discrimination - are responsible for the disproportionate consequences for mental health. Studies show that, despite the clear influence of social stressors on increasing the risk of developing mental illness in these populations, they are most likely not fully responsible for such an imbalance.

read PART II  (PDF, 32 pages)

PART III - Gender Identity

The concept of biological sex is well defined on the basis of the binary roles of men and women in the process of reproduction. On the contrary, the concept of gender does not have a clear definition. It is mainly used to describe the behavior and psychological characteristics that are usually characteristic of a particular gender. Some individuals are identified in a gender that does not match their biological gender. The reasons for this identification are currently poorly understood. Works investigating whether transgender individuals have certain physical traits or experiences similar to the opposite sex, such as brain structure or atypical prenatal hormonal effects, are currently unconvincing. Gender dysphoria - a sense of mismatch between one's own biological sex and gender, accompanied by severe clinical disorder or disorders - is sometimes treated in adults with hormones or surgery, but there is little scientific evidence that these therapeutic interventions have a beneficial psychological effect. As science shows, the problems of gender identity in children usually do not continue in adolescence and adulthood, and little scientific evidence confirms the medical benefits of delaying puberty. We are concerned about the growing tendency for children with gender identity problems to switch to their chosen gender through therapeutic and then surgical procedures. There is a clear need for additional research in this area.

read PART III (PDF, 29 pages)

CONCLUSION

Accurate, reproducible research results can and do affect our personal decisions and self-awareness and at the same time stimulate social discourse, including cultural and political disputes. If the study addresses controversial topics, it is especially important to have a clear and concrete idea of ​​what exactly is discovered by science and what is not. On complex, complex issues regarding the nature of human sexuality, there is at best preliminary scientific consensus; much remains unknown, because sexuality is an extremely complex part of human life, which resists our attempts to identify all its aspects and study them with the utmost precision.

However, to questions that are easier to empirically research, for example, on the level of adverse mental health effects in identifiable subpopulations of sexual minorities, studies still offer some clear answers: these subpopulations show a higher level of depression, anxiety, substance use and suicide compared to with the general population. One hypothesis — the social stress model — argues that stigma, prejudice, and discrimination are the main causes of increased rates of mental health problems for these subpopulations, and are often cited as a way to explain this difference. For example, non-heterosexuals and transgender people are often subjected to social stresses and discrimination, however, science has not proved that these factors alone determine completely, or at least predominantly, differences in health status between subpopulations of non-heterosexuals and transgenders and the general population. Extensive research is needed in this area to test the hypothesis of social stress and other potential explanations for differences in health status, as well as to find ways to solve health problems in these subpopulations.

Some of the most widespread beliefs about sexual orientation, for example, the hypothesis “are born that way,” are simply not supported by science. In the works on this topic, a small number of biological differences between non-heterosexuals and heterosexuals are really described, but these biological differences are not enough to predict sexual orientation, which is the ultimate test of any scientific result. Of the explanations of sexual orientation proposed by science, the strongest statement is as follows: some biological factors to some extent predispose some people to non-heterosexual orientation.

The assumption that “these are born” is more difficult to apply to gender identity. In a certain sense, the fact that we are born with a certain gender is well confirmed by direct observation: the vast majority of males are identified as men, and most females as women. The fact that children (with rare exceptions of hermaphrodites) are born of a male or female biological sex is not discussed. Biological sexes play complementary roles in reproduction, and there are a number of physiological and psychological differences between the sexes on a population scale. However, while biological gender is an inherent trait of a person, gender identity is a much more complex concept.

When considering scientific publications, it turns out that almost nothing is completely understood if we try to explain from the point of view of biology the reasons that lead some to argue that their gender identity does not correspond to their biological gender. As regards the results obtained, claims are often made against them in compiling the sample, in addition, they do not take into account changes in time and do not have explanatory power. Better research is needed to determine how you can help reduce the level of mental health problems and increase the awareness of participants in the discussion of subtle matters in this area.

Nevertheless, despite scientific uncertainty, radical interventions are prescribed and performed for patients who identify themselves or are identified as transgenders. This is of particular concern in cases where children become such patients. In official reports, we find information about planned medical and surgical interventions for numerous children of prepubertal age, some of whom are only six years old, as well as other therapeutic solutions for children from two years old. We believe that no one has the right to determine the gender identity of a two-year-old child. We have doubts about how well scientists understand what a developed sense of their gender means for a child, but, regardless of this, we are deeply concerned that these treatments, therapeutic procedures and surgical operations are disproportionate to the severity of stress, which these young people experience, and, in any case, are premature, since most children who identify their gender as the opposite of their biological sex, becoming adults, refuse this identification. In addition, there are insufficient reliable studies of the long-term effects of such interventions. We urge caution in this matter.

In this report, we tried to present the set of studies in such a way that it was understandable to a wide audience, including experts and ordinary readers. All people - scientists and doctors, parents and teachers, legislators and activists - have the right to have access to accurate information on sexual orientation and gender identity. Despite the many contradictions in our society’s attitude towards members of the LGBT community, no political or cultural views should impede the study and understanding of relevant medical and public health issues and the provision of assistance to people suffering from mental health problems, presumably due to their sexual identity.

Our work suggests some directions for future research in the biological, psychological and social sciences. More research is needed to identify the causes of increased levels of mental health problems in LGBT subpopulations. The model of social stress, which is mainly used in research on this topic, needs to be improved, and, most likely, supplemented by other hypotheses. In addition, the characteristics of development and changes in sexual desires throughout life, for the most part, are poorly understood. Empirical research can help us better understand relationship, sexual health, and mental health issues.

Criticism and contestation of both parts of the paradigm are “born like this” - both statements about the biological certainty and fixation of sexual orientation, and the related statement about the independence of the fixed gender from the biological sex — allows us to raise important questions about sexuality, sexual behavior, gender, and individual and social benefits from a new perspective. Some of these issues are beyond the scope of this work, but those that we have considered suggest that there is a huge gap between most of the public discourse and what science has discovered.

Thoughtful research and a thorough, careful interpretation of the results can advance our understanding of sexual orientation and gender identity. There is still a lot of work and questions that have not yet received answers. We tried to generalize and describe a complex set of scientific studies on some of these topics. We hope that this report will help to continue an open discussion about human sexuality and identity. We expect this report to trigger a lively reaction, and we welcome it.

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