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Aspectos fundamentales e implicaciones practicas de la identidad sexual.

Essential aspects and practical implications of sexual identity

Sexual identity is a multidimensional construct, which has changed over time. Today, the definition of the concept from a medical perspective may vary according to interests from physical and mental health professionals: clinical or research. Sexual identity involves gender identity (comfort with primary and secondary sexual characteristics), erotic identity or sexual orientation (erotic attraction to a particular gender), gender identity (the expected behaviors in a cultural context according to biological sex at birth), or socio-sexual identity (self-identification with a particular social group) (1). However, the concept of sexual identity should not be confused on the activity or behavior and sexual practices. Sexual activity is defined as the behavioral expression of sexuality, and sexual practices as the patterns of sexual activity, which people or communities show consistently (2).

The different connotations of the concept of sexual identity have theoretical and practical implications in sexual and reproductive health from the perspective of public health. For example, the estimation of the prevalence of homosexuality or bisexuality in a population depends on the operative definition of the concept according to the activity, the erotic identity, or the socio-sexual identity (3) and, consequently, on the definition of a particularly vulnerable group to sexually transmitted infections, discrimination, or social exclusion.

This narrative review has two objectives: to clarify the concepts of sexual identity, gender identity, erotic identity, and socio-sexual identity, and to show some practical implications of the inappropriate use of these terms within the context of public health.

CONCEPTUAL ACCURACIES

Sexual identity, as a whole, is a very complex concept that encompasses four distinctly different and highly rated elements: sexual identity, gender identity, erotic identity or sexual orientation, and socio-sexual identity (1,4). However, the term is sometimes used to refer only to one of these components leading to confusion (1).

Sex identity. Refers to the level of acceptance or rejection an adult feels or expresses about the physical characteristics, which are specific to the biological sex at birth (2,4). These characteristics are defined by essentially biological elements. The presence or absence of the SRY gene (sex-determining region on the Y chromosome), which is normally found on chromosome Y is almost limited. The presence of this gene encodes a group of proteins which regulates the production of testosterone in the testicle of the forming embryo (5).

Generally, the presence of one functional X chromosome and one functional Y chromosome is phenotypically associated with a man or boy, and with two complete X chromosomes, with a woman or girl (6). Usually, people who report discomfort with biological, primary, and secondary features of own biological sex and want the phenotype of the opposite sex are known as transgender or transsexual (7).

Gender identity. Gender identity refers to the degree of acceptance or discomfort which an adult manifests in terms of behavioral and emotional characteristics expected for a person, according to biological sex, to show within the interaction with other people (8). The pattern of gender-type behavior varies widely from one social and cultural context to another (9). The typical behavior of gender is built within a social context. So, femininity is routinely expected from women and masculinity is desirable for men. This is a complex and purely social and cultural construction (7,10).

A concept closely related to gender identity is gender role. Gender role refers only to observable behaviors commonly considered feminine or masculine within a culture or society. This is the daily experience of masculinity or femininity (2,8).

Traditionally, people expect concordance between biological sex and gender (identity and role). However, some people want to take gender characteristics of the opposite sex and only wear clothing, incorporate gestures and attitudes without subjective discomfort of the characteristics of their own sex and without the presence of a strong desire for permanent change of primary and secondary sexual characteristics of biological sex. People who show this pattern are called transvestis (7).

Erotic identity or sexual orientation. Erotic identity describes the biological sex of the person who frequently arouses attraction, desires, dreams, or erotic or sexual fantasies of an individual (11). Thus, sexual orientation as a category allows only three options: heterosexual (someone who feels preferably attraction towards the opposite sex), bisexual (people who report attraction in similar proportions, towards both people of same and opposite sex) and homosexual (person who is usually attracted to people of the same biological sex) (7,11).

Erotic identity is the most intimate or private component of sexual identity. Erotic identity is not necessarily manifested in evident sexual, specific and consistent behaviors. Researchers suggest that mainly biological, genetic or hormonal factors during critical periods of development account for the sexual orientation in adults (12,13). However, the way each person expresses the intimate sexual orientation within a social and cultural context is more related to environmental elements, i.e. social, cultural, political, religious aspects and so on, in which people develop (7,8,14).

Socio-sexual identity. Socio-sexual identity points out the social group with which a person identifies best if sexual orientation is taken as the basis (15). Socio-sexual identity implies lifestyle, cultural, and social connotations. In many contexts, it also has implications of political activism and militancy in defense of civil rights of non-heterosexual people (16). It is often called <<gay>> non-heterosexual people, homosexual or bisexual women and men, who take on this lifestyle. And <<straight>> is called the usual and traditional style of heterosexual men and women. Of course, social factors affect the process of identification with a social group or class of people who show a particular behavior (17-19). This affiliation or sympathy for this particular social group tends to strengthen self-esteem, even in minority social groups in which some gay men, lesbians, bisexuals, travesties, and transsexuals (GLBTT) may feel members (20).

Divergences. The construction of the sexual identity is a continuous process which covers all the vital cycle (9). According to the different approaches, the adult population between 1% and 10% self-recognizes as non-heterosexual, bisexual, or homosexual (21). Men represent the main percentage of this group (11). Likewise, an important percentage of adolescents and adults inform sexual activity or discordant sexual behavior with the erotic identity they report (18).

Commonly, adults are expected concordance or traditional congruence between biological sex, identity and gender role, and erotic identity. So, it is usual to find a man performing <<male>> behavior for the social and cultural context with which he is familiar and generating sexual desire exclusively for women, and, on the other hand, a woman performing a <<female>> behavior for the normal social environment and generating sexual desire only for men (7,8).

Undoubtedly, everyday life shows that there may be an important dissociation between the subjective identity and the objective observable behavior among people in different cultures around the world (22). For example, in the Western world today it is very common that adult men who have sex with men do not wish to change sex, do not show a gender discordant behavior (typically female), and report erotic identity as heterosexual (1,3). Given this situation, researchers introduced the concept of men who have sex with men (and women who have sex with women) in order to reduce the stigma against non-heterosexual people. It includes bisexual, gay and transgender men and people who self-identify as heterosexual and maintain sexual activity with men only to describe the behavior without including the social or cultural identity (23). It is also possible to listen to a man self-considering being homosexual. However, he is not self-defined as gay in the sense of being a part or member of the social group GLBTT, because he does not share some behaviors or does not live in a particular sector of a city which is labeled <<gay>> (1,23).

It is necessary to keep in mind that most variations as a whole included in the context of sexual identity and the dimensions it covers, are not technically considered illness or mental disorders today. Nevertheless, it is necessary to remember that there are still some codes in both the International Classification of Diseases (ICD-10) (24) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as potential clinical diagnostics (25).

The ICD-10 in the category of sexual identity disorder (F64) retains the diagnosis of transexualism (F64.0), non-fetishistic transvestism (F64.1), and sexual identity disorder in childhood (F64.2). It classifies sexual maturation disorder (F66.0) and ego-dystonic sexual orientation (F66.1) into the category of psychological disorders and behavioral development and sexual orientation (F66) (24). On the other hand, the DSM-IV-TR contains the category of gender identity disorders (302), and it must specify the gender identity disorder in children (302.6) and Gender Identity Disorder in adolescents or adults (302.85) (25).

Nevertheless, the fifth version of the Diagnostic and Statistical Manual of the American Psychiatric Association exclude the diagnosis of gender identity disorder in childhood (302.6) and, therefore, sexual identity disorder in adolescents or adults (302.85). The categorization as a mental disorder of gender discordant behaviors in children led to all kinds of treatment for these behaviors. None of these treatments significantly changed their normal behavior. In other words, they were completely unsuccessful (26).

It is important to note that most of the children who met criteria for gender identity disorder in childhood presented in adulthood homosexual or bisexual sexual orientation, or what is still called gender identity disorder of adults (302.85) according to DSM-IV-TR, or its equivalent in transexualism (F64.0), non-fetishistic transvestism (F64.1) according to ICD-10 (27-30).

PRACTICAL IMPLICATIONS

The confusion between the different components of sexual identity has important connotations, more in sexual health than in reproductive health, beyond the psychological implications in each person. For instance, it is accepted that homosexuality has existed since the appearance of first humans on the planet. Although the social connotations were and are different according to contexts, from the absolute refusal with the inclusion of the death penalty, to the recognition, in some countries, of similar civil rights to heterosexual persons (16,31-35).

The epidemiological and clinical research which explore the prevalence of homosexuality reported disparate frequencies, because of the way sexual orientation is asked (1,3). Table 1 shows how the different studies explored the behavior and sexual orientation in participants (1). Some of these questions focus more on the behavior presented than on desires or more suggestive erotic motivations of erotic identity (1). It is certainly possible that a person feels repeatedly and consistently erotic desire for same sex persons without having a sexual behavior which turns these desires into reality before, at the time, or in the future (1,11). Similarly, a significant group of men and women inform sexual relations with people of the same sex without considering themselves homosexuals, lesbians, or gays (11,23,36,37). A significant number of studies in different countries reports that men who have sex with men are more often in sexual risk behaviors of contracting HIV infection (33,34,38-41). In the same way, the population of men who have sex with men accounts for a significant portion of the spread through sexual route of HIV infection in women (42).

It must be remembered that the different dimensions of identity may present some variations over time (9,27,28). However, the identity of sex and erotic identity are more resistant to change (29,30). People with clear homosexual sexual orientation do not often engage in any homosexual behavior or relationships with people of the same sex at any time or during their whole lives (11,43,44). Like-wise, people who consider themselves gay, lesbian or bisexual do not feel members or participants in the gay community as a social group (1). Certainly, these aspects are very closed to the various nuances of sexual prejudice (biphobia, lesbofobia, homophobia and transphobia) which researchers may find in the general population (15,44). Sexual prejudice has two negative impacts on public health. First, it is related to an increase risk of emotional disorders among non-heterosexual people. Some studies suggest that emotional disorders or requesting mental health professional services is more common in gay, lesbian, or bisexual people (45,46). Up to now, it is appropriate to specify that studies show that these mental health problems are significantly more frequent in those homosexual or bisexual (women and men) who report a marked discomfort or dissatisfaction with his/her sexual orientation, or show high levels of internalized homophobia or sexual prejudice (non-heterosexual people who reject their non-heterosexual self-condition) (47). Second, sexual prejudice not only limits the application of the screening test for HIV (48), but also it becomes a barrier to access medical treatment and services once HIV-positive is identified, due to social rejection and occasional discrimination which come from health personnel (49,50). Third, sexual prejudice limits information about HIV seroconversion which has to be provided to heterosexual partners (51).

FUTURE DIRECTIONS

Future research attempting to investigate the frequency of homosexuality in different populations and contexts should direct the question to the wishes, dreams and sexual fantasies. Instead, it should measure sexual orientation, but not same-sex behaviors (1,3). Sexual behaviors can be modified. Nevertheless, sexual wishes, dreams and fantasies are less subject to change or influence cultural and social context (4,11).

However, bias may persist. Homosexuality is a stigmatized condition in most cultures and societies (52-54). Therefore, it is entirely possible a lower report of the condition; although, it can be investigated using anonymous questionnaires on paper or through Internet (55). It is always necessary to balance the desirability of the expected response (56,57). People can give fake answers in order to please, trick, or simply avoid a bad personal moment (55).

Undoubtedly, the purpose of the study should guide the choice of the aspect of sexual identity (sex identity, gender identity, sexual behavior or erotic identity) which will be researched (1,3,11,58,59). It must ensure the validity and reliability of the particular sexual identity assessment aspect which will be tackled (60). From a public health perspective, sexual behavior is more important than erotic identity in all matters related to the prevention and control of transmission of HIV-AIDS (1,3,59). Obviously, researchers are more interested in safe sexual behaviors than wishes or fantasies before, during, or after sexual behaviors (1,3). It is only enough to know the number of men who have sex with other men or women who have sex with other women without widely explore erotic identity (1,3,59).

However, if the interest is to explore the emotional aspects among non-heterosexual people researchers do necessarily need to include questions whose purpose is to know the sexual orientation and socio-sexual identity (3,59). On the other hand, if the intention is to characterize best non-heterosexual persons, it is necessary to assume the great heterogeneity of the group. If sexual identity and its domains are reviewed in the form of categories, it is possible to foresee more than thirty sexual identities. Further, the number of possibilities is almost infinite if identities are measured as continuous variables or dimensions. This point suggests that nonheterosexual people represent a sufficiently heterogeneous population with subgroups with special characteristics. Therefore, future research should indicate the characteristics of the population in the most comprehensive manner and all aspects of sexual identity. It should only generalize the results to groups with similar characteristics (60).

CONCLUSIONS

Sexual identity, as a whole, is a complex concept which builds itself throughout life and integrates the sex identity, the gender identity and the erotic identity. Biological elements are important to the sex identity. In the same way, cultural and social elements for gender identity, and biological elements, which interact with cultural and social aspects, for erotic identity. The lack of precision in the measurement of homosexuality in different populations is partly related to the confusion over these concepts. Future research should consider these definitions depending on the purpose of the study. They should also clarify many of the characteristics of global sexual identity of the population.

Received for publication September 8, 2009 Accepted for publication March 10, 2010

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Adalberto Campo-Arias, MD *

* Director of Researches and Publications, Human Behavioral Research Institute, Bogota, DC, Colombia. Student of Master in Sexual and Reproductive Health at the Universidad El Bosque, Bogota, DC, Colombia. e-mail: campoarias@comportamientohumano.org
Table 1
Methods of assessing sexual identity in some investigations (1)

Main question                       Answer options

Sexual behavior                     Answer options

1. During your life, persons you    I have never had sexual
have had sex with are:                intercourse
                                    Men
                                    Women
                                    Both men and women

2. Last year, your sexual           Not apply
partners were:                      Men
                                    Women
                                    Both men and women

Sexual orientation

3. On this scale, how would you     0: Exclusively heterosexual
self-identify?
                                    1: Predominantly heterosexual,
                                    only incidentally homosexual

                                    2: Predominantly heterosexual,
                                    sometimes homosexual

                                    3: Equally heterosexual and
                                    homosexual

                                    4: Predominantly homosexual,
                                    sometimes hetero sexual

                                    5: Predominantly homosexual,
                                    only incidentally heterosexual

                                    6: Exclusively homosexual

4. People have different sexual     Only attracted to women
attractions. How would you          Mostly attracted to women
describe your condition?            Equally attracted to men and women
You feel...                         Mostly attracted to men
                                    Only attracted to men
                                    Not sure

Sexual identity

5. What is your sexual identity     Heterosexual
or orientation? (Select only a      Lesbian, gay or homosexual
response)                           Bisexual
                                    None
                                    I'd rather not say

6. Which of the following options   Heterosexual (Straight)
best describes you?                 Gay or lesbian
                                    Bisexual
                                    Not sure
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Date:Apr 1, 2010
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