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Previous Volume 331:923-930 October 6, 1994 Number 14 Next

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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 not¹. 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 orientation².

Definitions

The term homosexual entered common usage in 1869³. 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 with sexual excitement 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 development⁴. The sense of being gay or lesbian is a facet of ego identity⁵. 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^6,7. 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^6,7.

Subsequent studies of subjects more representative of the general population have yielded lower estimates of homosexual behavior^8,9. 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 had at least one homosexual experience resulting in orgasm but only 7 percent had had such experiences after the age of 19¹⁰. Only 3 percent of the adult male population studied had homosexual contacts either occasionally or more often. In both the 1970 and the 1988 studies, the proportion of men with homosexual contact during the preceding year was approximately 2 percent¹⁰. 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 bisexual¹¹.

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 adolescence¹².

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 person¹¹. 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 years)¹³.

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 partners¹¹. 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 partners¹⁴. More recent population-based studies have found this to be relatively uncommon. For instance, Fay et al.¹⁰ found that of men who had homosexual contact after the age of 20, 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 partners¹⁰. 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 behavior¹⁵. 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 period¹¹. Blumstein and Schwartz reported that women in lesbian couples had fewer outside 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 relationship¹⁶.

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^17,18. Among unmarried heterosexual adults, women are also more likely to be abstinent than men¹¹.

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^9,16. 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^17,19.

Although anal sex is practiced by 10 percent of heterosexual couples at least occasionally,¹¹ 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^16,17,19.

The high risk of contracting infection with HIV among homosexual men is usually attributed to contact with semen during unprotected receptive anal intercourse or other practices associated with the exchange of body fluids. Efforts to educate gay men in safe-sex practices to prevent HIV infection have been only partially effective in changing behavior²⁰. 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^21,22. 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 by men who ordinarily do practice safe sex are also common -- in 45 percent over the previous six months in one study²³.

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 sex²⁴. 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 body 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^25,26. Perianal carcinomas also occur more frequently in this group²⁷. Lesbians do not have a higher risk of any sexually transmitted diseases than heterosexual women²⁸.

Homophobia

The term homophobia was coined in 1967 to signify an irrationally negative attitude toward homosexual people²⁹. 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 heterosexuality³⁰.

A widespread tendency to view homosexuality as a stigma and to depict homosexual people in terms of negative stereotypes has only very recently begun to lessen. A majority of respondents to a national poll in 1987 indicated that they would prefer not to work around homosexual people³¹. 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 people³². Most gay and lesbian people have been harassed or threatened because of their sexual orientation, and a sizable minority have been assaulted³³. Many negative beliefs about homosexual people are similar to those associated with other prejudices, such as racism^31,34.

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 family and 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 years³⁵. Many gay and lesbian people never reveal their sexual orientation, even to family members^35,36,37.

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 common³⁸. Homophobic attitudes have been reported among physicians, medical students, nurses, social workers, and mental health practitioners^{39,40,41,42,43,44,45}.

It is likely that many students enter professional schools with antihomosexual values that go unchallenged during their education. A recent survey of American medical schools, for example, found that on average only 3 1/2 hours were devoted to the topic of homosexuality during the four-year curriculum⁴⁶. 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 people⁴⁷.

AIDS

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)⁴⁸.

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^49,50,51.

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 bereaved⁵². 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 both are 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 AIDS⁵³. Studies of suicidality in patients with AIDS and those tested for HIV have not found an increased incidence, however^49,50. 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^49,50,51.

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 people⁵⁴. If identifying data on projective tests are deleted, it is impossible to distinguish homosexual from heterosexual people⁵⁵. This finding is compatible with clinical reports that emphasize similarities in psychodynamic motivations despite differences in sexual orientation^56,57. Studies testing the hypothesis that homosexual people have phobic anxiety about heterosexuality have had negative results⁵⁸. Research on specific disorders, such as sexual abuse of children, has not revealed an increased frequency of homosexual perpetrators⁵⁹. These data, in conjunction with research on the family, have invalidated the once popular idea that castrating mothers and detached or hostile fathers are necessary and sufficient causes of male homosexuality⁶⁰. The origins of sexual orientation appear to be multifactorial and diverse⁵⁷.

Internalized Homophobia

Developmental issues pertaining to sexual orientation are somewhat different in the two sexes. Usually boys follow an 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 adulthood⁶⁰. Those who are on a developmental path toward predominant or exclusive homosexuality often feel homosexual attraction during childhood even though they may never have 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 men⁶¹.

Gay adults often describe themselves as having felt "different" from other children⁵⁶. 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^36,62. 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, lifetime rates of major depression and abuse of or dependence on alcohol and other drugs have been reported to be increased among homosexual men, although their current rates of psychiatric disorders are not^63,64. 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^{65,66,67,68,69}. In a study of 137 homosexual youths, Remafedi et al. found that 41 had attempted suicide⁷⁰. More than half the attempts were of moderate-to-severe lethality and involved inaccessibility to 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^35,36. 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^63,71. Some researchers have reported a trend toward an increase in alcoholism or problem drinking among homosexual men^63,72,73. 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 men⁶³. Because such data are sparse and 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^37,74. Ideally, complex developmental processes culminate in positive gay or lesbian identity and self-acceptance⁵. 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^16,75,76.

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 possible 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,^77,78 and many are parents. Conservative estimates exceed 1 million each for lesbian mothers^79,80 and gay fathers^80,81. At least 6 million children have gay or lesbian parents^80,82. 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^79,83,84,85. 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^80,86. 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 donation 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^{87,88,89,90,91,92,93}.

The data on women, though extremely sparse, suggest that there is more variation with respect to the plasticity of sexual fantasies than with men^61,94. 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, exclusively homosexual fantasies have been present since childhood, and their total replacement by heterosexual fantasies is unlikely⁶¹.

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

Genetics

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 chromosome⁹⁵. 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 male homosexuality in the general population was possible⁹⁵.

Bailey et al. reported increased concordance for homosexuality among male and female monozygotic twins, as compared with dizygotic twins^96,97,98. Their data were consistent with results from a number of other studies of sexual orientation in twins^99,100 and of familial aggregation of homosexuality^95,101,102. 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-report¹⁰³. 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^99,104.

Sex Hormones and Psychosexual Development

Neither plasma hormone values nor other endocrine tests reliably distinguish groups with regard to sexual orientation^105,106,107. Studies of mammalian sexual behavior led to the hypothesis that a prenatal androgen deficit results in male homosexuality and that a prenatal androgen excess results in female homosexuality¹⁰⁸.

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^60,63,109. 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 play¹⁰⁷. 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^{63,109,110,111,112}. 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^113,114,115. 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 factors¹¹⁶.

Further Implications of Intersex Studies

Important general principles of psychosexual development have been derived from studies of patients with unusual intersex disorders^117,118,119. 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 of 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-occurring sexual orientation is modest¹⁰⁷. 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 superchiasmatic nucleus of the hypothalamus, decreased size of the third anterior interstitial nucleus, and increased size of the anterior commissure in homosexual men^120,121,122. Studies of left- and right-sided dominance^{123,124,125,126} and of cognitive functioning^127,128 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 apparent¹²⁹.

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 unproved^{106,107,121,122,130}.

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 sexual orientation in humans (although it has not been proved to do so)^{131,132,133,134}. In some people neither genetic nor prenatal hormonal influences may determine sexual orientation. Diverse lines of psychosexual development could lead to the same behavioral end point with regard to sexual orientation.

Conclusions

Although there has been rapid growth recently in our knowledge about human sexual orientation, fundamental questions remain^105,135. 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 discarded by behavioral scientists^30,83,136. 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 partners. 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.

We are indebted to David Lane and Luis Minaya of the New York State Psychiatric Institute Library for their invaluable assistance.

Source Information

From the Department of Psychiatry, Columbia University College of Physicians and Surgeons (R.C.F., J.I.D.), the New York State Psychiatric Institute (J.I.D.), and the Department of Psychology, Adelphi University (R.C.F.) -- all in New York.

Address reprint requests to Dr. Friedman at 225 Central Park West, Apt. 103, New York, NY 10024.

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