On the Biological Sexual Spectrum

teacher showing his class a human skull

Mark Vaughan

LGBTQ+ people are born, not made. Trying to change them is hurtful and harmful. Offer charity instead of therapy. Embrace, don’t disgrace.

Others have addressed the scriptural and doctrinal aspects of homosexuality. As a physician, I can provide some biological context to the conversation. First, we should define some terms. The words sex and gender are often mistakenly used interchangeably. Let me clarify. Sex refers to biological physical forms, while gender refers to behavior. Homosexuality is same-sex attraction. The terms lesbian and gay refer to homosexuality. The term “same-sex attraction” is used in some circles to refer to LGBTQ people who are not acting on their same-sex orientation by engaging in sexual behaviors, but this is incorrect. It is the attraction which defines homosexuality and not outward behavior. Bisexuality is attraction to both men and women. Transgender identity is the distinct personal identification as a different gender than the one which a person was assigned at birth.

How it Starts

The etiology (cause) of homosexuality was explained to my Nazarene church in the 1980s by James Dobson’s films. He attributed it to environmental factors, mainly family dynamics, experienced by the individual. While this is still an area of active research, most scientific data point to prenatal hormonal influences on the developing brain. These hormonal influences may sometimes be triggered by environmental factors, but this still implicates a biologic basis for homosexual orientation.

Male and Female

Although “male and female he created them,” (Gen. 1:27) we see a more nuanced spectrum clinically than this binary view of sexuality. I say “clinically” because a person who is seen casually in public appearing as either a man or a woman may have surprising secrets about their anatomy known only by them and their doctor. There are two main components which influence sex identification. They are chromosomes and hormones. A basic human biology class usually teaches that humans have 22 pairs of autosomal chromosomes and one pair of sex chromosomes. It also usually teaches that this pair of sex chromosomes determines the sex of the individual. While this is usually the case, it is not always that simple. If the sex chromosomes do not include the usual genes, or if there is another cause of an unusual prenatal hormone environment, the sex organs and outside appearance of the individual may be that of the opposite sex or even an in-between variation of the two (intersex). In some cases, a person with the typically male sex chromosomes (XY) will appear to be female until they reach puberty when a work up is commenced to determine why they never menstruate. It is then discovered that, although they identify as female and can even function sexually as female, they have a Y chromosome and testes inside their body. This is a pattern seen in some patients with a condition called androgen insensitivity. There is a mutation in a gene of the X chromosome which prevents androgen (male sex hormone, mostly testosterone) receptors from working correctly. It doesn’t matter how much testosterone they are given because the receptors on their cells don’t recognize it. Their brain and sex organs never receive the signal to develop in the typical male pattern, even though the male genes are there waiting for that signal to activate them.

To restate: these individuals are born with a Y (male) sex chromosome and testes, yet they also have a vagina, feel they are female, and may be sexually attracted to men. They are also infertile. I go into detail on this extreme example which is typical of complete androgen insensitivity (CAIS) to illustrate the potential for mismatches between chromosomes and a person’s sexual identification. In some aspects, these individuals have it simple compared to those with partial androgen insensitivity (PAIS) who may not have such an obviously female appearance, but whose genitals, historically, were made to appear female because it was the easier surgery to perform. As I stated, this was a relatively obvious example. Allow me to go into detail explaining how the other mismatches occur.

We have some understanding of how other variations work to cause someone’s brain to function like that of the opposite sex when their body does not look like the opposite sex. This can happen for either an individual’s gender identification (transgender identity) or sexual orientation (homosexual). The effects on the brain can be the opposite of effects on the sex organs. The time of the hormonal effect determining the appearance of the sex organs is during the first three months of prenatal development. The hormonal effect on the brain influencing sexual orientation or gender identity occurs during the last half of pregnancy. These are two completely separate periods during fetal development. A different hormonal environment, for various reasons, between these two critical periods of development results in a mismatch between the sex of the physical body and the sex-associated brain function. Research has mostly described this as a direct cause of homosexuality, and it seems transgender identity is caused by a similar mechanism. Despite the expectation that these brain effects would be permanent, some advocate for treatments to reverse the effects.

Conversion Therapy

Homosexuality used to be classified as a mental disorder. It is now considered a normal variant of human sexuality. When it was considered a mental disorder, various “treatments” were tried on patients to eliminate homosexual thoughts and inclinations, or at least to eliminate homosexual behavior. Little success was achieved by these efforts using a huge range of treatment modalities, including electroconvulsive (electric shock) therapy. Once homosexuality was recognized by both the American Psychiatric Association and the American Psychology Association as a normal behavioral variant, most attempts to reverse homosexuality were discontinued. In recent years conversion therapy has found a home in conservative Christian churches and parachurch organizations, motivated by the teaching that homosexuality is a sin.

The data for the effectiveness of conversion therapy to “cure” homosexuality or transgender identity is both limited and inconsistent. Overall, the more reliably conducted studies find poor outcomes for conversion therapy. Most report participants are more likely to describe harmful effects like depression and suicidality, rather than decreased homosexual thoughts or inclinations. One of the more well-done studies reported a success rate of less than 4% and a rate of harm of 37%, with improved psychological outcomes found in individuals instead undergoing affirming psychotherapy.[1] The successful conversions certainly represent a minority, and it comes at a much much higher rate of participants who feel that the experience harmed them without helping. To evaluate it in the same manner as any medical therapy I am considering for a patient, my recommendation would be to stay clear of it.

Being homosexual or transgender is associated with increased adversity which is worsened when affected individuals are told there is a way to “cure” their sexuality. I strongly urge loving support of affected individuals without applying pressure to change their sexuality.

[1]. Kate Bradshaw, et al., (2015) Sexual Orientation Change Efforts Through Psychotherapy for LGBQ Individuals Affiliated With the Church of Jesus Christ of Latter-day Saints, Journal of Sex & Marital Therapy, 41:4, 391-412.

Mark Vaughan, MD grew up on the Sacramento District of the Church of the Nazarene and graduated from NNC before completing medical school at Saint Louis University. He is the founder and medical director of the Auburn Medical Group. He is the co-host of the Changing Faith podcast and the Auburn Medical Group YouTube channel.

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