gender identity research paper

MINI REVIEW article

Sexual orientation and gender identity: review of concepts, controversies and their relation to psychopathology classification systems.

• Instituto Universitário de Lisboa ISCTE-IUL, CIS, Lisboa, Portugal

Numerous controversies and debates have taken place throughout the history of psychopathology (and its main classification systems) with regards to sexual orientation and gender identity. These are still reflected on present reformulations of gender dysphoria in both the Diagnostic and Statistical Manual and the International Classification of Diseases, and in more or less subtle micro-aggressions experienced by lesbian, gay, bisexual and trans patients in mental health care. The present paper critically reviews this history and current controversies. It reveals that this deeply complex field contributes (i) to the reflection on the very concept of mental illness; (ii) to the focus on subjective distress and person-centered experience of psychopathology; and (iii) to the recognition of stigma and discrimination as significant intervening variables. Finally, it argues that sexual orientation and gender identity have been viewed, in the history of the field of psychopathology, between two poles: gender transgression and gender variance/fluidity.

Numerous controversies and debates have taken place throughout the history of psychopathology and mental health care with regards to lesbian, gay, bisexual and transgender (LGBT) people. The present paper aims to review relevant concepts in this literature, its historical and current controversies, and their relation to the main psychopathology classification systems.

Concepts and Definitions

Concepts and definitions that refer to sexual orientation and gender identity are an evolving field. Many of the terms used in the past to describe LGBT people, namely in the mental health field, are now considered to be outdated and even offensive.

Sexual orientation refers to the sex of those to whom one is sexually and romantically attracted ( American Psychological Association, 2012 ). Nowadays, the terms ‘lesbian’ and ‘gay’ are used to refer to people who experience attraction to members of the same sex, and the term ‘bisexual’ describe people who experience attraction to members of both sexes. It should be noted that, although these categories continue to be widely used, sexual orientation does not always appear in such definable categories and, instead, occurs on a continuum ( American Psychological Association, 2012 ), and people perceived or described by others as LGB may identify in various ways ( D’Augelli, 1994 ).

The expression gender identity was coined in the middle 1960s, describing one’s persistent inner sense of belonging to either the male and female gender category ( Money, 1994 ). The concept of gender identity evolved over time to include those people who do not identify either as female or male: a “person’s self concept of their gender (regardless of their biological sex) is called their gender identity” ( Lev, 2004 , p. 397). The American Psychological Association (2009a , p. 28) described it as: “the person’s basic sense of being male, female, or of indeterminate sex.” For decades, the term ‘transsexual’ was restricted for individuals who had undergone medical procedures, including genital reassignment surgeries. However, nowadays, ‘transsexual’ refers to anyone who has a gender identity that is incongruent with the sex assigned at birth and therefore is currently, or is working toward, living as a member of the sex other than the one they were assigned at birth, regardless of what medical procedures they may have undergone or may desire in the future (e.g., Serano, 2007 ; American Psychological Association, 2009a ; Coleman et al., 2012 ). In this paper we use the prefix trans when referring to transsexual people.

Since the 1990’s the word transgender has been used primarily as an umbrella term to describe those people who defy societal expectations and assumptions regarding gender (e.g., Lev, 2004 ; American Psychological Association, 2009a ). It includes people who are transsexual and intersex, but also those who identify outside the female/male binary and those whose gender expression and behavior differs from social expectations. As in the case of sexual orientation, people perceived or described by others as transgender – including transsexual men and women – may identify in various ways (e.g., Pinto and Moleiro, 2015 ).

Discrimination and Impact on Mental Health

Lesbian, gay, bisexual and transgender people often suffer from various forms of discrimination, stigma and social exclusion – including physical and psychological abuse, bullying, persecution, or economic alienation ( United Nations, 2011 ; Bostwick et al., 2014 ; European Union Agency for Fundamental Rights, 2014 ). Moreover, experiences of discrimination may occur in various areas, such as employment, education and health care, but also in the context of meaningful interpersonal relationships, including family (e.g., Milburn et al., 2006 ; Feinstein et al., 2014 ; António and Moleiro, 2015 ). Accordingly, several studies strongly suggest that experiences of discrimination and stigmatization place LGBT people at higher risk for mental distress ( Cochran and Mays, 2000 ; Dean et al., 2000 ; Cochran et al., 2003 ; Meyer, 2003 ; Shilo, 2014 ).

For example, LGB populations may be at increased risk for suicide ( Hershberger and D’Augelli, 1995 ; Mustanski and Liu, 2013 ), traumatic stress reactions ( D’Augelli et al., 2002 ), major depression disorders ( Cochran and Mays, 2000 ), generalized anxiety disorders ( Bostwick et al., 2010 ), or substance abuse ( King et al., 2008 ). In addition, transgender people have been identified as being at a greater risk for developing: anxiety disorders ( Hepp et al., 2005 ; Mustanski et al., 2010 ); depression ( Nuttbrock et al., 2010 ; Nemoto et al., 2011 ); social phobia and adjustment disorders ( Gómez-Gil et al., 2009 ); substance abuse ( Lawrence, 2008 ); or eating disorders ( Vocks et al., 2009 ). At the same time, data on suicide ideation and attempts among this population are alarming: Maguen and Shipherd (2010) found the percentage of attempted suicides to be as high as 40% in transsexual men and 20% in transsexual women. Nuttbrock et al. (2010) , using a sample of 500 transgender women, found that around 30% had already attempted suicide, around 35% had planned to do so, and close to half of the participants expressed suicide ideation. In particular, adolescence has been identified as a period of increased risk with regard to the mental health of transgender and transsexual people ( Dean et al., 2000 ).

In sum, research clearly recognizes the role of stigma and discrimination as significant intervening variables in psychopathology among LGBT populations. Nevertheless, the relation between sexual orientation or gender identity and stress may be mediated by several variables, including social and family support, low internalized homophobia, expectations of acceptance vs. rejection, contact with other LGBT people, or religiosity ( Meyer, 2003 ; Shilo and Savaya, 2012 ; António and Moleiro, 2015 ; Snapp et al., 2015 ). Thus, it seems important to focus on subjective distress and in a person-centered experience of psychopathology.

On the History of Homosexuality and Psychiatric Diagnoses

While nowadays we understand that higher rates of psychological distress among LGB people are related to their minority status and to discrimination, by the early 20th century, psychiatrists mostly regarded homosexuality as pathological per se ; and in the mid-20th century psychiatrics, physicians, and psychologists were trying to “cure” and change homosexuality ( Drescher, 2009 ). In 1952, the American Psychiatric Association published its first edition of the Diagnostic and Statistical Manual (DSM-I), in which homosexuality was considered a “sociopathic personality disturbance.” In DSM-II, published in 1968, homosexuality was reclassified as a “sexual deviation.” However, in December 1973, the American Psychiatric Association’s Board of Trustees voted to remove homosexuality from the DSM.

The most significant catalyst to homosexuality’s declassification as a mental illness was lesbian and gay activism, and its advocacy efforts within the American Psychiatric Association ( Drescher, 2009 ). Nevertheless, during the discussion that led to the diagnostic change, APA’s Nomenclature Committee also wrestled with the question of what constitutes a mental disorder. Concluding that “they [mental disorders] all regularly caused subjective distress or were associated with generalized impairment in social effectiveness of functioning” ( Spitzer, 1981 , p. 211), the Committee agreed that homosexuality by itself was not one.

However, the diagnostic change did not immediately end the formal pathologization of some presentations of homosexuality. After the removal of the “homosexuality” diagnosis, the DSM-II contained the diagnosis of “sexual orientation disturbance,” which was replaced by “ego dystonic homosexuality” in the DSM-III, by 1980. These diagnoses served the purpose of legitimizing the practice of sexual “conversion” therapies among those individuals with same-sex attractions who were distressed and reported they wished to change their sexual orientation ( Spitzer, 1981 ; Drescher, 2009 ). Nonetheless, “ego-dystonic homosexuality” was removed from the DSM-III-R in 1987 after several criticisms: as formulated by Drescher (2009 , p. 435): “should people of color unhappy about their race be considered mentally ill?”

The removal from the DSM of psychiatric diagnoses related to sexual orientation led to changes in the broader cultural beliefs about homosexuality and culminated in the contemporary civil rights quest for equality ( Drescher, 2012 ). In contrast, it was only in 1992 that the World Health Organization ( World Health Organization, 1992 ) removed “homosexuality” from the International Classification of Diseases (ICD-10), which still contains a diagnosis similar to “ego-dystonic homosexuality.” However, this is expected to change in the next revision, planned for publication in 2017 ( Cochran et al., 2014 ).

Controversies on Gender Dysphoria and (Trans)Gender Diagnoses

Mental health diagnoses that are specific to transgender and transsexual people have been highly controversial. In this domain, the work of Harry Benjamin was fundamental for trans issues internationally, through the Harry Benjamin International Gender Dysphoria Association (presently, the World Professional Association for Transgender Health, WPATH). In the past few years, there has been a vehement discussion among interested professionals, trans and LGBT activists, and human rights groups concerning the reform or removal of (trans)gender diagnoses from the main health diagnostic tools. However, discourses on this topic have been inconclusive, filled with mixed messages and polarized opinions ( Kamens, 2011 ). Overall, mental health diagnoses which are specific to transgender people have been criticized in large part because they enhance the stigma in a population which is already particularly stigmatized ( Drescher, 2013 ). In fact, it has been suggested that the label “mental disorder” is the main factor underlying prejudice toward trans people ( Winter et al., 2009 ).

The discussion reached a high point during the recent revision process of the DSM-5 ( American Psychiatric Association, 2013 ), in which the diagnosis of “gender identity disorder” was revised into one of “gender dysphoria.” Psychiatric diagnosis was thus limited to those who are, in a certain moment of their lives, distressed about living with a gender assignment they experience as incongruent with their gender identity ( Drescher, 2013 ). The change of criteria and nomenclature “is less pathologizing as it no longer implies that one’s identity is disordered” ( DeCuypere et al., 2010 , p. 119). In fact, gender dysphoria is not a synonym for transsexuality, nor should it be used to describe transgender people in general ( Lev, 2004 ); rather, “[it] is a clinical term used to describe the symptoms of excessive pain, agitation, restless, and malaise that gender-variant people seeking therapy often express” ( Lev, 2004 , p. 910). Although the changes were welcomed (e.g., DeCuypere et al., 2010 ; Lev, 2013 ), there are still voices arguing for the “ultimate removal” ( Lev, 2013 , p. 295) of gender dysphoria from the DSM. Nevertheless, attention is presently turned to the ongoing revision of the ICD. Various proposals concerning the revision of (trans)gender diagnoses within ICD have been made, both originating from transgender and human rights groups (e.g., Global Action for Trans ∗ Equality, 2011 ; TGEU, 2013 ) and the health profession community (e.g., Drescher et al., 2012 ; World Professional Association for Transgender Health, 2013 ). These include two main changes: the reform of the diagnosis of transsexualism into one of “gender incongruence”; and the change of the diagnosis into a separate chapter from the one on “mental and behavioral disorders.”

Mental Health Care Reflecting Controversies

There is evidence that LGBT persons resort to psychotherapy at higher rates than the non-LGBT population ( Bieschke et al., 2000 ; King et al., 2007 ); hence, they may be exposed to higher risk for harmful or ineffective therapies, not only as a vulnerable group, but also as frequent users.

Recently, there has been a greater concern in the mental health field oriented to the promotion of the well-being among non-heterosexual and transgender people, which has paralleled the diagnostic changes. This is established, for instance, by the amount of literature on gay and lesbian affirmative psychotherapy which has been developed in recent decades (e.g., Davis, 1997 ) and, also, by the fact that major international accrediting bodies in counseling and psychotherapy have identified the need for clinicians to be able to work effectively with minority clients, namely LGBT people. The APA’s guidelines for psychotherapy with lesbian, gay, and bisexual client ( American Psychological Association, 2000 , 2012 ) are a main reference. These ethical guidelines highlight, among several issues, the need for clinicians to recognize that their own attitudes and knowledge about the experiences of sexual minorities are relevant to the therapeutic process with these clients and that, therefore, mental health care providers must look for appropriate literature, training, and supervision.

However, empirical research also reveals that some therapists still pursue less appropriate clinical practices with LGBT clients. In a review of empirical research on the provision of counseling and psychotherapy to LGB clients, Bieschke et al. (2006) encountered an unexpected recent explosion of literature focused on “conversion therapy.” There are, in fact, some mental health professionals that still attempt to help lesbian, gay, and bisexual clients to become heterosexual ( Bartlett et al., 2009 ), despite the fact that a recent systematic review of the peer-reviewed journal literature on sexual orientation change efforts concluded that “efforts to change sexual orientation are unlikely to be successful and involve some risk of harm” ( American Psychological Association, 2009b , p. 1).

Moreover, there is evidence of other forms of inappropriate (while less blatant) clinical practices with LGBT clients (e.g., Garnets et al., 1991 ; Jordan and Deluty, 1995 ; Liddle, 1996 ; Hayes and Erkis, 2000 ). Even those clinicians who intend to be affirmative and supportive of LGBT individuals can reveal subtle heterosexist bias in the work with these clients ( Pachankis and Goldfried, 2004 ). Examples of such micro-aggressions ( Sue, 2010 ) might be automatically assuming that a client is heterosexual, trying to explain the etiology of the client’s homosexuality, or focusing on the sexual orientation of a LGB client despite the fact that this is not an issue at hand (e.g., Shelton and Delgado-Romero, 2011 ). Heterosexual bias in counseling and psychotherapy may manifest itself also in what Brown (2006 , p. 350) calls “sexual orientation blindness,” i.e., struggling for a supposed neutrality and dismissing the specificities related to the minority condition of non-heterosexual clients. This conceptualization of the human experience mostly in heterosexual terms, found in the therapeutic setting, does not seem to be independent of psychotherapist’s basic training and the historical heterosexist in the teaching of medicine and psychology ( Simoni, 1996 ; Alderson, 2004 ).

With regards to the intervention with trans people, for decades the mental health professionals’ job was to sort out the “true” transsexuals from all other transgender people. The former would have access to physical transition, and the later would be denied any medical intervention other than psychotherapy. By doing this, whether deliberately or not, professionals – acting as gatekeepers – pursued to ‘ensure that most people who did transition would not be “gender-ambiguous” in any way’ ( Serano, 2007 , p. 120). Research shows that currently trans people still face serious challenges in accessing health care, including those related to inappropriate gatekeeping ( Bockting et al., 2004 ; Bauer et al., 2009 ). Some mental health professionals still focus on the assessment of attributes related to identity and gender expressions, rather than on the distress with which trans people may struggle with ( Lev, 2004 ; Serano, 2007 ). Hence, trans people may feel the need to express a personal narrative consistent with what they believe the clinicians’ expectations to be, for accessing hormonal or surgical treatments ( Pinto and Moleiro, 2015 ). Thus, despite the revisions of (trans)gender diagnoses within the DSM, more recent diagnoses seem to still be used as if they were identical with the diagnosis of transsexualism – in a search for the “true transsexual” ( Cohen-Kettenis and Pfäfflin, 2010 ). It seems clear that social and cultural biases have significantly influenced – and still do – diagnostic criteria and the access to hormonal and surgical treatments for trans people.

Controversies and debates with regards to medical classification of sexual orientation and gender identity contribute to the reflection on the very concept of mental illness. The agreement that mental disorders cause subjective distress or are associated with impairment in social functioning was essential for the removal of “homosexuality” from the DSM in the 1970s ( Spitzer, 1981 ). Moreover, (trans)gender diagnoses constitute a significant dividing line both within trans related activism (e.g., Vance et al., 2010 ) and the health professionals’ communities (e.g., Ehrbar, 2010 ). The discussion has taken place between two apposite positions: (1) trans(gender) diagnoses should be removed from health classifying systems, because they promote the pathologization and stigmatization of gender diversity and enhance the medical control of trans people’s identities and lives; and (2) trans(gender) diagnoses should be retained in order to ensure access to care, since health care systems rely on diagnoses to justify medical treatment – which many trans people need. In fact, trans people often describe experiences of severe distress and argue for the need for treatments and access to medical care ( Pinto and Moleiro, 2015 ), but at the same time reject the label of mental illness for themselves ( Global Action for Trans ∗ Equality, 2011 ; TGEU, 2013 ). Thus, it may be important to understand how the debate around (trans)diagnoses may be driven also by a history of undue gatekeeping and by stigma involving mental illness.

The present paper argues that sexual orientation and gender identity have been viewed, in the history of the field of psychopathology, between two poles: gender transgression and gender variance/fluidity.

On the one hand, aligned with a position of “transgression” and/or “deviation from a norm,” people who today are described as LGBT were labeled as mentally ill. Inevitably, classification systems reflect(ed) the existing social attitudes and prejudices, as well as the historical and cultural contexts in which they were developed ( Drescher, 2012 ; Kirschner, 2013 ). In that, they often failed to differentiate between mental illness and socially non-conforming behavior or fluidity of gender expressions. This position and the historical roots of this discourse are still reflected in the practices of some clinicians, ranging from “conversion” therapies to micro-aggressions in the daily lives of LGBT people, including those experienced in the care by mental health professionals.

On the other hand, lined up with a position of gender variance and fluidity, changes in the diagnostic systems in the last few decades reflect a broader respect and value of the diversity of human sexuality and of gender expressions. This position recognizes that the discourse and practices coming from the (mental) health field may lead to changes in the broader cultural beliefs ( Drescher, 2012 ). As such, it also recognizes the power of medical classifications, health discourses and clinical practices in translating the responsibility of fighting discrimination and promoting LGBT people’s well-being.

In conclusion, it seems crucial to emphasize the role of specific training and supervision in the development of clinical competence in the work with sexual minorities. Several authors (e.g., Pachankis and Goldfried, 2004 ) have argued for the importance of continuous education and training of practitioners in individual and cultural diversity competences, across professional development. This is in line with APA’s ethical guidelines ( American Psychological Association, 2000 , 2012 ), and it is even more relevant when we acknowledge the significant and recent changes in this field. Furthermore, it is founded on the very notion that LGBT competence assumes clinicians ought to be aware of their own personal values, attitudes and beliefs regarding human sexuality and gender diversity in order to provide appropriate care. These ethical concerns, however, have not been translated into training programs in medicine and psychology in a systematic manner in most European countries, and to the mainstreaming of LGBT issues ( Goldfried, 2001 ) in psychopathology.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Alderson, K. G. (2004). A different kind of outing: training counsellors to work with sexual minority clients. Can. J. Couns. 38, 193–210.

Google Scholar

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders , 5th Edn. Arlington, VA: American Psychiatric Publishing.

American Psychological Association (2000). Guidelines for psychotherapy with lesbian, Gay Bisexual Clients. Am. Psychol. 55, 1440–1451.

American Psychological Association (2009a). Report of the Task Force on Gender Identity and Gender Variance. Available at: http://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf

American Psychological Association (2009b). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Available at: https://www.apa.org/pi/lgbt/resources/therapeutic-response.pdf

American Psychological Association (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. Am. Psychol. 67, 10–42. doi: 10.1037/a0024659

PubMed Abstract | CrossRef Full Text | Google Scholar

António, R., and Moleiro, C. (2015). Social and parental support as moderators of the effects of homophobic bullying on psychological distress in youth. Psychol. Schools 52, 729–742. doi: 10.1002/pits.21856

CrossRef Full Text | Google Scholar

Bartlett, A., Smith, G., and King, M. (2009). The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation. BMC Psychiatry 9:11. doi: 10.1186/1471-244X-9-11

Bauer, G. R., Hammond, R., Travers, R., Kaay, M., Hohenadel, K. M., and Boyce, M. (2009). “I don’t think this is theoretical; this is our lives”: how erasure impacts health care for transgender people. J. Assoc. Nurses AIDS Care 20, 348–361. doi: 10.1016/j.jana.2009.07.004

Bieschke, K. J., McClanahan, M., Tozer, E., Grzegorek, J. L., and Park, J. (2000). “Programmatic research on the treatment of lesbian, gay, and bisexual clients: the past, the present, and the course for the future,” in Handbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual Clients , eds R. M. Perez, K. A. DeBord, and K. J. Bieschke (Washington DC: American Psychological Association), 309–335.

Bieschke, K. J., Paul, P. L., and Blasko, K. A. (2006). “Review of empirical research focused on the experience of lesbian, gay, and bisexual clients in counseling and psychotherapy,” in Handbook of Counseling and Psychotherapy with Lesbian, Gay, Bisexual, and Transgender Clients , eds K. Bieschke, R. Perez, and K. DeBord (Washington DC: American Psychological Association), 293–316.

Bockting, W., Robinson, B., Benner, A., and Scheltema, K. (2004). Patient satisfaction with transgender health services. J. Sex Marital Ther. 30, 277–294. doi: 10.1080/00926230490422467

Bostwick, W. B., Boyd, C. J., Hughes, T. L., and McCabe, S. E. (2010). Sexual orientation and the prevalence of mood and anxiety disorders in the United States. Am. J. Public Health 100, 468–475. doi: 10.2105/AJPH.2008.152942

Bostwick, W. B., Boyd, C. J., Hughes, T. L., West, B. T., and McCabe, S. E. (2014). Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. Am. J. Orthopsychiatry (Am. Psychol. Assoc.) 84, 35–45. doi: 10.1037/h0098851

Brown, L. S. (2006). “The neglect of lesbian, gay, bisexual and transgendered clients,” in Evidence-Based Practices in Mental Health , eds J. C. Norcross, L. E. Beutler, and R. F. Levant (Washington, DC: American Psychological Association), 346–353.

PubMed Abstract | Google Scholar

Cochran, S., Drescher, J., Kismödi, E., Giami, A., García-Moreno, C., Atalla, E., et al. (2014). Proposed declassification of disease categories related to sexual orientation in the international statistical classification of diseases and related health problems (ICD-11). Bull. World Health Organ. Bull. 92, 672–679. doi: 10.2471/BLT.14.135541

Cochran, S. D., and Mays, V. M. (2000). Relation between psychiatric syndromes and behaviourally defined sexual orientation in a sample of the U.S. population. Am. J. Public Health 92, 516–523.

Cochran, S. D., Sullivan, J. G., and Mays, V. M. (2003). Prevalence of mental disorders, psychological distress, and mental health services among lesbian, gay, and bisexual adults in the United States. J. Couns. Clin. Psychol. 71, 53–61.

Cohen-Kettenis, P. T., and Pfäfflin, F. (2010). The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Arch. Sex. Behav. 39, 499–513. doi: 10.1007/s10508-009-9562-y

Coleman, E., Bockting, W., Botzer, M., Cohen - Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version. Int. J. Transgend. 13, 165–232.

D’Augelli, A. R. (1994). “Identity development and sexual orientation: toward a model of lesbian, gay, and bisexual development,” in Human Diversity: Perspectives on People in Context , eds E. J. Trickett, R. J. Watts, and D. Birman (San Francisco, CA: Jossey-Bass).

D’Augelli, A. R., Pilkington, N. W., and Hershberger, S. L. (2002). Incidence and mental health impact of sexual orientation victimization of lesbian, gay, and bisexual youths in high school. School Psychol. Q. 17, 148–167. doi: 10.1521/scpq.17.2.148.20854

Davis, D. (1997). “Towards a model of gay affirmative therapy,” in Pink Therapy: A Guide for Counsellors and Therapists Working with Lesbian, Gay and Bisexual Clients , eds D. Davies and C. Neal (Buckingham: Oxford University Press), 24–40.

Dean, L., Meyer, I. H., Robinson, K., Sell, R. L., Sember, R., Silenzio, V. M. B., et al. (2000). Lesbian, gay, bisexual, and transgender health: findings and concerns. J. Gay Lesbian Med. Assoc. 4, 102–151. doi: 10.1023/A:1009573800168

DeCuypere, G. D., Knudson, G., and Bockting, W. (2010). Response of the world professional association for transgender health to the proposed dsm 5 criteria for gender incongruence. Int. J. Transgend. 12, 119–123. doi: 10.1080/15532739.2010.509214

Drescher, J. (2009). Queer diagnoses: parallels and contrasts in the history of homosexuality. Gender Variance, and the Diagnostic and Statistical Manual. Arch. Sex. Behav. 39, 427–460. doi: 10.1007/s10508-009-9531-5

Drescher, J. (2012). The removal of homosexuality from the dsm: its impact on today’s marriage equality debate. J. Gay Lesbian Mental Health 16, 124–135. doi: 10.1080/19359705.2012.653255

Drescher, J. (2013). Controversies in gender diagnoses. LGBT Health 1, 10–14.

Drescher, J., Cohen-Kettenis, F., and Winter, S. (2012). Minding the body: situating gender identity diagnoses in the ICD-1. Int. Rev. Psychiatry 24, 568–577. doi: 10.3109/09540261.2012.741575

Ehrbar, R. D. (2010). Consensus from differences: lack of professional consensus on the retention of the gender identity disorder diagnosis. Int. J. Transgend. 12, 60–74. doi: 10.1080/15532739.2010.513928

European Union Agency for Fundamental Rights (2014). European LGBT Survey: Main Results. Luxembourg: Publications Office of the European Union.

Feinstein, B. A., Wadsworth, L. P., Davila, J., and Goldfried, M. R. (2014). Do parental acceptance and family support moderate associations between dimensions of minority stress and depressive symptoms among lesbians and gay men? Prof. Psychol. Res. Pract. 45, 239–246. doi: 10.1037/a0035393

Garnets, L., Hancock, K. A., Cochran, S. D., Goodchilds, J., and Peplau, L. A. (1991). Issues in psychotherapy with lesbians and gay men. A Survey of Psychologists. Am. Psychol. 46, 964–972. doi: 10.1037/0003-066X.46.9.964

Global Action for Trans ∗ Equality (2011). It’s Time for Reform. Trans ∗ Health Issues in the International Classification of Diseases. A Report on the GATE Experts Meeting. Available at: http://globaltransaction.files.wordpress.com/2012/05/its-time-for-reform.pdf

Goldfried, M. R. (2001). Integrating lesbian, gay, and bisexual issues into mainstream psychology. Am. Psychol. 56, 977–988. doi: 10.1037/0003-066X.56.11.977

Gómez-Gil, E., Trilla, A., Salamero, M., Godás, T., and Valdés, M. (2009). Sociodemographic, clinical, and psychiatric characteristics of transsexuals from Spain. Arch. Sex. Behav. 38, 378–392. doi: 10.1007/s10508-007-9307-8

Hayes, J., and Erkis, A. (2000). Therapist homophobia, client sexual orientation, and source of client HIV infection as predictors of therapist reactions to clients with HIV. J. Couns. Psychol. 47, 71–78. doi: 10.1037/0022-0167.47.1.71

Hepp, U., Kraemer, B., Schynder, U., Miller, N., and Delsignore, A. (2005). Psychiatric comorbidity in gender identity disorder. J. Psychosom. Res. 58, 259–261. doi: 10.1016/j.jpsychores.2004.08.010

Hershberger, S. L., and D’Augelli, A. R. (1995). The impact of victimization on the mental health and suicidality of lesbian, gay, and bisexual youths. Dev. Psychol. 31, 65–74. doi: 10.1037/0012-1649.31.1.65

Jordan, K. M., and Deluty, R. H. (1995). Clinical Interventions by psychologists with lesbians and gay men. J. Clin. Psychol. 51, 448–456.

Kamens, S. R. (2011). On the proposed sexual and gender identity diagnoses for dsm-5: history and controversies. Hum. Psychol. 39, 37–59. doi: 10.1080/08873267.2011.539935

King, M., Semlyen, J., Killaspy, H., Nazareth, I., and Osborn, D. (2007). A Systematic Review of Research on Counselling and Psychotherapy for Lesbian, Gay, Bisexual & Transgender People. London: British Association for Counselling & Psychotherapy.

King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., et al. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 8:70. doi: 10.1186/1471-244X-8-70

Kirschner, S. R. (2013). Diagnosis and its discontents: critical perspectives on psychiatric nosology and the DSM. Fem. Psychol. 23, 10–28. doi: 10.1177/0959353512467963

Lawrence, A. A. (2008). “Gender identity disorders in adults: diagnosis and treatment,” in Handbook of Sexual and Gender Identity Disorders , eds D. L. Rowland and L. Incrocci (New York, NY: Wiley), 423–456.

Lev, A. I. (2004). Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families. New York, NY: Haworth Clinical Practice Press.

Lev, A. I. (2013). Gender dysphoria: two steps forward, one step back. Clin. Soc. Work J. 41, 288–296. doi: 10.1007/s10615-013-0447-0

Liddle, B. J. (1996). Therapist sexual orientation, gender, and counseling practices as they relate to ratings of helpfulness by gay and lesbian clients. J. Couns. Psychol. 43, 394–401. doi: 10.1037/0022-0167.43.4.394

Maguen, S., and Shipherd, J. (2010). Suicide risk among transgender individuals. Psychol. Sex. 1, 34–43. doi: 10.1080/19419891003634430

Meyer, I. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual. (issues)and research evidence. Psychol. Bull. 129, 674–697. doi: 10.1037/0033-2909.129.5.674

Milburn, N. G., Ayala, G., Rice, E., Batterham, P., and Rotheram-Borus, M. J. (2006). Discrimination and exiting homelessness among homeless adolescents. Cultur. Divers Ethn. Minor Psychol. 12, 658–672. doi: 10.1037/1099-9809.12.4.658

Money, J. (1994). The concept of gender identity disorder in childhood and adolescence after 39 years. J. Sex Marital Ther. 20, 163–177. doi: 10.1080/00926239408403428

Mustanski, B., and Liu, R. T. (2013). A longitudinal study of predictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Arch. Sex. Behav. 42, 437–448. doi: 10.1007/s10508-012-0013-9

Mustanski, B. S., Garofalo, R., and Emerson, E. M. (2010). Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. Res. Pract. 100, 2426–2432. doi: 10.2105/AJPH.2009.178319

Nemoto, T., Bodeker, B., and Iwamoto, M. (2011). Social support, exposure to violence, and transphobia: correlates of depression among male-to-female transgender women with a history of sex work. Am. J. Public Health 101, 1980–1988. doi: 10.2105/AJPH.2010.197285

Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., et al. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. J. Sex Res. 47, 12–23. doi: 10.1080/00224490903062258

Pachankis, J. E., and Goldfried, M. R. (2004). Clinical issues in working with lesbian, gay, and bisexual clients. Psychotherapy Theor. Res. Pract. Train. 41, 227–246. doi: 10.1037/0033-3204.41.3.227

Pinto, N., and Moleiro, C. (2015). Gender trajectories: transsexual people coming to terms with their gender identities. Prof. Psychol. Res. Pract. 46, 12–20. doi: 10.1037/a0036487

Serano, J. (2007). Whipping Girl. A Transsexual Woman on Sexism and the Scapegoating of Femininity. Berkeley, CA: Seal Press.

Shelton, K., and Delgado-Romero, E. A. (2011). Sexual orientation microaggressions: the experience of lesbian, gay, bisexual, and queer clients in psychotherapy. J. Couns. Psychol. 58, 210–221. doi: 10.1037/a0022251

Shilo, G. R., and Savaya, R. (2012). Mental health of lesbian, gay, and bisexual youth and young adults: differential effects of age, gender, religiosity, and sexual orientation. J. Res. On Adolesc. 22, 310–325.

Shilo, G. Z. (2014). The Impact of Minority Stressors on the Mental and Physical Health of Lesbian. Gay, and Bisexual Youths and Young Adults. Health Soc. Work 39, 161–171.

Simoni, J. M. (1996). Confronting heterosexism in the teaching of psychology. Teach. Psychol. 23, 220–226. doi: 10.1207/s15328023top2304_3

Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., and Ryan, C. (2015). Social support networks for lgbt young adults: low cost strategies for positive adjustment. Fam. Relations 64, 420–430. doi: 10.1111/fare.12124

Spitzer, R. L. (1981). The diagnostic status of homosexuality in the DSM-III: a reformulation of the issues. Am. J. Psychiatry 138, 210–215. doi: 10.1176/ajp.138.2.210

Sue, D. W. (2010). Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation. Hoboken, N.J: Wiley.

TGEU (2013). TGEU’s Position on the Revision of the ICD z10. Available at: http://www.tgeu.org/sites/default/files/TGEU%20Position%20ICD%20Revision_0.pdf

United Nations (2011). Discriminatory Laws and Practices and Acts of Violence Against Individuals Based on their Sexual Orientation and Gender Identity. Report of the United Nations High Commissioner for Human Rights. Available at: http://www2.ohchr.org/english/bodies/hrcouncil/docs/19session/A.HRC.19.41_English.pdf

Vance, S., Cohen-Kettenis, P. T., Drescher, J., Meyer-Bahlburg, H. F., Pfäfflin, F., and Zucker, K. J. (2010). Opinions about the dsm gender identity disorder diagnosis: results from an international survey administered to organizations concerned with the welfare of transgender people. Int. J. Transgend. 12, 1–14. doi: 10.1080/15532731003749087

Vocks, S., Stahn, C., Loenser, L., and Tegenbauer, U. (2009). Eating and body image disturbances in male-to-female and female-to-male transsexuals. Arch. Sex. Behav. 38, 364–377. doi: 10.1007/s10508-008-9424-z

Winter, S., Chalungsooth, P., Teh, Y., Rojanalert, N., Maneerat, K., Wong, Y., et al. (2009). Transpeople, transprejudice and pathologization: a seven-country factor analysis study. Int. J. Sex. Health 21, 96–118. doi: 10.1080/19317610902922537

World Health Organization (1992). International Statistical Classification of Diseases and Related Health Problems (10th rev.). Geneva: World Health Organization.

World Professional Association for Transgender Health (2013). WPATH ICD-11 Consensus Meeting. Available at: http://www.wpath.org/uploaded_files/140/files/ICD%20Meeting%20Packet-Report-Final-sm.pdf

Keywords : sexual orientation, gender identity, transgender, discrimination, psychopathology, mental health care

Citation: Moleiro C and Pinto N (2015) Sexual orientation and gender identity: review of concepts, controversies and their relation to psychopathology classification systems. Front. Psychol. 6:1511. doi: 10.3389/fpsyg.2015.01511

Received: 29 July 2015; Accepted: 18 September 2015; Published: 01 October 2015.

Reviewed by:

Copyright © 2015 Moleiro and Pinto. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Carla Moleiro, Instituto Universitário de Lisboa ISCTE-IUL, CIS, Avenida das Forças Armadas, 1649-026 Lisbon, Portugal, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Search Menu
• Sign in through your institution
• Advance articles
• Analysis Author Guidelines
• Analysis Reviews Author Guidelines
• Submission site
• Why Publish with Analysis?
• About Analysis
• About The Analysis Trust
• Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• Terms and Conditions
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

1. introduction, 2. gender identity first, 3. the no connection view, 4. contextualism, 5. pluralism, 6. further and future work.

• < Previous

Recent Work on Gender Identity and Gender

• Article contents
• Figures & tables
• Supplementary Data

Rach Cosker-Rowland, Recent Work on Gender Identity and Gender, Analysis , Volume 83, Issue 4, October 2023, Pages 801–820, https://doi.org/10.1093/analys/anad027

• Permissions Icon Permissions

Our gender identity is our sense of ourselves as a woman, a man, as genderqueer or as another gender. Trans people have a gender identity that is different from the gender they were assigned at birth. Some recent work has discussed what it is to have a sense of ourselves as a particular gender, what it is to have a gender identity ( Andler 2017 , Bettcher 2009 , 2017 , Jenkins 2016 , 2018 , McKitrick 2015 ). But beyond the question of how we should understand gender identity is the question of how gender identities relate to genders.

Our gender is the property we have of being a woman, being a man, being non-binary or being another gender. What is the relationship between our gender identity and our gender? According to many people’s conceptions and the standards operative in trans communities, our gender identity always determines our gender. Other people and communities have different views and standards: some hold that our gender is determined by the gender we are socially positioned or classed as, others hold that our gender is determined by whether we have particular biological features, such as the chromosomes we have. If our gender is determined by our gendered social position or whether we have certain biological features, then our gender identity will not determine our gender.

There are several different ways of approaching the question what is the relationship between our gender identity and our gender? We can approach this question as a descriptive or hermeneutical question about our current concepts of gender identity and gender: what is the relationship between our concept of gender identity and our concept of gender? ( Bettcher 2013 , Diaz-Leon 2016 , Laskowski 2020 , McGrath 2021 , Cosker-Rowland forthcoming , Saul 2012 ) Rather than focusing on descriptive questions about our gender concepts, many feminists, such as Sally Haslanger (2000) and Katharine Jenkins (2016) , have proposed ameliorative accounts of the concepts of gender which we should accept; these are gender concepts which they argue that we can use to further the feminist purposes of fights against gender injustice and campaigns for trans rights. We might then ask the ameliorative question, what is the relationship between our gender identity and our gender according to the concepts of gender and gender identity that we should accept? However, some of the most interesting recent work on the relationship between gender identity and gender has focussed on the metaphysical issue of the relationship between being a member of a particular gender kind G (e.g. being a woman) and having gender identity G (e.g. having a female gender identity). As we’ll see, we can answer these different questions in different ways: for instance, we can hold that we should adopt concepts such that someone is a woman iff they have a female gender identity but hold that metaphysically someone is a woman iff they are treated as a woman by their society, that is, iff they are socially positioned as a woman.

Four positions about the relationship between gender identity and gender that give answers to these ameliorative and metaphysical questions have emerged. This article will explain and evaluate these four positions. In order to understand these different views about the relationship between gender identity and gender it will help to have a little understanding of recent work on gender identity. The two most well-known and popular accounts of gender identity in the analytical philosophy literature are the self-identification account and the norm-relevancy account. On the self-identification account, to have a female gender identity is to self-identify as a woman. One way of explaining what it means to self-identify as a woman is to hold that such self-identification consists in a disposition to assert that one is a woman when asked what gender one is. 1 On the norm-relevancy account, to have a female gender identity is to experience the norms associated with women in your social context (e.g. the norm, women should shave their legs) as relevant to you ( Jenkins 2016 , 2018 ).

A first view of the relationship between gender and gender identity is what we can call gender identity first . According to a metaphysical version of gender identity first , what it is to be gender G (e.g. a woman) is to have a G gender identity (e.g. to have a female gender identity). Talia Bettcher (2009 : 112), B.R. George and R.A. Briggs (m.s.: §1.3–4), Iskra Fileva (2020 : esp. 193), and Susan Stryker (2006 : 10) argue for gender identity first or views similar to it. And the view that our gender is always determined by our gender identity is, as Briggs and George discuss, part of the standard view in many trans communities and among activists for trans rights. One key virtue of gender identity first is that it ensures that gender is always consensual: on this view, we can be correctly gendered as gender G (e.g. as a woman) only if we identify as a G , and so we can be correctly gendered as a G only if we consent to be gendered as a G by others ( George and Briggs m.s. : §1.3) ( Figure 1 ). 2

Gender identity first

Elizabeth Barnes (2022 : 2) argues that we should reject gender identity first as both a metaphysical and as an ameliorative view. She argues that

(i) Some severely cognitively disabled people do not have gender identities, but

(ii) These severely cognitively disabled people without gender identities have genders and should be categorized as having genders.

And in this case, although having gender identity G is sufficient for being gender G , it is not necessary for being gender G nor necessary for being categorized as a G according to the concepts of gender that we should accept. So, we should reject gender identity first as both a metaphysical view and as an ameliorative view.

Regarding (i), Barnes argues that gender identity

requires awareness of various social norms and roles (and, moreover an awareness of them as gendered), the ability to articulate one’s own relationship to those norms and roles, and so on. But many cognitively disabled people have little or no access to language. Many tend not to understand social norms, much less to identify those norms as specifically gendered. (6)

The norm-relevancy account of gender identity implies that this is true, since on this view having a gender identity involves taking certain gendered social norms to be relevant to you. And the self-identification account also seems to imply that having a gender identity involves having capacities that many severely cognitively disabled people do not have, since self-identification as a particular gender involves a linguistic capacity to say or be disposed to say that one is, or think of oneself as, a particular gender, and many severely cognitively disabled people do not have these capacities.

Barnes has two arguments for

(ii) Severely cognitively disabled people without gender identities have genders.

First, Barnes argues that severely cognitively disabled people who do not have gender identities nonetheless have genders because they suffer gender-based oppression ( 2022 : 11–12). For instance, severely cognitively disabled women are subject to gendered violence and forced sterilization to a greater degree than severely cognitively disabled men. This argument may seem strongest as an argument for (ii) as a metaphysical claim: the view that severely cognitively disabled people without gender identities have genders is the best explanation of what we find happening in the world.

Second, Barnes argues that holding that some severely cognitively disabled people do not have genders because they do not have gender identities would involve othering, alienating or dehumanizing these severely cognitively disabled people. Gender identity first implies that agender people do not have genders because their gender identity is that they have no gender. But Barnes argues that gender identity first’s implication that severely cognitively disabled people without gender identities lack a gender is more pernicious. Agender people have the capacity to form a gender identity but they opt-out of gender. Gender identity first implies that severely cognitively disabled people without gender identities fail to have genders because they do not have the capacity to form a gender identity. So, it implies that they fail to have a gender in the way that tables and animals fail to have a gender – by failing to have the right capacities to have a gender – rather than in the way that agender people do so; for agender people have these capacities. Therefore, Barnes argues, gender identity first others and alienates severely cognitively disabled people from other humans, since all other humans have the capacity to have a gender and having a gender (or opting out of it) is a central part of human (social life). 3 This second argument seems best understood as an argument that we shouldn’t adopt concepts of gender that imply that one is gender G iff one has gender identity G because there are moral and political costs to adopting such concepts.

A second account of the relationship between gender identity and gender is the opposite view; this view understands gender identity and gender as entirely disconnected. On this no connection view, the fact that a woman has a sense of herself as a woman is never what makes her a woman; other features of her, such as the way that she is socially positioned, the way she was socialized, or her biological features, make her a woman.

Several accounts of gender imply the no connection view, including Haslanger’s (2000) influential account of gender. Haslanger’s account was originally proposed as an ameliorative account of the concepts of gender that we should adopt rather than as a metaphysical account of gender properties. But in later work Haslanger also endorsed her account of gender as a metaphysical account of gender properties ( 2012 : e.g. 133–134). On Haslanger’s account, to be a woman is to be systematically subordinated because one is observed or imagined to have bodily features that are presumed to be evidence of a female’s biological role in reproduction; on Haslanger’s view, women are sexually marked subordinates. This view of what it is to be a woman implies that one’s being a woman is never determined by one’s female gender identity. Since, whether one has a sense of oneself as a woman, is disposed to assert that one is a woman or takes norms associated with women to be relevant to one, is neither necessary nor sufficient for one to be a sexually marked subordinate.

Although our gender is not directly determined by our gender identity on Haslanger’s account, one’s female gender identity can indirectly lead one to be a woman on Haslanger’s account. For instance, a trans woman’s female gender identity may lead her to take estradiol which will make her have female sex characteristics, which may lead to her being assumed to play a female biological role in reproduction, to be oppressed accordingly, and so to be a woman on Haslanger’s account. In this case, on Haslanger’s account, someone’s female gender identity can indirectly lead to their becoming a woman ( Figure 2 ).

The n o connection view

Other accounts of gender similarly imply the no connection view of the relationship between gender identity and gender. According to Bach’s (2012) account of gender, to be a woman one has to have been socialized as a woman. But one can have a sense of oneself as a woman without having been socialized as a woman and one can be socialized as a woman without forming a sense of oneself as a woman. So, having a female gender identity is neither necessary nor sufficient to be a woman on Bach’s account (although it may be more likely that A will have a sense of themself as a woman if A was socialized as a woman). Biological or sex-based accounts of gender on which our genders are determined by our biological features, such as our chromosomes, also imply the no connection view, since to have a female gender identity is neither necessary nor sufficient for having XX chromosomes. 4

The no connection view implies that many trans women are not women. For instance, Haslanger’s version of this view implies that trans women who are not presumed to have female sex characteristics by those in their society are not women; so trans women who are not recognised as women, or who ‘do not pass’, 5 are not women. This is because such trans women are not observed or imagined to have features that are presumed to be evidence of a female’s biological role in reproduction. There are many such trans women. So, no connection views such as Haslanger’s imply that many trans women are not women ( Jenkins 2016 : 398–402). Some have argued that this is an unacceptable result for a metaphysical view about the relationship between gender identity and gender, either because all trans women are women or because this view would marginalize trans women within contemporary feminism ( Mikkola 2016 : 100–102). These implications are even more problematic for ameliorative no connection views, that is, for views of how gender identity and gender are related according to the concepts that we ought to accept. For we should not adopt gender concepts that imply that we should not classify many trans women as women ( Jenkins 2016 ).

Furthermore, trans communities and trans-inclusive communities ascribe gender entirely on the basis of the gender identities people express or which people are presumed to have. Another problem with the no connection view is that it may seem to imply that there are no genders being tracked or ascribed in these communities ( Jenkins 2016 : 400–401; Ásta 2018 : 73–74).

These problems do not establish that Haslanger’s account of gender should be abandoned entirely. Elizabeth Barnes (2020) has recently argued that we can rescue Haslanger’s account of gender from the problem that it excludes trans women by understanding it as an account of what explains our experiences of gender. According to Barnes’ version of Haslanger’s account, our practices of gendering people, and our gender identities, are the product of Haslangerian social practices of subordinating and privileging people on the basis of perceived sex characteristics. Barnes’ version of Haslanger’s account does not imply that one is a woman iff one is systematically subordinated because one is observed or imagined to have bodily features that are presumed to be evidence of one’s playing a female’s biological role in reproduction. This is because Barnes’ account is only an account of what gives rise to our experiences of gender rather than an account of who has what gender properties or of the gender concepts that we should accept. Barnes might rescue a version of Haslanger’s account from the problem that it excludes trans women. But if she does, she does this by revising Haslanger’s account so that it drops the no connection view of the relationship between gender identities and gender; Barnes’ revised version of Haslanger’s account of gender is instead silent on the issue of the relationship between having gender identity G and being a member of gender G . So, Barnes’ rescue of Haslanger’s account of gender does not rescue the no connection view of the relationship between gender identity and gender.

Gender identity first and no connection views such as Haslanger’s are invariantist views of the relationship between gender identity and gender: they hold that the relationship between gender identity and gender does not vary across different contexts. A third account of the relationship between gender identity and gender is the opposite of invariantism, contextualism. According to this view, the features that determine our gender, and so the relationship between gender identity and gender, is different from context to context.

Ásta (2018) and Robin Dembroff (2018) have proposed and/or defended forms of (metaphysical) contextualism. On their views, the gender properties that we have, or the gender kinds that we are members of, are determined by the way that we are treated in particular contexts. We are a member of gender G in virtue of our gender identity G in certain contexts, namely trans-inclusive contexts where people are treated as genders based on their (avowed) gender identities. But in other contexts, we are never a member of gender G in virtue of our gender identity G : in contexts in which people are treated as a gender based on features other than their gender identities – such as traditional or conservative societies – we are not members of genders based on our gender identities. For instance, trans woman Amy is a woman in the context of the support group Trans Leeds – she is a woman (Trans Leeds) – but she is not a women in the context of her conservative parents in Henley who don’t recognize her as a woman and who treat people as women based on the chromosomes that they believe them to have – she is not a woman (family-in-Henley) . And Alex is non-binary in the context of the support group Non-Binary Leeds, where one is conferred a particular gender status based on one’s avowed self-identification – they are non-binary (Non-Binary Leeds) – but Alex is perceived as male in most contexts and is treated as male regardless of their self-identification at school, work and in public, and so Alex is not non-binary in most contexts – e.g. they are not non-binary (Alex’s school) . Importantly, on this view, there is no such thing as being gender G simpliciter , that is, beyond whether one is a G -relative-to-a-certain-context – and the way one is treated or the standards that are operative in that context. So, it is not the case that Alex is non-binary simpliciter or genuinely non-binary; they are merely non-binary relative to one standard or context and not non-binary relative to another.

Contextualism can explain why the way that some people are gendered varies from context to context: in explaining her contextualist view, Ásta (2018 : 73–74) gives an example of a coder who is one of the guys at work, neither a guy nor a girl at the bars they go to after work, and one of the women – and expected to help out like all the other women – at their grandmother’s house (85–86). Contextualism also allows us to explain how sometimes people are gendered on the basis of their perceived biological features and sometimes gendered based on their avowed (or assumed) gender identities. Dembroff argues that a contextualist view is particularly useful in explaining how, in many societies and contexts, trans people are unjustly constrained, or as they put it ‘ontologically oppressed’, by being constructed and categorized as a member of a category with which they do not identify; identifying such ontological oppression is essential to explaining the oppression that trans people face ( Dembroff 2018 : 24–26, Jenkins 2020 ) ( Figure 3 ).

Contextualism

However, there are several problems with contextualism. One problem is that it implies that gender critical feminists are, in a sense, right when they claim that trans women are not women and trans men are not men because trans women are not women according to the standards of many people and of many places: in many places trans women, for instance, are not treated as women, and in many places trans women are not women relative to the dominant standard for who is a woman, which is sex-based or biology-based. So, for instance, when in 2021 the then Tory UK Health Secretary Sajid Javid said that ‘only women have cervixes’, according to contextualism, what he said was true in a sense: only women (dominant UK-standards) have cervixes; and only women (Tory party conference) have cervixes. Even though it is false that only women (Trans Leeds) have cervixes because trans men have cervixes. This conclusion may seem problematic and paralyzing because it implies that Javid’s claim is true in a sense in certain contexts, and we cannot truthfully claim that it is just plain false ( Saul 2012 : 209–210, Diaz-Leon 2016 : 247–248). 6

Ásta (2018 : e.g. 87–88) and Dembroff (2018) argue that we can solve this problem by holding that, although it is true that trans men are not men relative to most dominant UK contexts, we should still treat and classify trans men as men. We should classify trans men as men because facts about how we should classify someone – the gender properties that we should treat them as having – are established by moral and political considerations. But although we should classify trans men as men, they are not – as a matter of social metaphysical fact – men (dominant UK contexts) . So, we should accept contextualism as a metaphysical view about the relationship between gender identity and gender but not as an ameliorative view about the gender concepts we should accept; we can call this combination of views purely metaphysical contextualism.

Dembroff (2018 : 38–48) recognizes that purely metaphysical contextualism may seem to have problematic implications. It may seem to imply that many trans women (for instance) are mistaken when they say that they are women in many contexts, such as dominant UK and US contexts, where there are chromosomes-based or assigned-sex-at-birth-based gender standards. Yet Dembroff argues that purely metaphysical contextualism does not have this problematic implication because trans women are women relative to the gender kinds operative in trans-inclusive contexts.

However, this will not always be a helpful form of correctness. Suppose that Alicia is a trans woman in London in 1840. There are no trans-inclusive societies, communities or contexts that she knows of. But she takes herself to be a woman, and suppose that according to both of the accounts of gender identity that we discussed in §1, Alicia has a female gender identity. We can say that Alicia’s judgement that she is a woman is correct in the sense that it is correct-relative to the gender kinds operative in future contexts and fictional contexts. But any judgment that we might make is true relative to the standards in some future or merely possible context. And we might wonder why it matters that someone’s judgment about their own gender is true relative to the standards operative in some future context that they could not possibly be aware of. This form of truth is not what they want and it’s hard to see why it should be relevant in this context. Furthermore, trans people are widely held to be misguided, mentally unstable, suffering from a delusion or making believe ( Bettcher 2007 , Serano 2016 : ch. 2, Lopez 2018 , Rajunov and Duane 2019 : xxiv). If the only interesting way in which Alicia is correct about her gender is that she is that gender according to standards far in the future that she is not aware of, then it would seem that Alicia is misguided about her gender – given that she could not know about these standards – and that she is in a sense making believe. This seems like an undesirable consequence, especially if we think that Alicia is really a woman, that is, that she is not misguided.

There are two further, more general, problems for contextualism. 7 First, contextualism seems to clash with how many of us think about our own and others’ genders. For instance, many trans men think that they should be classified as men because they are men, and not just because they are men-relative to the standards of trans-inclusive communities and societies ( Saul 2012 : 209–210). 8 Gender critical feminists think that trans women are not women, that standards which align with this view track the standard-independent truth, and standards which don’t align with this view do not.

Second, contextualism seems to be in tension with the idea that many of our disagreements about gender are genuine disagreements. Suppose that contextualism is true and that we (and everyone else) accept it. In this case, it is hard for us to sincerely genuinely disagree with Javid about whether only women have cervixes. Since, when he says that only women have cervixes we know that he means that only those who count as women, relative to the dominant UK standards or relative to the standards operative amongst Tory MPs and members, have cervixes. And we agree with him about this, since we know that according to these standards trans men are women. So, if contextualism is true and we accept it, it is hard for us to genuinely disagree with Javid. Contextualism could be true without our knowing or believing it. In this case, we could genuinely disagree with Javid. But our disagreement here would only be possible because we are significantly mistaken about what kinds of things gender kinds are; we think gender kinds are not all context- or standard-relative but in fact they are. And attributing such a significant mistake to all of us is a significant cost of a metaphysical theory, for other things equal we should accept more charitable theories that do not imply that we are significantly mistaken rather than theories that do imply this ( Olson 2011 : 73–77, McGrath 2021 : 35, 46–48).

These problems with contextualism about the relationship between gender identity and gender are analogues of problems that contextualist views face in other domains such as in metaethics. According to metaethical contextualism, moral claims, their meanings and their truth are always standard-relative. There is no such thing as an act being morally wrong, only its being morally-wrong-relative-to-utilitarianism or morally-wrong-relative-to-the-standards-of-Victorian-England. But metaethical contextualism faces a problem explaining fundamental moral disagreement. Act-utilitarians and Kantians agree that pushing the heavy man off of the bridge in the footbridge trolley case is wrong (Kantianism) and right (act-utilitarianism) but they still disagree and they take themselves to be disagreeing about which of their moral standards is correct, and which standard tracks the truth about which actions are right and wrong simpliciter ( Olson 2011 : 73–77, Cosker-Rowland 2022 : 57–59). If there are no non-context- or standard-relative properties of right and wrong, then although Kantians and Utilitarians do disagree – they think there are such properties – there is in fact nothing for them to disagree about. So, metaethical contextualism seems to be committed to a kind of error theory about morality that, other things equal, we should avoid: Kantians and Utilitarians think that they are talking about which of their moral standards is independently correct, but there is no such standard-independent moral correctness. Contextualists in metaethics have developed several types of resources to mitigate this kind of problem or to enable contextualism to explain what’s happening in these disagreements better. Perhaps these proposals could be used to mitigate the analogous problems with contextualism about the relationship between gender identity and gender. McGrath (2021 : esp. 42–49) considers this possibility and argues that these responses are not plausible, and that they face similar problems to the problems faced by the analogous responses proposed by contextualists in metaethics. 9 More broadly, whether contextualists’ proposals to mitigate these problems for metaethical contextualism do, or could, succeed is contested ( Cosker-Rowland 2022 : 59–64). 10

Contextualism holds that the features that determine our gender vary from context to context and so whether our gender identity determines our gender varies from context to context. Invariantist views such as gender identity first and the no connection view hold that one feature (e.g. gender identity or whether one is a sexually marked subordinate) determines our gender in every context. But we need not adopt such a monist invariantist view; we can instead adopt a pluralist invariantist view that holds that multiple features are relevant to, or determine, our genders across different contexts ( Figure 4 ). A version of pluralism that has been proposed is what we can call the two properties view. According to the two properties view, two and only two properties determine our gender in all contexts: our gender identity and our gendered social position or class. Gender identity first and Haslanger’s no connection view hold that one of these two properties determines our gender in every context; the two properties view holds that both of these properties can make us a particular gender in every context. 11

Views of the relationship between gender identity and gender

Katharine Jenkins (2016) proposes an ameliorative version of the two properties view. She proposes that we accept gender concepts according to which there are two senses of woman . In one sense of woman , to be a woman is to have a female gender identity; in another second sense, to be a woman is to be socially classed as a woman, which we can understand in terms of Haslanger’s account: to be a woman in this second sense is to be a sexually marked subordinate. Jenkins argues that if we accept gender concepts according to which there are two senses of ‘woman’, we do not objectionably exclude trans women, since trans women who are not socially classed as women do have female gender identities and so are still women on this view. So, Jenkins argues that we should accept gender concepts such that A is a woman iff A is socially classed as a woman or has a female gender identity. She then argues that, although we should accept gender concepts on which there are two senses of gender, we should, at least primarily, use ‘woman’ to refer to people with a female gender identity rather than those who are classed as women.

Jenkins’ two properties view avoids the problems with the ameliorative gender identity first and no connection views. It does not imply that severely cognitively disabled women are not women and it does not imply that trans women are not women. Yet if we adopt a concept of ‘woman’ with two senses but use ‘woman’ to refer to people with female gender identities, it still seems that we adopt concepts according to which trans women who are not socially classed as women are not women in an important sense. We may want to avoid this consequence with our ameliorative proposals, since trans women want to be thought of as women, and many trans women want to be thought of as in no way men, rather than merely being referred to as women rather than men (see e.g. Wynn 2018 ). We might also worry that adoption of Jenkins’ view would create a hierarchy of women on which someone who is a woman in both senses is more of a woman than someone who is a woman in only one sense: we might worry that if such concepts of gender were adopted, a trans woman who does not have her womanhood socially recognized would be seen as less of a woman than a trans woman who is socially positioned as a woman. 12

Elizabeth Barnes (2022 : 24–25) briefly articulates a similar metaphysical two properties view. On this view, there are two different properties that one can have that can make it the case that one is gender G : the property of being socially classed as a G and the property of having gender identity G . And the relevant gender identity property takes priority when A is socially classed as a G1 (e.g. as a man) but has gender identity G2 (e.g. a female gender identity): in such a case A is a G2 (a woman) rather than a G1 (a man) ( Figure 5 ).

The two properties view

However, the two properties view needs to explain why our gender identities take precedence over our gendered social position in determining our gender when the two conflict. Without further supplementation the metaphysical two property view does not do this; it does not explain why A is a man when A has a male gender identity but is socially positioned as a woman. If the two properties view does not explain this, it has an explanatory deficiency, and this deficiency gives us reason to accept competing views that do not face this explanatory problem over the two properties view.

One natural way to supplement the two properties view to try to solve this explanatory problem is to hold that moral and political considerations determine that gender identity takes priority over gender class when they conflict. 13 . First, it is controverisal that there is moral encroachment on gender metaphysics, that what's morally best makes a difference to what gender we metaphysically are. For instance, Ásta (2018) , Dembroff (2018) and Jenkins (2020) argue that morality does not encroach on gender metaphysics in this way.

Second, we can think of this as the moral encroachment explanation. However, moral encroachment does not look like a plausible explanation of how, metaphysically, gender identity takes priority over gendered social position in determining our genders. To see this, suppose that Alexa understands herself to be a woman and is treated by those around her as a woman. An evil demon will kill 2000 members of Alexa’s community unless we hold that Alexa is a man, treat Alexa as, think of Alexa as, and assert that Alexa is a man for the next hour. In this case, moral and political considerations establish that we morally ought to treat Alexa as a man for the next hour, but this doesn’t mean that Alexa is in fact a man. 14

It might seem that a nearby view on which moral and political considerations play a smaller role is more plausible. On this view, moral and political considerations only come in to determine whether, metaphysically, A is a member of gender G1 or of gender G2 when A is socially classed as a G1 but has identity G2 . But this view would also generate counterintuitive results. To see this, suppose that Beth has a female gender identity and she was assigned female at birth, but she is socially classed as a man – she doesn’t resist this because of the strong economic advantages she receives, which outweigh the discomfort she feels by being constantly misgendered. Now suppose that an eccentric, very powerful and malevolent millionaire brings these facts to light but will torture everyone in our society unless we continue to classify, think of and refer to Beth as a man. In this case, plausibly, moral and political considerations establish that we should classify Beth as a man, but these facts do not seem to bear on whether Beth is a man or a woman; intuitively Beth is a woman, and intuitively the fact that morally we should think of, treat, and classify Beth as a man does not make it the case that Beth is a man – and really has nothing to do with Beth’s gender in this case. So, if moral and political considerations play this more limited role in determining our genders, they still sometimes generate the wrong result because there are cases in which the social and political considerations side with someone’s gendered social position rather than their gender identity, but in which this does not seem to be relevant to, or establish that, their gender lines up with their gendered social position. So, the moral encroachment explanation does not seem to solve the explanatory problem for the two properties view. 15

These evil millionaire cases may be too fantastical for some. But the same point can be made with real world examples too. Norah Vincent (2006) disguised herself as a man for 18 months so that she could investigate men and their experiences. She became socially positioned as, and treated by others as, a man. While she was effectively disguised as a man, moral and political considerations seem to have established that everyone should treat her as a man: those who didn’t know her real gender had an obligation to take her assertions that she was a man as genuine and those who did know her real gender had an obligation not to blow her cover. But although everyone ought to have treated Vincent as a man, she was not a man: she did not identify as a man at the time, nor prior or subsequent to her journalistic project. Moral and political considerations favoured treating Vincent in line with her social position as a man rather than in line with her female gender identity. But these factors do not establish that she was a man rather than a woman. So, the moral encroachment explanation generates the wrong results in this case too.

One way to respond to this problem for the two properties view is to drop the view that gender identity takes priority. But this would be problematic for then trans women who are socially positioned as men would be both men and women on this view – and not just people with female gender identities who are socially positioned as men. This is implausible. This view is also different from contextualism since contextualism holds that such trans women are women-relative-to-the-standards-of-trans-inclusive-contexts and men-relative-to-other-contexts; a version of the two properties view that drops the priority of gender identity holds that such trans women are both men and women tout court .

In this paper I’ve discussed metaphysical and ameliorative inquiries into the relationship between gender identity and gender. I’ve discussed four different views about this relationship. All four views face problematic objections. Gender identity first seems to objectionably exclude some severely cognitively disabled people from having genders. No connection views seem to be objectionably trans exclusionary. Contextualism seems to be in tension with how we think about gender and implies that trans people are not the genders that line up with their gender identities in many contexts; despite contextualists’ best efforts, these implications still seem problematic. Pluralist views struggle to plausibly explain how their plurality of features interact when they conflict to determine our genders.

One avenue of future research involves examining the extent to which these objections really undermine these different views. For instance, we might question whether Barnes really shows that we should reject gender identity first. Barnes has two arguments for the view that, contra gender identity first, severely cognitively disabled people without gender identities have genders.

The first argument was that, if we reject this view, we cannot explain the gendered oppression that severely cognitively disabled women face. But we might wonder whether this is really true. All we need in order to explain the oppression that severely cognitively disabled women face is the claim that they are socially treated or understood to be women. But we can be socially treated or understood to be a gender other than the gender we are: e.g. many non-binary people who were assigned female at birth (AFAB) are discriminated against because they are understood to be women even though they are not women. We might think that we should explain the gendered oppression that AFAB severely cognitively disabled people without gender identities face and the gendered discrimination that AFAB non-binary people face in the same way: we should say that although they are not women, they are assumed to be women and are treated as women and this is why they face this gendered oppression. Barnes’ second argument was that the view that severely cognitively disabled people without gender identities do not have genders others and alienates these severely cognitively disabled people. However, we might wonder whether this is necessarily true. Perhaps we should think of the capacity to have a gender as inessential to human personhood just as we think of the capacity for membership in other categories as something that is not required for personhood: perhaps we should think that just as some severely cognitively disabled people lack the cognitive capacities to identify as a Christian or as a punk, and so are not Christians or punks, they similarly lack the capacities to identify as a woman and so are not women. If gender need not be central to human life, as religion (or music) need not be, perhaps we might reasonably claim to not other anyone by holding that they could not have a gender.

A second avenue of further work concerns genders beyond the gender category woman . Most of the work on the relationship between gender identity and gender has concerned the relationship between being a woman and having a female gender identity. But views about this may not straightforwardly generalize to provide plausible accounts of other genders such as genderqueer and other non-binary genders. 16 In one of the few published articles in analytic philosophy discussing genders beyond the gender binary, Dembroff (2020) argues that non-binary and genderqueer are critical gender kinds, which should be understood as kinds, membership in which constitutively involves engagement in the collective destabilization of dominant gender ideology. One way to destablize dominant gender ideology is to destabilize the idea that there are two mutually exclusive genders. Such destabilization of the binary gender axis can involve using gender neutral pronouns, cultivating gender non-conforming aesthetics, asserting one’s non-binary gender categorization, queering personal relationships, eschewing sexual binaries and/or switching between male and female coded spaces. Dembroff argues that to be genderqueer is ‘to have a felt or desired gender categorization that conflicts with the binary [gender] axis, and on that basis collectively destabilize this axis’ ( 2020 : 16). This understanding of the category genderqueer does not quite fit into the typology that I’ve explained in this article. For, on this account, a particular kind of non-binary gender identity is necessary but not sufficient for membership in the kind genderqueer .

There are issues with this account. For instance, Matthew Cull (2020 : 162) argues that this account misgenders agender people because many agender people have a felt or desired gender categorization that conflicts with the binary gender axis and are engaged in the collective destabilization of the gender binary but are not genderqueer; they are agender. 17 However, in general, more work is needed on gender kinds beyond the gender binary. This work may also provide new avenues for conceptualizing and/or complicating the relationship between gender identity and gender more generally. 18

See Bettcher (2009) ( 2017 : 396) and Jenkins (2018 : 727). cf. Barnes (2020 : 709).

See also Bornstein (1994 : 111, 123–124).

On the centrality of gender for social life see Witt 2011 .

See Bryne (2020) and Stock (2021 : ch. 2, ch. 6).

There are problems with using this terminology of passing. For instance, we typically think of A as passing as an F only if they are not an F . But if all trans women are women, then there are no ‘non-passing’ trans women. For discussion of issues with the concept of passing see e.g. Serano 2016 : 176–180.

Many gender critical feminists will want to reject contextualism for a similar but opposite reason: they believe that there is no sense in which Javid is mistaken, but contextualism implies that there is a sense in which he is mistaken.

For problems along these lines see McGrath 2021 : esp. 42–49.

Cf. Bettcher 2013 : esp. 242–243.

Cf. Dembroff 2018 : 44–45.

According to Jenkins’ (2023) ontological pluralism, there are a plurality of gender properties. For instance, there is the property of being a woman in the sense of having a female gender identity, and the property of being socially positioned as a woman in a particular context, but there is no further property of being a woman. Ontological pluralism about gender properties is a slightly different view about gender properties from the social position account of gender properties that Ásta and Dembroff propose; see Bettcher 2013 and Jenkins 2023. But ontological pluralism similarly implies that being a woman (social position) is not determined by one’s gender identity but being a woman (gender identity) is; and that there is no such thing as being a woman tout court beyond such a plurality of more specific gender properties. Since it has similar implications about the relationship between gender identity and gender to Ásta and Dembroff's views, it faces similar problems.

Other work on the metaphysics of gender, such as Stoljar’s (1995) nominalism or a view similar to it, could also be understood as a form of pluralist invariantism; although cf. Stoljar 1995 : 283 and Mikkola 2016 : 70.

Cf. Mikkola 2019 : §3.1.2 and Jenkins 2016 : 418–419.

Cf. Jenkins 2016 : 417–418 and Diaz-Leon 2016 .

Cases like this may also cause problems for Ásta’s and Dembroff’s social position accounts of gender.

Heather Logue suggested to me that a more specific form of moral encroachment might solve this problem: our autonomy might establish that our gender identities trump our gendered social positions when they conflict, without establishing that Beth is a man. However, we can imagine a version of this case in which Beth autonomously chooses to waive her right to be treated in line with her gender identity. In such a case Beth is still not a man.

We may also wonder whether this work will generalize to the category man given that human beings are still by default understood to be men in many contexts.

Another worry is that analogous accounts of the kind non-binary will either: (a) make the conditions for engagement in collective resistance too onerous and thereby exclude non-binary people who are not able to engage in this resistance due to oppressive circumstances; or (b) make these conditions too easy to satisfy, in which case it is unclear what work engagement in collective resistance is doing in this account; that is, it is unclear why we should prefer an account of the kind non-binary like this to a gender identity first account of the category non-binary . For work relevant to (a), arguing that trans people in the past who could not express their gender identities or resist the binary gender axis due to hostile circumstances may still be correctly considered to be trans, see Heyam 2022 : ch. 1.

I am grateful to a reviewer, who revealed themself to be Ray Briggs, for wonderful extremely thorough comments on a previous draft of this paper. I would also like to thank an audience of my colleagues at the University of Leeds for comments, thoughts and objections that shaped the final version of this paper.

Andler , M.S.   2017 . Gender identity and exclusion: a reply to Jenkins . Ethics   127 : 883 – 95 .

Google Scholar

Ásta . 2018 . The Categories We Live By . Oxford : Oxford University Press .

Google Preview

Bach , T.   2012 . Gender is a natural kind with a historical essence . Ethics   122 : 231 – 72 .

Barnes , E.   2020 . Gender and gender terms . Noûs   54 : 704 – 30 .

Barnes , E.   2022 . Gender without gender identity: the case of cognitive disability . Mind Online First: 1 – 28 .

Bettcher , T.M.   2007 . Evil deceivers and make-believers: on transphobic violence and the politics of illusion . Hypatia   22 : 43 – 65 .

Bettcher , T.M.   2009 . Trans identities and first-person authority . In You’ve Changed: Sex Reassignment and Personal Identity , ed. L.   Shrage . Oxford : Oxford University Press .

Bettcher , T.M.   2013 . Trans women and the meaning of ‘women’ . In Philosophy of Sex: Contemporary Readings , 6th edn., eds. A.   Soble , N.   Power , and R.   Halwani . London : Rowman and Littlefield .

Bettcher , T.M.   2017 . Through the looking glass: trans theory meets feminist philosophy . In The Routledge Companion to Feminist Philosophy , eds. A.   Garry , S.   Khader , and A.   Stone . London : Routledge .

Bornstein , K.   1994 . Gender Outlaw.   New York, NY : Routledge .

Byrne , A.   2020 . Are women adult human females ? Philosophical Studies   177 : 3783 – 803 .

Cosker-Rowland , R.   2022 . Moral Disagreement . London : Routledge .

Cosker-Rowland , R.   forthcoming . The normativity of gender . Noûs .

Cull , M.   2020 . Engineering Genders: Pluralism, Trans Identities, and Feminist Philosophy . PhD thesis, University of Sheffield .

Dembroff , R.   2018 . Real talk on the metaphysics of gender . Philosophical Topics   46 : 21 – 50 .

Dembroff , R.   2020 . Beyond binary: genderqueer as critical gender kind . Philosophers’ Imprint   20 : 1 – 23 .

Diaz-Leon , E.   2016 . Woman as a politically significant term: a solution to the puzzle . Hypatia   31 : 245 – 58 .

Fileva , I.   2020 . The gender puzzles . European Journal of Philosophy   29 : 182 – 98 .

George , B.R. and R.A.   Briggs . m.s. Science fiction double feature: trans liberation on twin Earth . Unpublished manuscript. https://philpapers.org/archive/GEOSFD.pdf .

Haslanger , S.   2000 . Gender and race: (what) are they? (What) do we want them to be ? Noûs   34 : 31 – 55 .

Haslanger , S.   2012 . Resisting Reality . Oxford : Oxford University Press .

Heyam , K.   2022 . Before We Were Trans . London : Basic Books .

Jenkins , K.   2016 . Amelioration and inclusion: gender identity and the concept of woman . Ethics   126 : 394 – 421 .

Jenkins , K.   2018 . Toward an account of gender identity . Ergo   5 : 713 – 44 .

Jenkins , K.   2020 . Ontic injustice . Journal of the American Philosophical Association   6 : 188 – 205 .

Jenkins , K.   2023 . Ontology and Oppression . Oxford : Oxford University Press .

Laskowski , N.G.   2020 . Moral constraints on gender concepts . Ethical Theory and Moral Practice   23 : 39 – 51 .

Lopez , G.   2018 . Transgender people: 10 common myths . Vox.com . < https://www.vox.com/identities/2016/5/13/17938120/transgender-people-mental-illness-health-care >, last accessed 14 November 2018 .

McGrath , S.   2021 . The metaethics of gender . In Oxford Studies in Metaethics , vol. 16 , ed. R.   Shafer-Landau . Oxford : Oxford University Press .

McKitrick , J.   2015 . A dispositional account of gender . Philosophical Studies   172 : 2575 – 89 .

Mikkola , M.   2016 . The Wrong of Injustice: Dehumanization and its Role in Feminist Philosophy . Oxford : Oxford University Press .

Mikkola , M.   2019 . Feminist perspectives on sex and gender . In The Stanford Encyclopedia of Philosophy , ed. E.N.   Zalta . Fall 2019 edition. < https://plato.stanford.edu/archives/fall2019/entries/feminism-gender/ >.

Olson , J.   2011 . In defense of moral error theory . In New Waves in Metaethics , ed. M.   Brady . Basingstoke : Palgrave .

Rajunov , M. and S.   Duane .   2019 . Introduction . In Nonbinary: Memoirs of Gender Identity , eds. M.   Rajunov and S.   Duane . New York, NY : Columbia University Press .

Saul , J.   2012 . Politically significant terms and philosophy of language: methodological issues . In Out from the Shadows: Analytical Feminist Contributions to Traditional Philosophy , eds. S.   Crasnow and A.   Superson . Oxford : Oxford University Press .

Serano , J.   2016 . Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity , 2nd ed. Berkeley, CA : Seal Press .

Stock , K.   2021 . Material Girls . London : Fleet .

Stoljar , N.   1995 . Essence, identity, and the concept of woman . Philosophical Topics   23 : 261 – 93 .

Stryker , S.   2006 . ( De)subjugated knowledges: an introduction to transgender studies . In The Transgender Studies Reader , eds. S.   Stryker and S.   Whittle . New York, NY : Routledge .

Vincent , N.   2006 . Self-Made Man . New York, NY : Viking .

Witt , C.   2011 . The Metaphysics of Gender . Oxford : Oxford University Press .

Wynn , N.   2018 . Pronouns . Contrapoints   31 : 55 . < https://youtu.be/9bbINLWtMKI >.

Email alerts

Companion article, citing articles via.

• Author Guidelines
• Contact Analysis Trust
• Recommend to your Library

Affiliations

• Online ISSN 1467-8284
• Print ISSN 0003-2638
• Copyright © 2024 The Analysis Trust
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Gender identity development in children and young people: A systematic review of longitudinal studies

Affiliations.

• 1 Research and Development Unit, Tavistock and Portman NHS Foundation Trust, London, UK.
• 2 Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust, London, UK.
• 3 Division of Psychiatry, University College London, UK.
• 4 Research Department of Clinical, Educational and Health Psychology, University College London, UK.
• PMID: 33827265
• DOI: 10.1177/13591045211002620

Background: Children are presenting in greater numbers to gender clinics around the world. Prospective longitudinal research is important to better understand outcomes and trajectories for these children. This systematic review aims to identify, describe and critically evaluate longitudinal studies in the field.

Method: Five electronic databases were systematically searched from January 2000 to February 2020. Peer-reviewed articles assessing gender identity and psychosocial outcomes for children and young people (<18 years) with gender diverse identification were included.

Results: Nine articles from seven longitudinal studies were identified. The majority were assessed as being of moderate quality. Four studies were undertaken in the Netherlands, two in North America and one in the UK. The majority of studies had small samples, with only two studies including more than 100 participants and attrition was moderate to high, due to participants lost to follow-up. Outcomes of interest focused predominantly on gender identity over time and emotional and behavioural functioning.

Conclusions: Larger scale and higher quality longitudinal research on gender identity development in children is needed. Some externally funded longitudinal studies are currently in progress internationally. Findings from these studies will enhance understanding of outcomes over time in relation to gender identity development in children and young people.

Keywords: Gender identity; children and young people; gender dysphoria; longitudinal; outcomes; prospective.

PubMed Disclaimer

Similar articles

• Longitudinal Outcomes of Gender Identity in Children (LOGIC): protocol for a prospective longitudinal cohort study of children referred to the UK gender identity development service. Kennedy E, Spinner L, Lane C, Stynes H, Ranieri V, Carmichael P, Omar R, Vickerstaff V, Hunter R, Wright T, Senior R, Butler G, Baron-Cohen S, Young B, King M. Kennedy E, et al. BMJ Open. 2021 Sep 7;11(9):e045628. doi: 10.1136/bmjopen-2020-045628. BMJ Open. 2021. PMID: 34493504 Free PMC article.
• Longitudinal outcomes of gender identity in children (LOGIC): a study protocol for a prospective longitudinal qualitative study of the experiences and well-being of families referred to the UK Gender Identity Development Service. McKay K, Kennedy E, Lane C, Wright T, Young B. McKay K, et al. BMJ Open. 2021 Nov 3;11(11):e047875. doi: 10.1136/bmjopen-2020-047875. BMJ Open. 2021. PMID: 34732477 Free PMC article.
• Longitudinal Outcomes of Gender Identity in Children (LOGIC): study protocol for a retrospective analysis of the characteristics and outcomes of children referred to specialist gender services in the UK and the Netherlands. Kennedy E, Lane C, Stynes H, Ranieri V, Spinner L, Carmichael P, Omar R, Vickerstaff V, Hunter R, Senior R, Butler G, Baron-Cohen S, de Graaf N, Steensma TD, de Vries A, Young B, King M. Kennedy E, et al. BMJ Open. 2021 Nov 10;11(11):e054895. doi: 10.1136/bmjopen-2021-054895. BMJ Open. 2021. PMID: 34758999 Free PMC article.
• Beverage Consumption and Growth, Size, Body Composition, and Risk of Overweight and Obesity: A Systematic Review [Internet]. Mayer-Davis E, Leidy H, Mattes R, Naimi T, Novotny R, Schneeman B, Kingshipp BJ, Spill M, Cole NC, Bahnfleth CL, Butera G, Terry N, Obbagy J. Mayer-Davis E, et al. Alexandria (VA): USDA Nutrition Evidence Systematic Review; 2020 Jul. Alexandria (VA): USDA Nutrition Evidence Systematic Review; 2020 Jul. PMID: 35349233 Free Books & Documents. Review.
• IMPRoving Outcomes for children exposed to domestic ViolencE (IMPROVE): an evidence synthesis. Howarth E, Moore THM, Welton NJ, Lewis N, Stanley N, MacMillan H, Shaw A, Hester M, Bryden P, Feder G. Howarth E, et al. Southampton (UK): NIHR Journals Library; 2016 Dec. Southampton (UK): NIHR Journals Library; 2016 Dec. PMID: 27977089 Free Books & Documents. Review.
• Early Female Transgender Identity after Prenatal Exposure to Diethylstilbestrol: Report from a French National Diethylstilbestrol (DES) Cohort. Gaspari L, Soyer-Gobillard MO, Kerlin S, Paris F, Sultan C. Gaspari L, et al. J Xenobiot. 2024 Jan 12;14(1):166-175. doi: 10.3390/jox14010010. J Xenobiot. 2024. PMID: 38249107 Free PMC article.
• Consistency of gender identity and preferences across time: An exploration among cisgender and transgender children. Hässler T, Glazier JJ, Olson KR. Hässler T, et al. Dev Psychol. 2022 Nov;58(11):2184-2196. doi: 10.1037/dev0001419. Epub 2022 Aug 11. Dev Psychol. 2022. PMID: 35951394 Free PMC article.

Publication types

• Search in MeSH

LinkOut - more resources

Full text sources.

• Ovid Technologies, Inc.

Other Literature Sources

• scite Smart Citations

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Psychology of Sexual Orientation and Gender Diversity

• Read this journal
• Read free articles
• Journal snapshot
• Advertising information

Journal scope statement

Psychology of Sexual Orientation and Gender Diversity ® , the official publication of APA Division 44 (Society for the Psychology of Sexual Orientation and Gender Diversity), is a scholarly journal dedicated to the dissemination of information in the field of sexual orientation and gender diversity. It is a primary outlet for research particularly as it impacts practice, education, public policy, and social action.

The journal is intended to be a forum for scholarly dialogue that explores the multifaceted aspects of sexual orientation and gender diversity. Its focus is on empirical research (both quantitative and qualitative), theoretical and conceptual articles, in-depth reviews of the research and literature, clinical case studies, book reviews, and letters to the editor.

Many issues include a major article or set of articles on a specific theme of importance to theory, research, and/or practice in the psychology of sexual orientation and gender diversity. In addition, articles address professional issues, methodological and theoretical issues, and comments on previous publications in the journal as well as such topics that advance the psychological knowledge of lesbian, gay, bisexual, and transgender individuals and their families, couples and marriage, health and health care, aging, work, and careers.

The journal includes all areas of psychological research, especially developmental, social, clinical, community, counseling, family, gender roles and gender nonconformity, lifespan and aging, cultural diversity including race and ethnicity, and international issues.

Equity, diversity, and inclusion

Psychology of Sexual Orientation and Gender Diversity supports equity, diversity, and inclusion (EDI) in its practices. More information on these initiatives is available under EDI Efforts .

Editor's Choice

Each issue of the Psychology of Sexual Orientation and Gender Diversity will honor one accepted manuscript per issue by selecting it as an “ Editor’s Choice ” paper. Selection is based on the discretion of the editor if the paper offers an unusually large potential impact to the field and/or elevates an important future direction for science.

Author and editor spotlights

Explore journal highlights : free article summaries, editor interviews and editorials, journal awards, mentorship opportunities, and more.

Prior to submission, please carefully read and follow the submission guidelines detailed below. Manuscripts that do not conform to the submission guidelines may be returned without review.

To submit to the editorial office of M. Paz Galupo, PhD, please submit manuscripts electronically through the Manuscript Submission Portal in Microsoft Word (.docx) or LaTex (.tex) as a zip file with an accompanied Portable Document Format (.pdf) of the manuscript file.

Prepare manuscripts according to the Publication Manual of the American Psychological Association using the 7 th edition. Manuscripts may be copyedited for bias-free language (see Chapter 5 of the Publication Manual ). APA Style and Grammar Guidelines for the 7 th edition are available.

Submit Manuscript

M. Paz Galupo Washington University at St. Louis Missouri

Manuscript types

Psychology of Sexual Orientation and Gender Diversity ® ( PSOGD ) accepts a variety of article types consistent with the journal's mission, including:

Standard articles containing a maximum of 7,500 words of text (excluding tables and references). These will be the most typical articles.

Longer, monograph-style articles containing a maximum of 12,000 words of text. These longer contributions will not be typical and to be considered, must provide a particularly enhanced coverage of the topic addressed.

This can take the form of:

• especially extensive literature review with a methodological critique and/or public policy implications explicated
• description of an interlocked series of research projects
• synthesis of material on sexual orientation and gender diversity with material from other aspects of psychology and/or other disciplines
• similarly extensive contributions

Authors MUST OBTAIN  APPROVAL OF THE EDITOR PRIOR TO SUBMITTING THIS ARTICLE TYPE .

Brief reports are research-oriented and contain a maximum of 4,000 words of text.

Letters to the editor should be limited to 500 words. In unusual circumstances, the editor may allow a longer limit with the author.

Commentaries may address developments in the behavioral sciences and related fields, the legal system, national or world events, as these pertain to the content areas of PSOGD . These should be a maximum of 1000 words, unless a longer length is allowed by the founding editor.

As a rule of thumb one double-spaced page of standard font and size text contains about 300 words. If submissions contain an unusually larger number of references for the article type and/or unusually large tables/charts/graphs, authors may be required to reduce these. "Words" refers to words and other symbols or characters.

Qualitative research

PSOGD welcomes a variety of methodologies in its submissions, including quantitative, qualitative, and mixed quantitative/qualitative methodologies.

All submissions are expected to maintain word limits specific to the type of manuscript (see manuscript types); offer replicable methodology; involve an N commensurate with the purpose of the research and which allows reasonable inference; and be written in a concise and focused manner.

In particular, extensive quotations from research participants are ill-advised, and should be limited to a few which are especially evocative of key themes. The theme descriptions should be the predominant vehicle for conveying participants' responses in qualitative research.

Manuscript preparation

Review APA's Journal Manuscript Preparation Guidelines before submitting your article.

Since PSOGD first began publishing in 2014, a number of recurring questions and situations have arisen.

This material attempts to respond to these proactively, in the hope that potential authors have a clearer sense of PSOGD's expectations and procedures.

Please feel free to contact the editor with any inquiries about these topics below or others.

Masked submission

Nothing in your manuscript should indicate authors' identities, institutional affiliation, or other identifying features. Common examples include: naming the institution that granted institutional review board approval; citing by name previous publications on which the current submission explicitly builds; naming specific organizations that cooperated in data collection, etc.

The words " MASKED FOR REVIEW " should be substituted.

When masking earlier work on which the current submission is based, remember to remove the identifying citation both from the text and the references. Insufficiently masked submissions will be returned to authors for masking before being sent for review, which slows the review process.

If the article is accepted for publication, the identifying information can be added subsequently.

Please ensure that the final version for production includes a byline and full author note for typesetting.

Language guidelines

Authors should be cognizant that language and terminologies used to describe sexual orientation and gender diversity have been used in pejorative ways, have undergone transitions, may likely undergo more transitions, and should be used in ways that convey respect yet maintain precision.

When APA offers language guidelines or policy statements that address terminology, authors are generally expected to use these guidelines and statements. There are exceptions to this, such as accurately quoting or describing older literature which might use outdated or problematic terminology.

Revisions must be accompanied by a description of changes made, including previously rejected and rewritten papers incorporating feedback.

As the decision letters state, when submitting a revision, authors must include a letter or memo describing the changes made in response to reviewer and editor feedback. This letter should address all the points raised by the editor and reviewers. It is acceptable to disagree with feedback and reject or modify a requested change; this should be clearly stated, and a rationale provided for the disagreement.

Resubmission of a previously rejected manuscript is generally not recommended without consultation with the editor. If resubmission of a previously rejected manuscript is made, authors should note the manuscript number of the earlier rejected submission, and include the same full description of changes made as described in the above paragraph.

Revisions/resubmissions without a description of changes made will not be read and will be returned to authors with instructions to provide this description.

Abstract and keywords

All manuscripts must include an abstract containing a maximum of 250 words typed on a separate page.

After the abstract, please supply up to five keywords or brief phrases.

PSOGD encourages submissions from all countries and aspires to disseminate knowledge about sexual orientation and gender diversity internationally.

To this end, authors should submit abstracts and keywords in English and, if they wish, in addition provide abstracts in any other language(s) relevant to the submission in question.

Specifically, authors may submit abstracts and keywords in languages in addition to English in the following circumstances:

• When the research subjects or content matter involve non-English speaking populations
• When the authors are based in a non-English speaking country or comprise a multi-national team with some members from non-English speaking countries.
• There may be other circumstances where authors wish abstracts in other languages to be included. These should be reviewed and approved by the editor.

Note that all submissions must include an abstract and keywords in English.

Non-English language abstracts

PSOGD is committed to encouraging and disseminating scholarship on sexual orientation and gender diversity world-wide as much as is feasible. To facilitate this goal, authors working in a non-English speaking country, or whose sample is from a non-English speaking country, should submit another abstract in their other language, or that of the sample. This will appear below the English abstract if the article is published.

If authors or samples are from multiple non-English speaking countries, abstracts in all the relevant languages should be included. These additional abstracts need not be provided until the final accepted revision.

PSOGD does not have the resources to provide a final copyediting of non-English abstracts, so authors should carefully check the non-English abstracts.

PSOGD can publish the main article text only in English.

Public significance statement

Authors submitting manuscripts to PSOGD are required to provide a short statement of one to two sentences to summarize the article's findings and significance to the educated public (e.g., understanding human thought, feeling, and behavior and/or assisting with solutions to psychological or societal problems). This description should be included within the manuscript on the abstract/keywords page.

• View Guidance for Translational Abstracts and Public Significance Statements

Equity, Diversity, and Inclusion in Psychology of Sexual Orientation and Gender Diversity

Psychology of Sexual Orientation and Gender Diversity is committed to improving equity, diversity, and inclusion (EDI) in scientific research, in line with the APA Publishing EDI framework and APA’s trio of 2021 resolutions to address systemic racism in psychology.

To promote a more equitable research and publication process, Psychology of Sexual Orientation and Gender Diversity has adopted the following standards for inclusive research reporting.

Author contribution statements using CRediT

The APA Publication Manual ( 7th ed. ) stipulates that "authorship encompasses…not only persons who do the writing but also those who have made substantial scientific contributions to a study." In the spirit of transparency and openness, Psychology of Sexual Orientation and Gender Diversity has adopted the Contributor Roles Taxonomy (CRediT) to describe each author's individual contributions to the work. CRediT offers authors the opportunity to share an accurate and detailed description of their diverse contributions to a manuscript.

Submitting authors will be asked to identify the contributions of all authors at initial submission according to the CRediT taxonomy. If the manuscript is accepted for publication, the CRediT designations will be published as an author contributions statement in the author note of the final article. All authors should have reviewed and agreed to their individual contribution(s) before submission.

CRediT includes 14 contributor roles, as described below:

• Conceptualization : Ideas; formulation or evolution of overarching research goals and aims.
• Data curation : Management activities to annotate (produce metadata), scrub data and maintain research data (including software code, where it is necessary for interpreting the data itself) for initial use and later re-use.
• Formal analysis : Application of statistical, mathematical, computational, or other formal techniques to analyze or synthesize study data.
• Funding acquisition : Acquisition of the financial support for the project leading to this publication.
• Investigation : Conducting a research and investigation process, specifically performing the experiments, or data/evidence collection.
• Methodology : Development or design of methodology; creation of models.
• Project administration : Management and coordination responsibility for the research activity planning and execution.
• Resources : Provision of study materials, reagents, materials, patients, laboratory samples, animals, instrumentation, computing resources, or other analysis tools.
• Software : Programming, software development; designing computer programs; implementation of the computer code and supporting algorithms; testing of existing code components.
• Supervision : Oversight and leadership responsibility for the research activity planning and execution, including mentorship external to the core team.
• Validation : Verification, whether as a part of the activity or separate, of the overall replication/reproducibility of results/experiments and other research outputs.
• Visualization : Preparation, creation and/or presentation of the published work, specifically visualization/data presentation.
• Writing—original draft : Preparation, creation and/or presentation of the published work, specifically writing the initial draft (including substantive translation).
• Writing—review & editing : Preparation, creation and/or presentation of the published work by those from the original research group, specifically critical review, commentary or revision—including pre- or post-publication stages.

Authors can claim credit for more than one contributor role, and the same role can be attributed to more than one author. Not all roles will be applicable to a particular scholarly work.

Participant description, sample justification, and informed consent

Authors are encouraged to include a detailed description of the study participants in the Method section of each empirical report, including (but not limited to) the following:

• Sexual orientation
• Racial identity
• Nativity or immigration history
• Socioeconomic status
• Clinical diagnoses and comorbidities (as appropriate)
• Any other relevant demographics (e.g., disability status; sexual orientation)

In both the abstract and in the discussion section of the manuscript, authors are encouraged to discuss the diversity of their study samples and the generalizability of their findings (see also the constraints on generality section below).

Authors are also encouraged to justify their sample demographics in the Discussion section. If Western, educated, industrialized, rich, and democratic (WEIRD) or all-White samples are used, authors should justify their samples and describe their sample inclusion efforts (see Roberts, et al., 2020 for more information on justifying sample demographics).

The Method section also must include a statement describing how informed consent was obtained from the participants (or their parents/guardians), including for secondary use of data if applicable, and indicate that the study was conducted in compliance with an appropriate Internal Review Board.

Reporting year(s) of data collection

Authors are encouraged to disclose the year(s) of data collection in both the Abstract and in the Method section in order to appropriately contextualize the study.

Positionality statements

Authors are encouraged to include a positionality statement in the author note. Positionality statements are intended to address potential author bias by transparently reporting how the identities of the authors relate to the research/article topic and to the identity of the participants, as well as the extent to which those identities are represented in the scientific record. The statement should be included in the author note and expanded upon in the Discussion section. See this example from Jovanova, et al. (2022) :

• Sample positionality statement: “Mindful that our identities can influence our approach to science ( Roberts, et al. 2020) , the authors wish to provide the reader with information about our backgrounds. With respect to gender, when the manuscript was drafted, four authors self-identified as women and four authors as men. With respect to race, six authors self-identified as white, one as South Asian and one as East Asian.”

For more guidance on writing positionality statements, see Roberts, et al. (2020) and Hamby (2018) .

Inclusive reference lists

Research has shown that there is often a racial/ethnic and gender imbalance in article reference lists, and that Black women’s work is disproportionately not credited or cited as often as White authors’ work ( Kwon, 2022 ). Authors are encouraged to ensure their citations are fully representative by both gender and racial identity before submitting and during the manuscript revision process. Authors are encouraged to evaluate the race and gender of the authors in their reference lists (see this open-source code by Zhou, et al., 2020 , that authors can use to predict the gender and race of the authors in their reference lists) and to report the results in a citation diversity statement in the author note or Discussion section of the manuscript.

See Dworkin, et al. (2020) ’s sample citation diversity statement:

“ Citation Diversity Statement . Recent work in neuroscience and other fields has identified a bias in citation practices such that papers from women and other minorities are under-cited relative to the number of such papers in the field (Caplar et al., 2017, Chakravartty et al., 2018, Dion et al., 2018, Dworkin et al., 2020, Maliniak et al., 2013, Thiem et al., 2018). Here, we sought to proactively consider choosing references that reflect the diversity of the field in thought, gender, race, geography, seniority, and other factors. We used automatic classification of gender based on the first names of the first and last authors (Dworkin et al., 2020, Zhou et al., 2020), with possible combinations including man/man, man/woman, woman/man, and woman/woman. Code for this classification is open source and available online (Zhou et al., 2020). We regret that our current methodology is limited to consideration of gender as a binary variable. Excluding self-citations to the first and last authors of our current paper, the references contain 12.5% man/man, 25% man/woman, 25% woman/man, 37.5% woman/woman, and 0% unknown categorization. We look forward to future work that could help us to better understand how to support equitable practices in science.”

Data, materials, and code

Authors must state whether data and study materials are available and, if so, where to access them. Recommended repositories include APA’s repository on the Open Science Framework (OSF), or authors can access a full list of other recommended repositories .

In both the author note and at the end of the method section, specify whether and where the data and material will be available or note the legal or ethical reasons for not doing so. For submissions with quantitative or simulation analytic methods, state whether the study analysis code is available, and, if so, where to access it (or the legal or ethical reason why it is not available).

For example:

• All data have been made publicly available at the [repository name] and can be accessed at [persistent URL or DOI].
• Materials and analysis code for this study are not available.
• The code behind this analysis/simulation has been made publicly available at the [repository name] and can be accessed at [persistent URL or DOI].

View Guidance for Translational Abstracts and Public Significance Statements .

Clinicians' Digest

PSOGD  includes a Clinicians' Digest section providing practitioners with clinically useful, yet scientifically robust ideas from articles published in the journal.

The Digest, consisting of one- or two-paragraph synopses of clinically relevant concepts from articles in that issue, presented together as one piece, is written by a rotating team coordinated by Kim Skerven, PhD.

Authors of the source articles from which the Digest synopses are drawn have the prerogative to decline their articles' participation in the Digest. They are, however, strongly encouraged to allow their articles to be included in order to facilitate their findings being maximally useful to practitioners.

Digest authors will work with source articles' authors to maintain fidelity with the source article.

The synopses in the Clinicians' Digest are intended to be used with the source article and its abstract, but offer original clinically relevant ideas based on the source article.

Double-space all copy. Other formatting instructions, as well as instructions on preparing tables, figures, references, metrics, and abstracts, appear in the Manual . Additional guidance on APA Style is available on the APA Style website .

Below are additional instructions regarding the preparation of display equations, computer code, and tables.

Display equations

We strongly encourage you to use MathType (third-party software) or Equation Editor 3.0 (built into pre-2007 versions of Word) to construct your equations, rather than the equation support that is built into Word 2007 and Word 2010. Equations composed with the built-in Word 2007/Word 2010 equation support are converted to low-resolution graphics when they enter the production process and must be rekeyed by the typesetter, which may introduce errors.

To construct your equations with MathType or Equation Editor 3.0:

• Go to the Text section of the Insert tab and select Object.
• Select MathType or Equation Editor 3.0 in the drop-down menu.

If you have an equation that has already been produced using Microsoft Word 2007 or 2010 and you have access to the full version of MathType 6.5 or later, you can convert this equation to MathType by clicking on MathType Insert Equation. Copy the equation from Microsoft Word and paste it into the MathType box. Verify that your equation is correct, click File, and then click Update. Your equation has now been inserted into your Word file as a MathType Equation.

Use Equation Editor 3.0 or MathType only for equations or for formulas that cannot be produced as Word text using the Times or Symbol font.

Computer code

Because altering computer code in any way (e.g., indents, line spacing, line breaks, page breaks) during the typesetting process could alter its meaning, we treat computer code differently from the rest of your article in our production process. To that end, we request separate files for computer code.

In online supplemental material

We request that runnable source code be included as supplemental material to the article. For more information, visit Supplementing Your Article With Online Material .

In the text of the article

If you would like to include code in the text of your published manuscript, please submit a separate file with your code exactly as you want it to appear, using Courier New font with a type size of 8 points. We will make an image of each segment of code in your article that exceeds 40 characters in length. (Shorter snippets of code that appear in text will be typeset in Courier New and run in with the rest of the text.) If an appendix contains a mix of code and explanatory text, please submit a file that contains the entire appendix, with the code keyed in 8-point Courier New.

Use Word's insert table function when you create tables. Using spaces or tabs in your table will create problems when the table is typeset and may result in errors.

Academic writing and English language editing services

Authors who feel that their manuscript may benefit from additional academic writing or language editing support prior to submission are encouraged to seek out such services at their host institutions, engage with colleagues and subject matter experts, and/or consider several vendors that offer discounts to APA authors .

Please note that APA does not endorse or take responsibility for the service providers listed. It is strictly a referral service.

Use of such service is not mandatory for publication in an APA journal. Use of one or more of these services does not guarantee selection for peer review, manuscript acceptance, or preference for publication in any APA journal.

Submitting supplemental materials

APA can place supplemental materials online, available via the published article in the PsycArticles ® database. Please see Supplementing Your Article With Online Material for more details.

List references in alphabetical order. Each listed reference should be cited in text, and each text citation should be listed in the references section.

Examples of basic reference formats:

Journal article

McCauley, S. M., & Christiansen, M. H. (2019). Language learning as language use: A cross-linguistic model of child language development. Psychological Review , 126 (1), 1–51. https://doi.org/10.1037/rev0000126

Authored book

Brown, L. S. (2018). Feminist therapy (2nd ed.). American Psychological Association. https://doi.org/10.1037/0000092-000

Chapter in an edited book

Balsam, K. F., Martell, C. R., Jones. K. P., & Safren, S. A. (2019). Affirmative cognitive behavior therapy with sexual and gender minority people. In G. Y. Iwamasa & P. A. Hays (Eds.), Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed., pp. 287–314). American Psychological Association. https://doi.org/10.1037/0000119-012

Preferred formats for graphics files are TIFF and JPG, and preferred format for vector-based files is EPS. Graphics downloaded or saved from web pages are not acceptable for publication. Multipanel figures (i.e., figures with parts labeled a, b, c, d, etc.) should be assembled into one file. When possible, please place symbol legends below the figure instead of to the side.

• All color line art and halftones: 300 DPI
• Black and white line tone and gray halftone images: 600 DPI

Line weights

• Color (RGB, CMYK) images: 2 pixels
• Grayscale images: 4 pixels
• Stroke weight: 0.5 points

APA offers authors the option to publish their figures online in color without the costs associated with print publication of color figures.

The same caption will appear on both the online (color) and print (black and white) versions. To ensure that the figure can be understood in both formats, authors should add alternative wording (e.g., “the red (dark gray) bars represent”) as needed.

For authors who prefer their figures to be published in color both in print and online, original color figures can be printed in color at the editor's and publisher's discretion provided the author agrees to pay:

• $900 for one figure
• An additional $600 for the second figure
• An additional $450 for each subsequent figure

Permissions

Authors of accepted papers must obtain and provide to the editor on final acceptance all necessary permissions to reproduce in print and electronic form any copyrighted work, including test materials (or portions thereof), photographs, and other graphic images (including those used as stimuli in experiments).

On advice of counsel, APA may decline to publish any image whose copyright status is unknown.

• Download Permissions Alert Form (PDF, 13KB)

Publication policies

For full details on publication policies, including use of Artificial Intelligence tools, please see APA Publishing Policies .

Duplicate publication

APA policy prohibits an author from submitting the same manuscript for concurrent consideration by two or more publications.

Splitting data sets; data fragmentation

Please read the Open Letter to Authors for APA Journals (PDF, 40KB) , but especially, please note the following:

Duplicate/fragmented publication . Duplicate publication involves publishing the same data more than once. Fragmented (or piecemeal) publication involves dividing the report of a research project into multiple articles. Duplicate or fragmented publications are misleading if they appear to represent independent instances. They can distort the scientific literature, especially in reviews or meta-analyses.

On occasion, it may be appropriate to publish several reports referring to the same database. The author should inform the editor at the time of submission about all previously published or submitted reports so the editor can judge if the article represents a new contribution. Readers also should be informed; the text of an article should cite other reports that used the same sample (or a subsample) or the same data and methods.

Since PSOGD allows for longer submissions, up to 12,000 words, there should be few circumstances where publishing several pieces from the same data set is warranted. Data sets that have both quantitative and qualitative components should generally be published as a whole.

PSOGD recognizes, however, that some large data sets, for example as are common in epidemiological research, appropriately lend themselves to multiple publications. Authors are expected to contact the Editor before submitting a piece which may have fragmented data, provide a rationale for this, and obtain the Editor's consultation on the appropriateness.

Authors who undermine these guidelines by covertly splitting data sets and creating separate publications will be denied future consideration for PSOGD publication.

Submissions contingent on another article under development or review

If the submission is contingent on data under development or being published elsewhere, authors should wait until the underlying data is at least accepted for publication before submitting a secondary submission to PSOGD . For example, if authors rely on a measure whose reliability and validity data have not been published or are under review, authors should delay submission to PSOGD until acceptance for publication and final form of those underlying data are confirmed.

Submissions that rely on unpublished underlying data will be rejected without review.

Internet posting, disclosure of interests, and copyright

See APA Journals ® Internet Posting Guidelines .

APA requires authors to reveal any possible conflict of interest in the conduct and reporting of research (e.g., financial interests in a test or procedure, funding by pharmaceutical companies for drug research).

• Download Full Disclosure of Interests Form (PDF, 41KB)

Ethical Principles

Previously published data.

It is a violation of APA Ethical Principles to publish "as original data, data that have been previously published" (Standard 8.13).

Availability of raw data

APA Ethical Principles specify that "after research results are published, psychologists do not withhold the data on which their conclusions are based from other competent professionals who seek to verify the substantive claims through reanalysis and who intend to use such data only for that purpose, provided that the confidentiality of the participants can be protected and unless legal rights concerning proprietary data preclude their release" (Standard 8.14).

APA expects authors to adhere to these standards. Specifically, APA expects authors to have their data available throughout the editorial review process and for at least 5 years after the date of publication.

On a case by case basis, PSOGD 's editor may request that authors provide all or some of the raw data on which research reported in a submission is based. This might typically occur at the request of a reviewer, or when the editor believes there is something unusual, atypical or unclear about the reported results.

Authors are expected to provide the raw data requested in a timely manner. Authors' unwillingness to do so will result in the submission's rejection. Data may not be considered proprietary.

Ethical principles certification

Authors are required to state in writing that they have complied with APA ethical standards in the treatment of their sample, human or animal, or to describe the details of treatment.

• Download Certification of Compliance With APA Ethical Principles Form (PDF, 26KB)

The APA Ethics Office provides the full Ethical Principles of Psychologists and Code of Conduct electronically on its website in HTML, PDF, and Word format. You may also request a copy by emailing or calling the APA Ethics Office (202-336-5930). You may also read "Ethical Principles," December 1992, American Psychologist , Vol. 47, pp. 1597–1611.

General expectations of submissions

Given the wide variety of manuscript types that PSOGD accepts, all of these recommendations may not be suitable for all submissions, but are most true for standard and longer research articles.

• Clear description/intro. Make certain readers are quickly oriented to the purpose and focus of your manuscript. Make sure that the words used to describe your purpose and focus are the same throughout the manuscript.
• Literature review to set context. The literature review should situate your work both in the literature on sexual orientation and gender diversity, and in the behavioral sciences more generally. It should include enough to make a compelling argument for why your study was needed, and should lead directly to your purpose and hypotheses/research questions. Too little, too much, or tangential literature review are common errors. Ensure that your sources present credible scientific findings.
• Clear methodology. Could others replicate it? Are the chosen methodologies adequately justified? Provide citations to support your rationale for selecting your given methodology and analytical strategy. Are your data appropriate for the study questions and analyses (e.g., adequate sample size)?
• Information about measures. Basic reliability/validity of measures should be summarized and, when possible, these data should be obtained from samples consistent with your study sample. Provide reasons for choosing the specific measures. In addition, report the number of items, scoring procedures, the directionality of scores (e.g., higher scores on this measure indicate higher...), and how scores are computed. If measures were modified in your study, describe the rationale for the modification, the specific modification, and whether this modification was guided by any theory or previous study's methods, and how the measure "behaved" in your study (e.g., reliabilities, factor scores).
• Sample. Describe clearly sampling and recruitment procedures. Describe demographics and other characteristics. Have you used up-to-date terminology?
• Statistics. Are your statistical results presented in a clear and accessible manner? Does your statistical plan map to your hypotheses? When programs other than SPSS or SAS are utilized to conduct the analyses, report the program (e.g., MPlus). Only identify quantitative results as significant when they meet the generally accepted minimum criterion of p < .05 (i.e., do not suggest that scores "trended toward significance" unless you did a trend analysis). Discuss missing data (i.e., amount and whether data were missing at random) and how missing data were addressed. Were the tables/charts/graphs etc. checked for accuracy?
• APA Style. Headings, references, citations, and tables/charts are frequently done incorrectly. Please check these carefully.
• Copyediting. Your submission should be free of spacing, formatting, grammatical, spelling, and other copyediting errors. Manuscripts judged to contain an unreasonable number of errors will be rejected without review.
• Conclusions. Are the conclusions that are drawn clearly supported by the data and congruent with the limitations of your methodology? It is a common mistake to reach beyond your data, especially when discussing implications for practice, advocacy, education, etc. However, not discussing the full implications of one's findings can be problematic as well. Strive for balance, but err on the side of caution. Attempt to relate the findings to conclusions reached in previous research but watch speculating beyond the data.
• Limitations. Do not minimize or avoid. Describe limitations directly, and when possible use your limitations as a springboard for recommendations for future research.

Note compliance with institutional review board and ethical requirements, without sacrificing masking of the manuscript.

Concise writing

Be concise and avoid expansive writing.

Journal space is at a premium. Please review your submissions to keep the writing as concise and focused as possible. The goal is to write just enough to fully communicate the integrity of your work.

Manuscripts with an unnecessarily verbose writing style will be returned to authors, unreviewed, for a more focused and shorter revision. This is also true of references, which should be sufficient to fully justify and contextualize the submission-but no more.

Tables, charts, figures etc. should similarly summarize and clarify, and contribute to the understanding of the research being presented beyond the information reported in the text. If they do not do so, they serve no useful function and authors will be asked to condense or delete them.

Stylistic differences

Be aware of the stylistic differences between student and institutional papers versus journal publications. Papers that are initially prepared as student assignments, reports of research grant activities, internal institution documents, etc., are typically in formats and styles inconsistent with journal publication.

For example, faculty often expect student papers to demonstrate wide-ranging literature reviews and elaborate justifications of methodology and instrumentation; grant and institution-focused papers often address goals and issues uniquely relevant to those entities.

Such papers usually require considerable revision before they are appropriate journal submissions. This is almost always in the direction of sharper focus, more concise writing style, and significant shortening.

Faculty and funding sources usually expect such student and institutional paper authors to demonstrate skill sets and goals that go beyond concise presentation of the material. Journal publications seek only concise presentation of the material.

Please edit your work accordingly before submitting it.

Other information

See APA’s Publishing Policies page for more information on publication policies, including information on author contributorship and responsibilities of authors, author name changes after publication, the use of generative artificial intelligence, funder information and conflict-of-interest disclosures, duplicate publication, data publication and reuse, and preprints.

Visit the Journals Publishing Resource Center for more resources for writing, reviewing, and editing articles for publishing in APA journals.

M. Paz Galupo, PhD Washington University at St. Louis, United States Pronouns: She/They

Associate editors

Roberto L. Abreu, PhD University of Florida, United States Pronouns: He/Him/él

Stephanie L. Budge, PhD University of Wisconsin–Madison, United States Pronouns: She/Her

Franco Dispenza, PhD Georgia State University, United States Pronouns: He/Him

Brian Feinstein, PhD Rosalind Franklin University of Medicine and Science, United States Pronouns: He/Him

Charlotte Tate, PhD San Francisco State University, United States Pronouns: She/Her

Associate editor for the Clinician's Digest+

Kim Skerven, PhD Center for Behavioral Medicine, United States Pronouns: She/Her

Consulting editors

Kimberly Balsam, PhD Palo Alto University, United States Pronouns: She/Her and They/Them

Sebastian Barr, PhD United States Pronouns: He/Him

Jaime Barrientos, PhD Universidad Alberto Hurtado, Chile Pronouns: He/Him

Markus Bidell, PhD City University of New York, Hunter College, United States Pronouns: Xe/Xem or They/Them

Karen Blair, PhD Trent University, Canada Pronouns: She/Her

Armand R. Cerbone, PhD Independent Practice, Chicago, IL, United States Pronouns: He/Him

Andrew Young Choi, PhD University of Hawaiʻi, Mānoa, United States Pronouns: He/Him

Kirsty Clark, PhD Yale School of Public Health, United States Pronouns: She/Her

Zakary Clements Washington University in St. Louis, United States Pronouns: He/Him

Susan Cochran, PhD UCLA Fielding School of Public Health, United States Pronouns: She/Her

Lynae Darbes, PhD University of Michigan, United States Pronouns: She/Her

Chris Davids, PhD Westminster College, United States Pronouns: He/Him

Kevin Delucio, PhD Western Washington University, United States Pronouns: He/Him

Annesa Flentje, PhD University of California, San Francisco, United States Pronouns: She/Her

Ryan Flinn, PhD University of North Dakota, United States Pronouns: They/Them

William Foote, PhD University of New Mexico, United States Pronouns: He/Him

J. Garrett-Walker University of San Francisco, United States Pronouns: She/Her

John Gatermann, PhD NorthPoint Health and Wellness Center, Minneapolis, United States   Pronouns: He/Him

Abbie Goldberg, PhD Clark University, United States Pronouns: She/Her

Kirsten Gonzalez, PhD University of Tennessee, United States Pronouns: She/Her

Patrick Grzanka, PhD University of Tennessee, United States Pronouns: He/Him

Nicholas C. Heck, PhD Putnam County Hospital, New York, United States Pronouns: He/Him

Michael L. Hendricks, PhD Washington Psychological Center, PC, District of Columbia, United States Pronouns: He/Him

Keith Horvath, PhD San Diego State University, United States Pronouns: He/Him

Kiet Huynh Palo Alto University, United States Pronouns: He/Him

Skyler Jackson, PhD Yale School of Public Health, United States Pronouns: He/Him

Peter Ji, PhD Adler University, United States Pronouns: He/Him

Douglas Knutson, PhD Oklahoma State University, United States Pronouns: He/Him

G. Tyler Lefevor, PhD Utah State University, United States Pronouns: He/Him

Christopher Martell, PhD University of Massachusetts Amherst, United States Pronouns: He/Him

E. Larry Martinez, PhD Portland State University, United States Pronouns: He/Him

Daragh McDermott, PhD Anglia Ruskin University, United Kingdom Pronouns: He/Him

Ethan Mereish, PhD University of Maryland, United States Pronouns: He/Him

Joe Miles, PhD University of Tennessee, Knoxville, United States Pronouns: He/Him

Lauren Mizock, PhD Fielding Graduate University, United States Pronouns: She/Her

Michael Mobley, PhD Merrimack College, United States Pronouns: He/Him

Melanie Morrison, PhD University of Saskatchewan, Canada Pronouns: She/Her

Todd G. Morrison, PhD University of Saskatchewan, Canada Pronouns: He/Him

Nadine Nakamura, PhD University of La Verne, United States Pronouns: She/Her

Kimberly Nelson, PhD Boston University School of Public Health, United States Pronouns: She/Her

Tiffany O'Shaughnessy, PhD San Francisco State University, United States Pronouns: She/Her

David W. Pantalone, PhD University of Massachusetts, Boston, United States Pronouns: He/Him

Joshua G. Parmenter, PhD, Licensed Psychologist University of Missouri, United States Pronouns: They/He

Charlotte J. Patterson, PhD University of Virginia, United States Pronouns: She/Her

Qazi Rahman, PhD King's College London, United Kingdom Pronouns: He/Him

Roberto Rentería, PhD Rosalind Franklin University of Medicine and Science, United States Pronouns: He/Him

Amy Reynolds, PhD University at Buffalo, United States Pronouns: She/Her

Ellen D. B. Riggle, PhD University of Kentucky, United States Pronouns: They/Them

Ian Rivers, PhD University of Strathclyde, Scotland, United Kingdom Pronouns: He/Him

Lori E. Ross, PhD University of Toronto, Canada Pronouns: She/Her

Sharon Scales Rostosky, PhD University of Kentucky, United States Pronouns: She/Her

Esther Rothblum, PhD San Diego State University, United States Pronouns: She/Her

Glenda Russell, PhD University of Colorado Boulder, United States Pronouns: She/Her

Elissa Sarno, PhD Northwestern University, United States Pronouns: She/Her

Thomas Sasso, MA University of Guelph, Canada Pronouns: He/They

Jillian R. Scheer, PhD Syracuse University, United States Pronouns: She/Her or They/Them

Zach Schudson, PhD California State University, Sacramento, United States Pronouns: He/Him or They/Them

Joanna Semlyen, PhD University of East Anglia, United Kingdom Pronouns: She/Her

Anneliese A. Singh, PhD Tulane University, United States Pronouns: She/Her and They/Them

Nathan Smith, PhD University of Houston, United States Pronouns: He/Him

Eric Swank, PhD Arizona State University, United States Pronouns: He/Him

Elliot Tebbe, PhD University of Wisconsin, Madison, United States Pronouns: He/Him

Liadh Timmins, PhD Swansea University, United Kingdom Pronouns: They/Them

Samantha Tornello, PhD Pennsylvania State University, United States Pronouns: She/Her and They/Them

Sari van Anders, PhD Queen's University, Canada Pronouns: She/Her

Jacob J. van den Berg, PhD Brown University, United States Pronouns: He/Him

Doug VanderLaan, PhD University of Toronto, Mississauga, Canada Pronouns: He/Him

Jaimie Veale, PhD University of Waikato, Aotearoa Pronouns: She/Her

Cindy Veldhuis, PhD Columbia University, United States Pronouns: She/Her

Brandon L. Velez, PhD Teacher's College, Columbia University, United States Pronouns: He/Him

Jennifer Vencill, PhD Mayo Clinic, United States Pronouns: She/Her

David G. Zelaya, PhD Brown University, United States Pronouns: He/Him/El

Peer review coordinator

Maddie Boots American Psychological Association, United States

Abstracting and indexing services providing coverage of Psychology of Sexual Orientation and Gender Diversity ®

Special issue of APA's journal Psychology of Sexual Orientation and Gender Diversity, Vol. 8, No. 3, September 2021. This special issue surveys the current state of our psychological research in several key areas, with the hopes of cultivating and improving the psychological landscape for a more promising and hopeful future.

Special issue of APA's journal Psychology of Sexual Orientation and Gender Diversity, Vol. 8, No. 2, June 2021. This special issue focuses on the impact of COVID-19 on sexual and gender minorities.

Special issue of the APA journal Psychology of Sexual Orientation and Gender Diversity, Vol. 2, No. 3, September 2015. Includes articles about resilience from stigma and prejudice among lesbians, gay men, bisexuals, and transgender individuals.

Inclusive reporting standards

• Bias-free language and community-driven language guidelines (required)
• Author contribution roles using CRediT (required)
• Positionality statements (recommended)
• Data sharing and data availability statements (recommended)
• Impact statements (required)
• Year(s) of data collection (recommended)
• Participant sample descriptions (recommended)
• Sample justifications (recommended)
• Inclusive reference lists (recommended)

More information on this journal’s reporting standards is listed under the submission guidelines tab .

Other EDI offerings

Orcid reviewer recognition.

Open Research and Contributor ID (ORCID) Reviewer Recognition provides a visible and verifiable way for journals to publicly credit reviewers without compromising the confidentiality of the peer-review process. This journal has implemented the ORCID Reviewer Recognition feature in Editorial Manager, meaning that reviewers can be recognized for their contributions to the peer-review process.

Translated abstracts

Abstracts which are translated into multiple languages provide accessibility and discoverability for a global community of scholars.

Masked peer review

This journal offers masked peer review (where both the authors’ and reviewers’ identities are not known to the other). Research has shown that masked peer review can help reduce implicit bias against traditionally female names or early-career scientists with smaller publication records (Budden et al., 2008; Darling, 2015).

Clinician’s Digest

• Read clinically-oriented article summaries

From APA Journals Article Spotlight ®

• Sexual orientation and gender diversity research manuscript writing guide
• Do beliefs about sexual orientation predict voting? Findings from the 2016 U.S. presidential election
• Who identifies as queer? A study looks at the partnering patterns of sexual minority populations
• What's the relational toll of living in a sexist and heterosexist context?

Editor Spotlight

• Read an interview with Editor M. Paz Galupo, PhD

Journal Alert

Sign up to receive email alerts on the latest content published.

Welcome! Thank you for subscribing.

Subscriptions and access

• Pricing and individual access
• APA PsycArticles database

Calls for Papers

Access options

• APA publishing resources
• Educators and students
• Editor resource center

APA Publishing Insider

APA Publishing Insider is a free monthly newsletter with tips on APA Style, open science initiatives, active calls for papers, research summaries, and more.

Social media

Contact Journals

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 01 September 2020

Fluidity of gender identity induced by illusory body-sex change

• Pawel Tacikowski 1 , 2 ,
• Jens Fust   ORCID: orcid.org/0000-0002-4706-092X 1 , 3 &
• H. Henrik Ehrsson   ORCID: orcid.org/0000-0003-2333-345X 1  

Scientific Reports volume  10 , Article number:  14385 ( 2020 ) Cite this article

34k Accesses

33 Citations

142 Altmetric

Metrics details

• Cognitive neuroscience
• Human behaviour

Gender identity is a collection of thoughts and feelings about one’s own gender, which may or may not correspond to the sex assigned at birth. How this sense is linked to the perception of one’s own masculine or feminine body remains unclear. Here, in a series of three behavioral experiments conducted on a large group of control volunteers (N = 140), we show that a perceptual illusion of having the opposite-sex body is associated with a shift toward a more balanced identification with both genders and less gender-stereotypical beliefs about own personality characteristics, as indicated by subjective reports and implicit behavioral measures. These findings demonstrate that the ongoing perception of one’s own body affects the sense of one’s own gender in a dynamic, robust, and automatic manner.

Similar content being viewed by others

Daily gender expression is associated with psychological adjustment for some people, but mainly men

Male recognition bias in sex assignment based on visual stimuli

Male sexual orientation, gender nonconformity, and neural activity during mental rotations: an fMRI study

Introduction.

Gender identity is a collection of thoughts and feelings about one’s own gender, which may or may not correspond to the sex assigned at birth 1 , 2 , 3 , 4 , 5 . This multifaceted, subjective sense of being male, female, both, or neither occurs in our conscious self-awareness, but the associated perceptions and beliefs can also be largely implicit 3 , 4 , 5 . In the past, gender identity was conceptualized as a male–female dichotomy; however, current theories consistently postulate that gender identity is a spectrum of associations with both genders 1 , 3 , 4 , 5 , 6 . There is also a general consensus in the field that gender identity is determined by multiple factors, such as person’s genes, hormones, patterns of behaviors, or social interactions 4 , 5 , 6 , 7 , 8 ; and that the sense of own gender (e.g., “I’m male”) is closely linked to one’s beliefs about males and females in general (e.g., “males are competitive”), as well as to the associated beliefs about own personality (“I am competitive”) 1 , 3 , 6 . The specific content of such beliefs and their strength contribute to what it means for a given person to be male or female in a given sociocultural context, which in some cases hinders the realization of one’s full personal or professional potential. Although gender identity has a profound impact on our lives, little is known about how this sense is formed or maintained. A better understanding of the neurocognitive mechanisms of gender identity is also important in the context of gender dysphoria (DSM-5 9 ; gender incongruence ICD-11 10 ), which is characterized by the prolonged and clinically relevant distress that some transgender individuals experience due to inconsistency between their sex assigned at birth and their subjective sense of gender.

Various observations suggest that gender identity and the perception of one’s own body are tightly connected. For example, people with gender dysphoria (see above) often avoid looking in the mirror, hide their bodies under loose-fitting clothes, and seek hormonal and/or surgical procedures to adjust their physical appearance to meet their subjective sense of own gender 6 , 11 , 12 . Moreover, among individuals whose gender identity matches their sex assigned at birth, mastectomy and androgen deprivation cancer therapies, which both involve changes to one’s feminine or masculine bodily characteristics, are often related to a gender identity crisis 13 , 14 . There are also data suggesting that the mental representation of one’s own body is altered in transgender individuals 15 and that the brain regions involved in this representation are anatomically and functionally different in this group compared to controls 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 . However, the link between own body perception and gender identity remains poorly understood from a behavioral experimental perspective, and we do not know whether, and if so how, the perceived sex of own body influences the sense of own gender in nontransgender individuals.

The full-body ownership illusion 24 is a powerful experimental tool for manipulating the perception of one’s own body 25 , 26 , 27 , 28 , 29 , 30 . During this illusion, the participants wear head-mounted displays (HMDs) and observe a stranger’s body from a first-person perspective. The stranger’s body is continuously stroked with a stick or a brush, and the experimenter applies synchronous touches on the corresponding parts of the participant’s body, which is out of view. Synchronous visuotactile stimulation induces a feeling that the stranger’s body is one’s own, whereas asynchronous stimulation breaks the illusion and serves as a well-matched control condition 24 , 31 , 32 , 33 . The full-body ownership illusion, similar to the rubber hand illusion involving a single limb 34 , 35 , 36 , 37 , occurs when visual, tactile, proprioceptive, and other sensory signals from the body are combined at the central level into a coherent multisensory representation of one’s own body 24 , 25 , 26 , 30 . Body ownership illusions involving limbs 37 and full bodies 31 , 33 , 38 are related to increased neural activity in regions of the frontal and parietal association cortices that are related to multisensory integration, such as the premotor and intraparietal cortices. Because these brain regions contain trimodal neurons that integrate visual, tactile, and proprioceptive signals and because body illusions closely follow the temporal and spatial constraints of multisensory integration, it has been proposed that combining bodily signals from different modalities is a key mechanism for attributing ownership to our bodies 25 , 26 , 27 , 28 , 29 , 30 . The full-body illusion has been replicated in numerous studies 24 , 31 , 32 , 33 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , even with bodies of a sex opposite to that of the participants 24 , 43 , but the cognitive consequences of this transient physical sex change on gender identity have not been assessed.

Here, we conducted three within-subject behavioral experiments on a total of one hundred forty naïve control volunteers to investigate a possible dynamic relationship between the perception of own body and the sense of own gender. In all three experiments, we induced the “body-sex-change illusion”, which is analogous to the standard full-body illusion (see earlier), but in the HMDs, the participants observe the opposite-sex stranger’s body (Movies S1 and S2). Thus, we aimed to experimentally manipulate how the participants perceived the secondary sex characteristics of their own bodies to measure what outcome this manipulation has on different aspects of gender identity. Specifically, in Experiment I, we asked the participants to rate how masculine or feminine they felt after the body-sex-change illusion to assess the subjective and conscious facets of gender identity. Explicit methods such as the one above provide information about participants’ phenomenological experience, but ideally, they should be combined with objective tests to provide more conclusive results. Therefore, in Experiment II, we used a well-controlled behavioral method—the Implicit Association Test (IAT)—to measure the cognitive and implicit aspects of gender identity; this test is largely immune to conscious strategies 46 and has been validated for gender identity research in control 47 , 48 as well as in transgender individuals 48 . Finally, in Experiment III, we tested whether the perception of own body affects gender-related beliefs about own personality (see earlier) by asking the participants to rate after the illusion how much different traits, stereotypically related to males and females, pertain to their own personality. Applying such different measurements aimed to capture the multifaceted character of the sense of own gender (see earlier), while using continuous scales in all experiments addressed gender identity as a spectrum (see earlier). We hypothesized that if own body perception dynamically shapes gender identity, then even a brief transformation of one’s own perceived physical sex during the body-sex-change illusion should shift different aspects of gender identity toward the opposite gender.

Experiment I tested whether the perception of one’s own body dynamically shapes one’s subjective feeling of masculinity/femininity. The experiment comprised a two-by-two factorial design with four conditions (Fig.  1 a): “synchronous opposite sex” (syncO), “synchronous same sex” (syncS), “asynchronous opposite sex” (asyncO), and “asynchronous same sex” (asyncS). This design allowed us to manipulate the sex-related characteristics of the perceived bodily self in the body-sex-change illusion condition (syncO) while controlling for potential confounding factors related to experiencing a full-body ownership illusion itself (syncS) or cognitive biases due to simply looking at a male or female body (asyncS, asyncO). We measured the illusion psychometrically by asking the participants to rate their subjective experience of owning the stranger’s body (Fig.  1 b) and objectively by recording the participants’ physiological fear reactions (skin conductance responses) when the stranger’s body was physically threatened with a knife (Fig.  1 c). Both of these illusion measures should be higher during the synchronous than during the asynchronous conditions 24 , 32 , 38 , 39 , 42 . Importantly, before experiencing any body perception manipulation (baseline) and after every full-body illusion condition, the participants rated how masculine or feminine they felt (Fig.  1 d,e).

Perceptual illusion of having the opposite-sex body modulated the subjective experience of feeling masculine or feminine (Experiment I). ( a ) The participants (N = 32; 15 females) lay on a bed and wore a head-mounted display in which a body of an unknown male or female was shown from a first-person perspective (the participant’s real body was out of view). Video frames illustrate all four conditions for a male participant (top picture). For a female participant, the videos from the lower and upper rows would be swapped. In the synchronous conditions, touches applied to the participant and touches applied to the stranger’s body were matched (see the red triangle), whereas in the asynchronous conditions, touches applied to the participants were delayed by 1 s. We expected to induce the body-sex-change illusion specifically in the syncO condition, and the other conditions served as controls. ( b ) After each condition, the participants rated illusion (I1:I3) and control (C1:C4) statements on a 7-point scale (− 3—“strongly disagree”; + 3— “strongly agree”). The illusion statements assessed the feeling that the stranger’s body is one’s own, whereas the control statements controlled for any potential effects of suggestibility or task compliance. ( c ) Genuine ownership of the stranger’s body should be associated with increased physiological stress responses of the participant when the stranger’s body is physically threatened. Thus, we measured the participants’ skin conductance responses elicited by brief “knife threat” events that occurred in the videos. ( d ) Before the experiment (baseline) and after each condition, the participants rated how feminine or masculine they felt. The upper row shows scale assignment for female participants and the lower row for males. ( e ) The order of conditions was counterbalanced across the participants, and the whole experiment lasted ~ 30 min. ( f ) The illusion ratings and the magnitude of skin conductance responses were significantly higher in the synchronous than in the asynchronous conditions, which shows that the full-body ownership illusion was elicited as expected. ( g ) During syncO, the female participants indicated feeling less feminine, and the male participants indicated feeling less masculine than during other conditions. ( h ) Strong illusory ownership of the opposite-sex body was related to a significant shift toward the opposite gender, specifically in syncO. For clarity of display, only ratings from syncO and asyncO are shown; syncS, asyncS, and baseline are colored in gray for comparison. ( i ) The participants who experienced a strong body-sex-change illusion (above-median I1 ownership ratings: syncO–asyncO; N = 12) indicated feeling more masculine (females) or more feminine (males) during syncO than during other conditions. Plots show means ± SE.

The full-body ownership illusion was induced as expected, that is, “illusion scores” [illusion questionnaire ratings: (I1 + I2 + I3)/3 + (C1 + C2 + C3 + C4)/4] were higher in the synchronous than in the asynchronous conditions, and knife threats during the synchronous conditions triggered stronger skin conductance responses than knife threats during the asynchronous conditions (Fig.  1 f; Table S2 ; main effect of synchrony; illusion scores: F 1,32  = 64.48; P  < 0.005; skin conductance: F 1,27  = 10.98; P  < 0.005; two-sided; N = 32). With regard to our main hypothesis, we found that during syncO, female participants indicated feeling significantly less feminine and male participants significantly less masculine than during the baseline, syncS, and asyncS control conditions; the difference between syncO and asyncO showed a significant trend in the hypothesized direction (Fig.  1 g; Tables S2 and S3 ). Importantly, the shift toward the opposite gender, specifically in the syncO condition, was enhanced by the illusory ownership of the opposite-sex body (Fig.  1 h; Tables S2 and S3 ; synchrony × body × ownership: F 1,32  = 8.05; P  = 0.008; main effect of ownership in syncO: b  = − 0.6; SE  = 0.2; t 30  = − 2.29; P  = 0.022; two-sided; N = 32). Please note that “ownership” in the analysis above corresponds to I1 questionnaire ratings: syncO—asyncO (one value per participant). Moreover, we found that the participants who experienced a strong body-sex-change illusion (N = 12; median-split; see “ Materials and methods ”) indicated feeling more like the opposite gender in syncO compared to the other conditions (Fig.  1 i; Tables S2 and S3 ). Overall, Experiment I shows that the ongoing perception of one’s own body dynamically updates one’s subjective feelings of masculinity or femininity.

Experiment II tested whether the perceived sex of one’s own body also modulates implicit associations between oneself and gender categories. This experiment had the same two-by-two factorial design as Experiment I (Fig.  1 a), but this time, gender identity was measured with the IAT 47 , 48 . During this test, the participants heard words belonging to four semantic categories ( male , female , self , or other ) and sorted these words into just two response categories. In one block, the participants responded with the same key to words from the self and female categories, which made this block congruent for females and incongruent for males. In the other block, the participants responded with the same key to words from the self and male categories, which made this block incongruent for females and congruent for males (Fig.  2 b). Faster responses in the congruent block than in the incongruent block (i.e., congruent block being cognitively less demanding) indicate that a given person associates with the gender that is consistent with his/her sex. In turn, longer reaction times in the congruent block suggest an inclination toward the opposite gender, whereas similar responses in both blocks suggest a balanced gender identity. Thus, the IAT provides a fine-grained behavioral proxy of where a person is located on a gender identity spectrum (see “ Introduction ”). The participants performed the IAT four times, once during each condition, which allowed us to track changes in implicit gender identification across different embodiment contexts (Fig.  2 c).

The body-sex-change illusion balanced implicit associations between the self and both genders (Experiment II). ( a ) This experiment (N = 64; 32 females) comprised the same four conditions as Experiment I (Fig.  1 a), but we used recordings of a different male and female body to enhance the generalizability of our findings. ( b ) The left panel is a schematic representation of the congruent IAT block for the female participants (incongruent for males), as words from the self and female categories are assigned to the same response category (left arrow). The right panel shows the IAT block that is incongruent for the female participants and congruent for males. Please note that exactly the same words are used in both blocks, only the instructions (key assignment) are different. ( c ) During each condition, the participants completed one full IAT (two blocks). The condition order and block order were counterbalanced across participants. The whole experiment lasted ~ 60 min. ( d ) The body-sex-change illusion was successfully induced, as shown by questionnaire data and the magnitude of threat-evoked skin conductance responses. ( e ) In all conditions, reaction times were significantly shorter in the congruent than in the incongruent IAT blocks, which shows that it was generally easier for the participants to associate themselves with the gender consistent with their sex. ( f ) Strong illusory ownership of the opposite-sex body was related to the balancing of implicit associations between the self and both genders, specifically in syncO. For clarity of display, individual data points are not shown (n = 7,290). ( g ) The participants who experienced a strong body-sex-change illusion (above-median I1 ownership ratings: syncO–asyncO; N = 24) responded similarly quickly in the incongruent and congruent IAT blocks during syncO. Bar plots show means ± SE.

The body-sex-change illusion was also successfully induced in Experiment II, as demonstrated by the questionnaire and skin conductance data (Fig.  2 d; Table S4 ; main effect of synchrony; illusion scores: F 1,64  = 125.65; P  < 0.005; skin conductance: F 1,60  = 4.97; P  = 0.03; two-sided; N = 64). In all conditions, it was easier for the participants to associate themselves with the gender consistent with their sex, as indicated by shorter reaction times in the congruent than in the incongruent blocks (Fig.  2 e; Tables S4 and S5 ). More importantly, however, strong illusory ownership of the opposite-sex body was related to a reduced difference between the incongruent and congruent blocks specifically in syncO, which shows that the illusion balanced the strength of implicit associations between the self and both genders (Fig.  2 f; Table S4 ; synchrony × body × congruence × ownership: F 1,28878  = 17.03; P  < 0.005; congruence × ownership in syncO: F 1,7207  = 9.37; P  < 0.005; two-sided; N = 64). Furthermore, the participants who experienced strong illusory ownership of the opposite-sex body (N = 24; median-split; see “ Materials and methods ”) had similar reaction times in the congruent and incongruent IAT blocks during syncO (Fig.  2 g; Tables S4 and S5 ). Thus, the main finding of Experiment II is that the moment-to-moment perception of one’s own body balances the strength of implicit associations between the self and both genders.

Experiment III investigated whether the illusion-induced fluidity of gender identity is generalized to gender-related beliefs about one’s own personality (see “ Introduction ”). This experiment consisted of two conditions (syncO and asyncO); thus, in the HMDs, female participants always observed a male body, and male participants always observed a female body (Fig.  3 a,b). After each condition, the participants filled out a short version of the Bem Sex-Role Inventory (BSRI) 49 , 50 that contained personality characteristics stereotypically associated with males and females (Fig.  3 b,c). The participants’ task was to rate how much they thought each trait refers to their own personality. We found that the body-sex-change illusion was efficiently induced in Experiment III as well (Fig.  3 d; Table S6 ; main effect of synchrony; illusion scores: F 1,44  = 35.88; P  < 0.005; two-sided; N = 44). Ratings of stereotype-congruent traits were generally higher than ratings of stereotype-incongruent traits (Fig.  3 e; Tables S6 and S7 ). Crucially, however, this stereotypical tendency was significantly reduced in the syncO condition by the illusory ownership of the opposite-sex body (Fig.  3 f; Tables S6 and S7 ; synchrony × congruence × ownership: F 1,759  = 5.6; P  = 0.018; congruence × ownership in syncO: F 1,374  = 13.46; P  < 0.005; two-sided; N = 44). The participants who experienced a strong body-sex-change illusion (N = 20; median-split; see “ Materials and methods ”) rated stereotype-congruent and stereotype-incongruent traits during syncO similarly high (Fig.  3 g; Table S7 ). These findings show that the perception of one’s own masculine or feminine physical characteristics flexibly updates gender-stereotypical beliefs about one’s own personality.

Illusory ownership of the opposite-sex body was associated with less gender-stereotypical beliefs about one’s own personality traits (Experiment III). ( a ) Frames from the videos used in this experiment (N = 44; 22 females). ( b ) The experiment consisted of two conditions (syncO and asyncO); thus, in the head-mounted display, the female participants always observed a male body and the male participants a female body that was stroked either synchronously or asynchronously with regard to touches delivered to the participants. The condition order was counterbalanced across the participants, and the whole experiment took ~ 45 min. ( c ) After each condition, the participants rated how well each personality characteristic describes the self (1—“not at all”; 7—“very much”). Each BSRI sublist contained five traits stereotypically related to males (gray) and five traits stereotypically related to females (black). ( d ) The illusion ratings were significantly higher in the syncO condition than in the asyncO condition, which demonstrates that the body-sex-change illusion was efficiently induced. ( e ) Stereotype-congruent personality traits were generally rated higher than stereotype-incongruent traits. ( f ) Strong illusory ownership of the opposite-sex body was associated with less gender-stereotypical beliefs about own personality traits, specifically in the syncO condition. For clarity of display, individual data points are not shown (n = 434). ( g ) The participants who experienced a strong body-sex-change illusion (above-median I1 ownership ratings: syncO–asyncO; N = 20) rated stereotype-congruent and stereotype-incongruent traits similarly high, specifically in the syncO condition. Bar plots show means ± SE.

Finally, to assess the overall robustness of the relationship between own body perception and gender identity, we performed a post hoc meta-analysis of the data from all three experiments combined. We found that strong illusory ownership of the opposite-sex body in syncO was related to increased updating of the sense of own gender (Fig. S1 ; ρ 138  = 0.24; P  < 0.005; Spearman correlation; two-tailed). Control analyses showed that the male and female participants experienced the body-sex-change illusion equally strongly and that there was no consistent significant relationship between the illusion strength and the participants’ age or baseline masculinity/femininity ratings (Fig. S2 ; for analogous evidence regarding syncS, see Fig. S3 ). Moreover, the degree of gender identity updating did not significantly differ between males and females and was not significantly related to the participants’ age or baseline masculinity/femininity ratings (Fig. S4 ). These results are in line with the notion that the full-body illusion is a robust perceptual phenomenon that generally is not affected by high-level cognitive or emotional processes 25 , 30 , which validates the current illusion-based approach to dynamically changing the perceptual basis of the bodily self in a mixed group of male and female subjects.

The present study used the body-sex-change illusion to experimentally investigate the link between own body perception and gender identity. We found that even a brief transformation of one’s own perceived bodily sex dynamically updated the subjective, implicit, and personality-related aspects of the sense of own gender and made these aspects more balanced across male and female categories. This main finding was consistent across three separate experiments conducted on a large group of control volunteers, with the use of subjective and objective behavioral measures. The fluidity of gender identity that we report here extends previous knowledge by demonstrating that the link between own body perception and the sense of own gender is dynamic, robust, and direct. It is dynamic because the effects that we detected occurred after several minutes of the body-sex-change illusion, it is robust because these effects were present at explicit and implicit levels, and it is direct because the changes in gender identity precisely followed our experimental manipulation of perceived own body sex.

By highlighting the role of own body perception in the shaping of the sense of own gender, this study adds a new perspective to existing theories of gender identity development. Specifically, it has been previously proposed that during their first year of life, infants construct presymbolic, perceptual, and unconscious representations of gender, based on patterns of maternal and paternal interactive styles; their touch, activity levels, timbre of voice, affective reactions, etc. 4 , 5 . Around the same age, babies can also detect synchronous visuotactile and synchronous visuomotor information related to their body 51 , 52 , 53 , 54 , which suggests that they have already developed a basic multisensory representation of their own body that continues to mature throughout childhood 55 . Thus, it is possible that during direct interactions with their caregivers, infants experience various degrees of sensory alignment between their own body representation and the perceptual representations of gender; this alignment might be a foundation for what older children and adolescents refine into a conscious sense of own gender 4 , 5 . The present findings fit well with the above idea and offer important new insights by showing that the moment-to-moment perception of one’s own body continues to affect gender identity even in adult participants.

The fluidity of gender identity that we demonstrate here does not deny that most people experience a stable sense of own gender. Instead, our findings indicate that a change is possible if a sufficient modification of own body representation occurs. Thus, the present study is in line with the general notion that gender identity is a “softly assembled, self-organizing system” that involves dynamic coupling between relevant biological, psychological, and sociocultural factors, such as a person’s hormonal and anatomical status, thoughts and feelings about his or her own gender, or perceived societal norms; when all these factors cohere tightly, gender identity remains stable, but when coherence is poor, gender identity is updated accordingly 4 , 5 , 8 . What current results add to this perspective is experimental support that the perception of own secondary sex characteristics is an integral part of the gender identity construction process that can considerably perturb the sense of own gender in nontransgender adults.

A thorough reader might ask how, if the perception of one’s own body is so critical for gender identity, these two aspects can remain in conflict for a prolonged period of time in transgender individuals. First, our results should not be treated as evidence that perceived bodily sex is the only factor that shapes the sense of own gender; this sense is a complex phenomenon that is constructed from multiple factors (see “ Introduction ”). Second, some characteristics of gender dysphoria, such as avoiding looking in the mirror or hiding one’s body under loose-fitting clothes 11 , 12 , suggest that these individuals might actively suppress the link between their own body perception and their subjective sense of gender. Our results contribute to the discussion about the mechanisms of gender identity by suggesting that there is a continuous bottom-up influence from the perceptual body representation on the cognitive, conceptual, and possibly affective representations of gender identity in terms of the body’s secondary sexual characteristics. Future studies should address the important question of how transgender people, with and without gender dysphoria, update their sense of own gender during the body-sex-change illusion and whether the illusion could partly alleviate distress by reducing the incongruence between the body and subjective gender.

Another key finding of the present study is that the body-sex-change illusion reduced gender-stereotypical beliefs about own personality. This result supports the claim that gender identification (e.g., “I’m a male”), gender stereotypes (e.g., “Males are competitive”), and gender-stereotypical beliefs about one’s own personality (e.g., “I’m competitive”) are connected with each other 1 , 3 , 6 , so that a change in one aspect (gender identification), due to the body-sex-change illusion, affects the other aspects (stereotypical self-beliefs). It is worth mentioning that existing programs against gender discrimination, such as media campaigns or educational workshops, mainly target explicit manifestations of gender stereotypes 56 . However, people are often unaware that their way of thinking is biased, and thus, they cannot deliberately change it. Body-oriented techniques, similar to the one used here, could possibly overcome this limitation and target more covert aspects of gender discrimination. Future research is needed to validate this approach.

Previous studies have shown that different versions of the full-body ownership illusion have various cognitive, emotional, and behavioral consequences. For example, attitudes toward other people change after illusory ownership of their bodies 29 , emotional feelings of social fear 42 and body dissatisfaction 32 , 33 can be modulated by the full-body ownership illusion, and the encoding of episodic memories depends on the embodied first-person perspective 57 . Even beliefs about own personality characteristics 58 , the recognition of one’s own face 59 , 60 , 61 , the style of one’s own behavior 62 , and implicit associations with the past-self 45 are flexibly adjusted based on the ongoing perception of one’s own body. With regard to gender, it has been shown that it is possible to induce the body-sex-change illusion 24 , 43 and that female participants who looked at male avatars from a first-person perspective improved their working memory performance during a stereotype-threatening situation 63 ; however, the latter finding needs to be interpreted with caution, as there was no conclusive evidence that the participants felt ownership of the avatar’s body. Our study extends the above literature in three ways: first, by showing that even the supposedly most stable aspects of the psychological sense of self, that is, gender identity, are dynamically updated based on the ongoing perception of one’s own body; second, by demonstrating that this updating affects both implicit and explicit beliefs about the self; and third, by clarifying that the illusory ownership of another person’s body not only modifies attitudes toward that person or toward a social group that he or she is a member of but also modifies beliefs about the self.

With regard to the cognitive mechanisms behind the body-related flexibility of self-concept, there are several possible explanations. Embodied cognition theories propose that all concepts are grounded in sensorimotor and situated representations 64 ; thus, a change in own body representation, for example, during a full-body ownership illusion, affects conceptual knowledge about the self. In turn, predictive processing theories suggest that if the low-level perceptual representation of one’s own body creates a conflict further up in the processing hierarchy, then this conflict is resolved by updating higher-order beliefs about oneself 28 , 65 . Other authors proposed that illusory ownership of someone else’s body (1) involves making inferences about own attitudes, e.g., “I am polite, because the person whose body I have is polite” 62 ; (2) that the illusion allows new associations to be formed within the “self-image network” 66 ; (3) that “owning” another person’s body makes knowledge about that person, or about a social group that this person belongs to, more accessible (i.e., primed) in the conceptual knowledge system 67 ; or (4) that body experiences of this kind increase the perceived physical similarity between the self and the other, which consequently increases the perceived conceptual similarity between the two 29 . What the present study adds to this complex discussion is the demonstration that gender identity updating is not a result of deliberate inference, as the effect occurred for implicit associations measured by the IAT; and this updating could not simply be explained by conceptual priming, because the semantic category of the opposite gender was likely “activated” even by looking at the opposite sex body during asyncO. Moreover, our results suggest that creating new associations within the self-image network is not the only mechanism involved in the updating of self-concept because, at the implicit level, the body-sex-change illusion mainly weakened associations between the self and the preferred gender category (i.e., lengthening reaction times in the congruent IAT block; Fig.  2 f; Table S5 ). Thus, the perceived bodily-sex-change possibly increased a cognitive conflict within the existing beliefs about oneself at the implicit level, which in turn was compensated by revising self-beliefs with new information at the explicit level (i.e., increasing ratings of stereotype-incongruent traits; Fig.  3 f; Table S7 ). Future studies should determine whether the body-related flexibility of self-concept involves different cognitive mechanisms depending on the degree of conscious awareness.

We speculate that at the neural level, the fundamental interplay between the perception of one’s own body and gender identity is implemented by functional interactions between the multisensory frontoparietal areas that represent the bodily self 30 , 31 , 37 , on the one hand, and the medial prefrontal regions that are involved in the self-concept representation 68 , 69 , affective body representations in the insula and anterior cingulate cortex 33 , and higher-order visual representation of the body in the lateral occipital cortex 70 , 71 , on the other. Multisensory representations in the posterior parietal cortex may be particularly important in this respect, as this region is sensitive to the perceived size and shape of one’s own body 33 , 72 , including waist size 72 , which is likely to be important for the identification of the body’s sex based on secondary sex characteristics. Notably, the pattern of resting-state connectivity in the posterior parietal cortex is different in transgender individuals compared to age-matched controls 21 , and a recent study reported that individuals with gender dysphoria display greater cortical thickness of the anterior cingulate cortex and lateral occipital cortex than controls 23 . Interestingly, the lateral occipital cortex, which includes the extrastriate body area—a higher-order visual area that is involved in the processing of images of human body parts 73 —shows increased activation during body ownership illusions 33 , 38 , 70 , 71 . Future neuroimaging studies could use the present body-sex-change illusion to perturb the sense of gender identity experimentally and investigate how the patterns of activity and functional connectivity within the above fronto-parieto-occipital networks change accordingly.

It is noteworthy that our findings are mainly related to balancing the identification with both genders rather than to a “full switch” to the opposite gender. This could be because the perception of one’s own body is not potent enough to completely override the existing sense of own gender or because the body-sex-change illusion in the present study was not induced for long enough. Future studies are needed to reveal the extent to which gender identity could change as a result of modified body representation and the persistence of such changes over time. Another methodological aspect that is noteworthy is that the body-induced fluidity of gender identity showed relatively large interindividual differences. This variability was related mainly to how vividly the participants experienced the body-sex-change illusion, which of course makes sense because if there was no change in the representation of own body, then there was no reason to update one’s gender identity. Individual differences in the strength of body ownership illusions are most likely related to how brains integrate visual, tactile, and proprioceptive signals 30 , 74 and depend on the relative weights assigned to different sensory channels, as well as prior knowledge that varies across subjects 34 , 75 . For example, if more weight is given to vision than to proprioception, the illusion should be stronger, and vice versa. Based on our data, we can conclude that variability in the illusion strength was not significantly related to the participants’ sex, age, or baseline feelings of masculinity/femininity (Figs. S2 and S3 ). Finally, it is worth mentioning that our within-subject experimental design allowed us to demonstrate a particularly strong case of gender identity flexibility that occurred for the same participants across different body perception contexts.

In sum, the present study shows that there exists a dynamic and automatic link between the perception of own body and different aspects of the sense of own gender. This main finding has important bearings on neurocognitive models of gender identity, as well as on clinical psychology and psychiatry. Moreover, the body-sex-change illusion that we report here allows for a manipulation of gender identification in nontransgender participants, which offers an unprecedented opportunity to investigate the sense of own gender in a controlled experimental setting. Importantly, people with gender dysphoria who consider surgical and hormonal procedures to adjust their physical appearance to match their gender identity could perhaps benefit from future iterations of the body-sex-change illusion, which combined with virtual reality and 3D body scanners might alleviate distress and allow these individuals to somewhat experience their own “new body” before undergoing more permanent procedures.

Materials and methods

All participants provided written informed consent before the start of each experiment. The Regional Ethics Review Board of Stockholm approved the studies. All methods were performed in accordance with the approved guidelines. The inclusion criteria were as follows: (1) age between 18 and 65 years old; (2) no history of severe psychiatric illness or neurological disorder; (3) normal or corrected-to-normal vision and hearing; (4) not wearing glasses during the experiment; and (5) understanding English (see below). These criteria were assessed during an initial interview. Sample sizes were based on similar previous studies (see “ Introduction ”) and our counterbalancing schemes. Data collection was finalized when the planned number of participants was reached. At the end of each experiment, the participants were debriefed and received compensation. All measures that were used are reported in the manuscript. Because the participants were of different nationalities, all experiments were conducted in English; the participants followed instructions without problems. The stroking procedure in Experiment I was performed by P.T., and in Experiments II and III, it was performed by J.F.

Experiment I

Participants.

Thirty-three naïve adults participated (age: 25 ± 4; 4 left-handed; 15 females). Data from one participant were excluded due to a procedural error (same condition repeated twice).

The participants first rated how masculine or feminine they felt before experiencing any body perception manipulation (baseline; Fig.  1 d). The main experiment consisted of four conditions: “synchronous opposite sex” (syncO), “synchronous same sex,” (syncS), “asynchronous opposite sex,” (asyncO), and “asynchronous same sex” (asyncS). Each condition lasted 3.5 min. During each condition, the participants lay on a bed with their heads tilted forward (~ 45°) and wore a head-mounted display (HMD; Oculus Rift Development Kit 2, Oculus VR, Menlo Park, CA, USA) so that they could not see their actual body. In the HMD, the participants watched prerecorded 3D videos of a stranger’s body, male or female, that was shown from a first-person perspective. The stranger’s body was continuously stroked on the thighs and abdomen, and the experimenter delivered synchronous (syncO, syncS) or asynchronous (1 s delayed; asyncO, asyncS) touches on the corresponding parts of the participant’s body (Fig.  1 a). During each condition, there were three “knife threats” that occurred 1, 2, and 3 min after the beginning of each video (Fig.  1 c,e). After each condition, the participants took off the HMD, filled out the illusion questionnaire (Fig.  1 b) and rated how masculine or feminine they felt during the preceding session (Fig.  1 d). The order of conditions was counterbalanced across the participants, and the whole experiment lasted ~ 30 min (Fig.  1 e).

Prerecorded videos

During filming, a male and a female lay still on a bed. The experimenter used a 90-cm-long stick with a white plastic ball (diameter 10 cm) attached to its end to deliver strokes to each model’s abdomen, left thigh, or right thigh. The duration of each stroke was 1 s, and each stroke covered ~ 20 cm of the model’s body. The time between the end of one touch and the onset of the next touch ranged between 3 and 5 s. The frequency of strokes was 12 times per minute. The order of strokes was pseudorandom (i.e., no more than two successive strokes of the same body part). Altogether, 36 strokes (12 to each body part) were delivered during each video. The videos were recorded with two identical cameras (GoPro HERO4 Silver, GoPro, Inc., San Mateo, CA, USA) placed parallel to each other (8 cm apart) just above the models’ heads. The recordings from both cameras were combined into a single frame using Final Cut Pro software (version 7, Apple Inc., Cupertino, CA, USA). Two versions of high-quality 3D videos were created: one for the male and one for the female body. Audio cues were then added to each video. These cues were either congruent with touches applied in the videos (same body parts, same onset, same duration) or delayed by 1 s. The experimenter listened to these cues during the experiment and applied touches accordingly. All other aspects were identical in the synchronous and asynchronous videos.

Knife threats

For each of the two videos, we recorded knife-threat events. During these events, a hand holding a knife entered the field of view from above and performed a stabbing movement toward the model’s body (Fig.  1 c). The knife stopped just before hitting the body, changed direction (− 180°), and exited the field of view in the same way that it had entered. The whole event lasted 2 s. Great care was taken to ensure that the knife threats in the male and female versions of the videos looked as similar as possible. Knife threats in the synchronous and asynchronous versions of the same video (male or female) were identical. Subsequent knife threats within a given condition were also identical. After each knife threat, there was a 10 s pause when no strokes were delivered. In line with good ethical practice, before the experiment, we informed the participants about the knife threats in the videos to prevent overly high emotional stress.

Visuotactile stimulation during the experiment

The experimenter listened to audio cues from the videos (see earlier) and accordingly applied touches to the participant’s body. These cues were played via headphones, so the participants could not hear them. The number, order, type, length, velocity, and frequency of strokes during the experiment precisely followed the prerecorded videos (see earlier). To deliver touches, the experimenter used the same white ball attached to a stick that had been used in the video recordings.

Illusion questionnaires

Subjective experience of the full-body ownership illusion was quantified with a questionnaire that began with an open-ended sentence (“During the last session, there were times when…”). This sentence was followed by three illusion statements that quantified the explicit feeling of body ownership (I1; Fig.  1 b) and the sensation of touch directly on the stranger’s body (I2 and I3; Fig.  1 b). Ownership and referral of touch are considered to be the two core elements of the multisensory full-body illusion 25 , 26 . Apart from the illusion statements, the questionnaire included four control statements (C1–C4; Fig.  1 b) that were added to control for potential task compliance or suggestibility effects. The questionnaire administered to the participants had items listed in the following pseudorandom order: C1, I1, C2, I2, C3, C4, I3. The participants marked their responses on a scale from − 3 (“strongly disagree”) to + 3 (“strongly agree”).

Skin conductance responses

The skin conductance response reflects increased sweating attributable to the activation of the autonomic nervous system 76 . When one’s own body is physically threatened, the threat triggers emotional feelings of fear and anticipation of pain that are associated with autonomic arousal. This arousal can be registered as a brief increase in skin conductance a few seconds after the threat event. Increased threat-evoked skin conductance responses, compared to a well-matched control condition, are often used as an index of body ownership in body illusion paradigms 24 , 30 , 38 . In the current experiment, data were recorded continuously with the Biopac system MP150 (Biopac Systems Inc., Goleta, CA, USA) and AcqKnowledge software (version 3.9). The following parameters were used: sampling rate = 100 Hz, low-pass filter = 1 Hz, high-pass filter = DC, gain = 5 μS/V, and CAL2 scale value = 5. Two Ag–AgCl electrodes (model TSD203, Biopac Systems Inc., Goleta, CA, USA) were placed on the volar surfaces of the distal phalanges of the participants’ left index and middle fingers. Isotonic paste (GEL101; Biopac Systems Inc., Goleta, CA, USA) was used to improve the skin contact and recording quality. At the beginning of the experiment, we asked the participants to take the deepest breath possible and hold it for a couple of seconds. In this way, we tested our equipment and established a near maximum response for each participant. The timing of threat events was marked in the recording file by the experimenter by pressing a laptop key immediately after the threat occurred.

Masculinity/femininity ratings

The participants marked their responses on a visual analog scale (Fig.  1 d). Scale assignment was different for the male and female participants (Fig.  1 d). Baseline ratings were generally greater than zero, as expected for a nontransgender group, but showed some degree of variability (mean = 2.22; SD = 0.97; min = − 1; max = 4).

Experiment II

Sixty-four naïve adults participated (age: 27 ± 5; all right-handed; 32 females).

The participants first completed a practice IAT (20 trials). The main study consisted of the same four conditions as those in Experiment I, that is, syncO, asyncO, syncS, and asyncS (Figs.  1 a, 2 a). After the initial phase of just watching the videos and feeling touches (30 s), the participants started the first IAT block (Fig.  2 b,c). IAT stimuli were presented via headphones (Spectrum, Maxell Europe Ltd., Berkshire, UK). The participants used a wireless computer mouse held in the right hand to indicate responses. During each condition, the participants observed two “knife threats” (see further), one in the middle and one at the end of each condition (Fig.  2 c). After each condition, the participants completed the same illusion questionnaire as in Experiment I (Fig.  1 b). The order of the conditions was counterbalanced. The whole study lasted ~ 1 h (Fig.  2 c).

The videos were prepared analogously to those in Experiment I, but a different male and female were filmed to assure that our results were not driven by a certain body type or clothing style of the models (Fig.  2 a). Strokes were applied to three body parts: abdomen, left thigh, and right thigh. The abdomen strokes were either single or double (1 s apart). The duration of each stroke was 1 s, and each stroke covered ~ 20 cm of the model’s body. The time between the offset of one touch and the onset of the next touch ranged from 3 to 6 s. The frequency of strokes was 12 times per minute. The touches were delivered in a pseudorandom sequence, with no more than three successive strokes on the same body part. Altogether, 88 touches (22 on each body part) were applied in each video. The videos were recorded with Infinity cameras (1080p Full HD, CamOneTec, Delbrück, Germany) and prepared in the same way as in Experiment I. In the synchronous videos, audio cues were matched with the touches applied in the videos, whereas in the asynchronous videos, the cues were delayed by 1 s and pertained to different body parts. Altogether, we created four versions (syncO, syncS, asyncO, asyncS) of the high-quality 3D videos, each lasting 7 min 5 s.

We used the auditory version of the brief gender identity IAT 47 , 77 . The instruction for one block was as follows: “The test will start in a few seconds. Please listen to the instructions. Try to go as fast as possible while making as few mistakes as possible. If the word belongs to the categories female or self , press left. If the word does not belong to these categories, press right. The test will begin now.” The instruction for the other block differed only with regard to category assignment: “If the word belongs to the categories male or self , press left. If the word does not belong to these categories, press right.” The key assignment remained the same for a given participant across all conditions but was counterbalanced between the participants. The order of IAT blocks was counterbalanced in the same way. The stimulus set consisted of twenty words (Fig.  2 b) that were read by an English native speaker. The volume of each word sound was adjusted using Audacity software (the “normalize” effect; version 2.1.2, https://www.audacityteam.org ). Each word was edited to have a duration similar to that of other words. Please note that the physical differences between stimuli cannot explain the main IAT results because the congruent and incongruent blocks used exactly the same stimuli. The participants had a maximum of 3 s to provide a response (time from the stimulus onset to the end of each trial). If no key was pressed within this time or the wrong key was pressed, the participants heard a “wrong” feedback beep. Each IAT block consisted of 60 trials (three repetitions of all 20 words) presented in random order. The procedure was self-paced, that is, the next trial started as soon as the participant responded in the previous trial (maximum duration of one block ~ 3 min). Presentation software (Neurobehavioral Systems Inc., Albany, CA, USA) was used to present the stimuli and record responses.

These events were recorded in the same way as in Experiment I (i.e., stabbing movement toward the abdomen; 2 s duration). We used triggers from the Presentation software to automatically flag the onset of the knife threats in the skin conductance recording files.

Experiment III

Forty-five naïve adults participated (age: 26 ± 5; all right-handed; 22 females). One participant was excluded because he did not complete one of the questionnaires.

The study lasted ~ 35 min and comprised two conditions: syncO and asyncO (Fig.  3 a,b). Each condition lasted 14 min 10 s. After each condition, the participants filled out the illusion questionnaire (the same as in Experiments I and II) and the Bem Sex-Role Inventory; BSRI 49 , 50 (see further). The order of conditions was counterbalanced across participants (Fig.  3 b).

The videos were prepared analogously to those in Experiments I and II. Four types of strokes (single abdomen, double abdomen, left thigh, and right thigh) were applied. The duration of each stroke was 1 s, and each stroke covered ~ 20 cm of the model’s body. The time between the offset of one touch and the onset of the next touch ranged from 2 to 10 s. The frequency of strokes was 12 times per minute. Different touches were delivered in a pseudorandom sequence, with no more than three successive strokes on the same body part. Altogether, 160 touches (40 on each body part) were applied in each video. Infinity cameras (1080p Full HD, CamOneTec, Delbrück, Germany) were used to record the videos. Audio cues were matched to touches in the synchronous videos and delayed by 1 s in the asynchronous videos.

After each condition, the participants filled out a version of the BSRI 49 , 50 . The questionnaire contained 5 stereotypically masculine and 5 stereotypically feminine personality traits (Fig.  3 c). Using a 7-point Likert scale (1—“not at all”; 7—“very much”), the participants rated how well each trait described them. Ten traits were rated after the first condition and the other ten after the second condition. The order of BSRI versions was counterbalanced.

Analysis of illusion questionnaires

For each participant and condition, we calculated “illusion scores” as the differences between the average illusion (I1–I3) and the control (C1–C4) ratings. To confirm successful induction of the illusion, we compared these illusion scores between the synchronous and asynchronous conditions. The results for individual questionnaire items are shown in Figs. S5 and S6 . The effect of “ownership” used in the correlation analyses (Figs.  1 h, 2 f, 3 f) was the difference between I1 ownership ratings in syncO–asyncO (one value per participant). The participants who experienced a strong body-sex-change illusion were selected using the median-split method applied to ownership scores (see above). The median-split analyses (Figs.  1 i, 2 g, and 3 g) were performed mainly for display purposes and to complement the main analyses using continuous scores.

Analysis of skin conductance responses

Each response was measured as the difference between the maximum and minimum values during the 0–6 s period after each knife threat. Responses below 0.02 μS were treated as zeroes but were included in the analysis of the magnitude of skin conductance responses 76 . Statistical outliers were identified with the ± 1.5 interquartile criterion and removed from the dataset (16% and 6% of the values in Experiments I and II, respectively). Keeping the outliers did not change the main findings (main effect of synchrony in Experiment I: F 1,31  = 5.76; P  = 0.023; N = 32; Experiment II: F 1,63  = 6.43; P  = 0.014; N = 64; two-sided). We applied a square-root transformation to the skin conductance data 76 . Statistical models included the effect of “repetition”, which indicated how many knife threats had already occurred in the study (max. 12 in Experiment I and max. 8 in Experiment II). The magnitude of the skin conductance responses decreased exponentially with subsequent knife threats (Fig. S7 ). To “linearize” this relationship, we transformed the repetition number (1/repetition), which substantially improved the fit of the linear models to the data (Fig. S7 ; Experiment I: χ 2  = 4.36; P  < 0.005; Experiment II: χ 2  = 37.26; P  < 0.005; two-sided; N = 32 and N = 64, respectively). The effect of repetition (habituation) was highly significant (Tables S2 and S4), which was expected 76 . For the control analyses presented in Figs. S2 and S3 , we (1) calculated residuals from the following model: SCR ~ repetition; (2) averaged them for a given participant and condition; and (3) calculated the difference: syncO–asyncO (Fig. S2 ) or syncS–asyncS (Fig. S3 ). Using the residuals accounted for the habituation effect (see earlier).

Analysis of masculinity/femininity ratings, IAT, and BSRI

Raw masculinity/femininity ratings were analyzed (n = 160; one value per condition). IAT data included only correct trials, in which reaction times were longer than 200 ms and shorter than 1,500 ms (95.5% of all trials; n = 29,147). Reaction times were log-transformed. The BSRI analysis was performed on raw ratings (n = 862; 18 ratings missing). Analyses of IAT and BSRI included random intercepts of “1|Item”, which accounted for possible variability between different words (Tables S4 – S7 ).

Meta-analysis

For each participant in each experiment, we calculated the degree of gender identity updating. In Experiment I, this updating score was calculated as the following difference between the masculinity/femininity ratings: [(syncS + asyncS + asyncO)/3]–syncO. In Experiment II, this score was calculated as the difference between the average reaction times in each IAT block: [(syncS i-c  + asyncS i-c  + asyncO i-c )/3] – syncO i-c , where “i” and “c” denote “incongruent” and “congruent”, respectively. Finally, in Experiment III, the updating was calculated as the difference between average personality ratings from each condition: asyncO c-i –syncO c-i , where “c” and “i” correspond to stereotype-congruent and stereotype-incongruent traits, respectively. Because these scores were on different scales, we standardized them (i.e., from each participant’s score, we subtracted the group mean from the respective experiment and divided the result by the group standard deviation).

General statistical information

All statistical analyses were performed in RStudio and R software (version 3.3.3, The R Foundation for Statistical Computing, https://www.r-project.org ). Linear mixed models were estimated using the “lme4” package. Information regarding model selection is provided in Table S1 . All results are reported in Tables S2 – S7 . The distribution of residuals from each main model are shown in Fig. S8 . P -values for the F-tests were based on Satterthwaite’s approximation to degrees of freedom, as implemented by the “lmerTest” package (Tables S2 , S4 , and S6 ). P -values for effect size coefficients (Tables S3 , S5 , and S6 ) and their 95% confidence intervals were obtained with the bootstrapping method by comparing a given coefficient value to its null distribution derived from resampling the original dataset (“boot” package; 1,000 simulations).

Data availability

We do not have ethics approval to make the raw data from individual subjects publicly available.

Egan, S. K. & Perry, D. G. Gender identity: a multidimensional analysis with implications for psychosocial adjustment. Dev. Psychol. 37 , 451–463 (2001).

PubMed   CAS   Google Scholar  

Tate, C. C., Youssef, C. P. & Bettergarcia, J. N. Integrating the study of transgender spectrum and cisgender experiences of self-categorization from a personality perspective. Rev. Gen. Psychol. 18 , 302–312 (2014).

Google Scholar  

Tobin, D. D. et al. The intrapsychics of gender: a model of self-socialization. Psychol. Rev. 117 , 601–622 (2010).

PubMed   Google Scholar  

Fausto-Sterling, A. The dynamic development of gender variability. J. Homosex. 59 , 398–421 (2012).

Fausto-Sterling, A. Gender/sex, sexual orientation, and identity are in the body: how did they get there?. J. Sex Res. 56 , 529–555 (2019).

Money, J. The concept of gender identity disorder in childhood and adolescence after 39 years. J. Sex Marital Ther. 20 , 163–177 (1994).

Frable, D. E. S. Gender, racial, ethnic, sexual, and class identities. Annu. Rev. Psychol. 48 , 139–162 (1997).

Martin, C. L. & Ruble, D. N. Patterns of gender development. Annu. Rev. Psychol. 61 , 353–381 (2009).

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.) . (2013).

World Health Organization. International statistical classification of diseases and related health problems (11th ed.) . (2019).

Becker, I. et al. Body image in young gender dysphoric adults: a European multi-center study. Arch. Sex. Behav. 45 , 559–574 (2016).

van de Grift, T. C. et al. Body satisfaction and physical appearance in gender dysphoria. Arch. Sex. Behav. 45 , 575–585 (2016).

Piot-Ziegler, C., Sassi, M.-L., Raffoul, W. & Delaloye, J.-F. Mastectomy, body deconstruction, and impact on identity: a qualitative study. Br. J. Health Psychol. 15 , 479–510 (2010).

Wassersug, R. J., Mckenna, E. & Lieberman, T. Eunuch as a gender identity after castration. J. Gend. Stud. 21 , 253–270 (2012).

Feusner, J. D. et al. Female-to-male transsexual individuals demonstrate different own body identification. Arch. Sex. Behav. 45 , 525–536 (2016).

Majid, D. S. A. et al. Neural systems for own-body processing align with gender identity rather than birth-assigned sex. Cereb. Cortex 30 , 2897–2909 (2020).

Manzouri, A., Kosidou, K. & Savic, I. Anatomical and functional findings in female-to-male transsexuals: testing a new hypothesis. Cereb. Cortex 27 , 998–1010 (2017).

Burke, S. M., Manzouri, A. H. & Savic, I. Structural connections in the brain in relation to gender identity and sexual orientation. Sci. Rep. 7 , 17954 (2017).

ADS   PubMed   PubMed Central   Google Scholar  

Burke, S. M. et al. Testosterone effects on the brain in transgender men. Cereb. Cortex 28 , 1582–1596 (2018).

Kilpatrick, L. A., Holmberg, M., Manzouri, A. & Savic, I. Cross sex hormone treatment is linked with a reversal of cerebral patterns associated with gender dysphoria to the baseline of cisgender controls. Eur. J. Neurosci. 50 , 3269–3281 (2019).

Lin, C.-S. et al. Neural network of body representation differs between transsexuals and cissexuals. PLoS ONE 9 , e85914 (2014).

Case, L. K., Brang, D., Landazuri, R., Viswanathan, P. & Ramachandran, V. S. Altered white matter and sensory response to bodily sensation in female-to-male transgender individuals. Arch. Sex. Behav. 46 , 1223–1237 (2017).

Manzouri, A. & Savic, I. Possible neurobiological underpinnings of homosexuality and gender dysphoria. Cereb. Cortex 29 , 2084–2101 (2019).

Petkova, V. I. & Ehrsson, H. H. If I were you: perceptual illusion of body swapping. PLoS ONE 3 , e3832 (2008).

Ehrsson, H. H. The concept of body ownership and its relation to multisensory integration. in The new handbook of multisensory processes (ed. Stein, B. E.) 775–792 (MIT Press, 2012).

Kilteni, K., Maselli, A., Kording, K. P. & Slater, M. Over my fake body: body ownership illusions for studying the multisensory basis of own-body perception. Front. Hum. Neurosci. 9 , 141 (2015).

PubMed   PubMed Central   Google Scholar  

Blanke, O. Multisensory brain mechanisms of bodily self-consciousness. Nat. Rev. Neurosci. 13 , 556–571 (2012).

Tsakiris, M. The multisensory basis of the self: from body to identity to others. Q. J. Exp. Psychol. 70 , 597–609 (2017).

Maister, L., Slater, M., Sanchez-Vives, M. V. & Tsakiris, M. Changing bodies changes minds: owning another body affects social cognition. Trends Cogn. Sci. 19 , 6–12 (2014).

Ehrsson, H. H. Multisensory processes in body ownership. In Multisensory Perception: From Laboratory to Clinic (eds. Sathian, K. & Ramachandran, V.) 179–200 (Academic Press, 2020).

Petkova, V. I. et al. From part- to whole-body ownership in the multisensory brain. Curr. Biol. 21 , 1118–1122 (2011).

Preston, C. & Ehrsson, H. H. Illusory changes in body size modulate body satisfaction in a way that is related to non-clinical eating disorder psychopathology. PLoS ONE 9 , e85773 (2014).

Preston, C. & Ehrsson, H. H. Illusory obesity triggers body dissatisfaction responses in the insula and anterior cingulate cortex. Cereb. Cortex 26 , 4450–4460 (2016).

Ehrsson, H. H. & Chancel, M. Premotor cortex implements causal inference in multisensory own-body perception. Proc. Natl. Acad. Sci. USA 116 , 19771–19773 (2019).

Botvinick, M. & Cohen, J. Rubber hands ‘feel’ touch that eyes see. Nature 391 , 756 (1998).

ADS   PubMed   CAS   Google Scholar  

Guterstam, A., Larsson, D. E. O., Zeberg, H. & Ehrsson, H. H. Multisensory correlations—not tactile expectations—determine the sense of body ownership. PLoS ONE 14 , e0213265 (2019).

PubMed   PubMed Central   CAS   Google Scholar  

Ehrsson, H. H., Spence, C. & Passingham, R. E. That’s my hand! Activity in premotor cortex reflects feeling of ownership of a limb. Science 305 , 875–877 (2004).

Guterstam, A., Björnsdotter, M., Gentile, G. & Ehrsson, H. Posterior cingulate cortex integrates the senses of self-location and body ownership. Curr. Biol. 25 , 1416–1425 (2015).

van der Hoort, B., Guterstam, A. & Ehrsson, H. H. Being Barbie: the size of one’s own body determines the perceived size of the world. PLoS ONE 6 , e20195 (2011).

Peck, T. C., Seinfeld, S., Aglioti, S. M. & Slater, M. Putting yourself in the skin of a black avatar reduces implicit racial bias. Conscious. Cogn. 22 , 779–787 (2013).

Maister, L., Sebanz, N., Knoblich, G. & Tsakiris, M. Experiencing ownership over a dark-skinned body reduces implicit racial bias. Cognition 128 , 170–178 (2013).

Guterstam, A., Abdulkarim, Z. & Ehrsson, H. H. Illusory ownership of an invisible body reduces autonomic and subjective social anxiety responses. Sci. Rep. 5 , 9831 (2015).

ADS   PubMed   PubMed Central   CAS   Google Scholar  

Slater, M., Spanlang, B., Sanchez-Vives, M. V. & Blanke, O. First person experience of body transfer in virtual reality. PLoS ONE 5 , e10564 (2010).

Banakou, D., H, P. D. & Slater, M. Virtual embodiment of white people in a black virtual body leads to a sustained reduction in their implicit racial bias. Front. Hum. Neurosci. 10 , 601 (2016).

Banakou, D., Groten, R. & Slater, M. Illusory ownership of a virtual child body causes overestimation of object sizes and implicit attitude changes. Proc. Natl. Acad. Sci. 110 , 12846–12851 (2013).

Egloff, B. & Schmukle, S. C. Predictive validity of an implicit association test for assessing anxiety. J. Pers. Soc. Psychol. 83 , 1441–1455 (2002).

Sriram, N. & Greenwald, A. G. The brief implicit association test. Exp. Psychol. 56 , 283–294 (2009).

Olson, K. R., Key, A. C. & Eaton, N. R. Gender cognition in transgender children. Psychol. Sci. 26 , 467–474 (2015).

Stern, B. B., Barak, B. & Gould, S. J. Sexual identity scale: a new self-assessment measure. Sex Roles 17 , 503–519 (1987).

Bem, S. L. The measurement of psychological androgyny. J. Consult. Clin. Psychol. 42 , 155–162 (1974).

Bahrick, L. E. & Watson, J. S. Detection of intermodal proprioceptive-visual contingency as a potential basis of self-perception in infancy. Dev. Psychol. 21 , 963–973 (1985).

Filippetti, M. L., Johnson, M. H., Lloyd-Fox, S., Dragovic, D. & Farroni, T. Body perception in newborns. Curr. Biol. 23 , 2413–2416 (2013).

Filippetti, M. L., Lloyd-Fox, S., Longo, M. R., Farroni, T. & Johnson, M. H. Neural mechanisms of body awareness in infants. Cereb. Cortex 25 , 3779–3787 (2015).

Bremner, A. J. Developing body representations in early life: combining somatosensation and vision to perceive the interface between the body and the world. Dev. Med. Child Neurol. 58 , 12–16 (2016).

Cowie, D., McKenna, A., Bremner, A. J. & Aspell, J. E. The development of bodily self-consciousness: changing responses to the full body illusion in childhood. Dev. Sci. e12557 (2017).

Lai, C. K. et al. Reducing implicit racial preferences: I. A comparative investigation of 17 interventions. J. Exp. Psychol. Gen. 143 , 1765–85 (2014).

Bergouignan, L., Nyberg, L. & Ehrsson, H. H. Out-of-body-induced hippocampal amnesia. Proc. Natl. Acad. Sci. 111 , 4421–4426 (2014).

Tacikowski, P., Weijs, M. L. & Ehrsson, H. H. Perception of our own body influences self-concept and self-incoherence impairs episodic memory. iScience (2020). https://doi.org/10.1016/j.isci.2020.101429 .

Tsakiris, M. Looking for myself: current multisensory input alters self-face recognition. PLoS ONE 3 , e4040 (2008).

Tajadura-Jimenez, A., Grehl, S. & Tsakiris, M. The other in me: interpersonal multisensory stimulation changes the mental representation of the self. PLoS ONE 7 , e40682 (2012).

Sforza, A., Bufalari, I., Haggard, P. & Aglioti, S. M. My face in yours: visuo-tactile facial stimulation influences sense of identity. Soc. Neurosci. 5 , 148–162 (2010).

Yee, N., Bailenson, J. N. & Ducheneaut, N. The Proteus effect implications of transformed digital self-representation on online and offline behavior. Communic. Res. 36 , 285–312 (2009).

Peck, T. C., Doan, M., Bourne, K. A. & Good, J. J. The effect of gender body-swap illusions on working memory and stereotype threat. IEEE Trans. Vis. Comput. Graph. 24 , 1604–1612 (2018).

Barsalou, L. W. Grounded cognition. Annu. Rev. Psychol. 59 , 617–645 (2008).

Apps, M. A. J. & Tsakiris, M. The free-energy self: a predictive coding account of self-recognition. Neurosci. Biobehav. Rev. 41 , 85–97 (2014).

Bedder, R. L. et al. A mechanistic account of bodily resonance and implicit bias. Cognition 184 , 1–10 (2019).

Peña, J., Hancock, J. T. & Merola, N. A. The priming effects of avatars in virtual settings. Communic. Res. 36 , 838–856 (2009).

Tacikowski, P., Berger, C. C. & Ehrsson, H. H. Dissociating the neural basis of conceptual self-awareness from perceptual awareness and unaware self-processing. Cereb. Cortex 27 , 3768–3781 (2017).

Macrae, C. N., Moran, J. M., Heatherton, T. F., Banfield, J. F. & Kelley, W. M. Medial prefrontal activity predicts memory for self. Cereb. Cortex 14 , 647–654 (2004).

Gentile, G., Guterstam, A., Brozzoli, C. & Ehrsson, H. H. Disintegration of multisensory signals from the real hand reduces default limb self-attribution: an fMRI study. J. Neurosci. 33 , 13350–13366 (2013).

Limanowski, J. & Blankenburg, F. Integration of visual and proprioceptive limb position information in human posterior parietal, premotor, and extrastriate cortex. J. Neurosci. 36 , 2582–2589 (2016).

Ehrsson, H. H., Kito, T., Sadato, N., Passingham, R. E. & Naito, E. Neural substrate of body size: illusory feeling of shrinking of the waist. PLoS Biol. 3 , e412 (2005).

Downing, P. E., Jiang, Y., Shuman, M. & Kanwisher, N. A cortical area selective for visual processing of the human body. Science 293 , 2470–2473 (2001).

Costantini, M. et al. Temporal limits on rubber hand illusion reflect individuals’ temporal resolution in multisensory perception. Cognition 157 , 39–48 (2016).

Samad, M., Chung, A. J. & Shams, L. Perception of body ownership is driven by Bayesian sensory inference. PLoS ONE 10 , e0117178 (2015).

Dawson, M., Schell, A. & Filion, D. The electrodermal system. in The handbook of psychophysiology (eds. Cacioppo, J., Tassinary, L. & Berntson, G.) 152–191 (Cambridge University Press, 2007).

Nosek, B. A., Bar-Anan, Y., Sriram, N., Axt, J. & Greenwald, A. G. Understanding and using the brief implicit association test: Recommended scoring procedures. PLoS ONE 9 , 1–31 (2014).

Download references

Acknowledgements

This study was funded by the Swedish Research Council, Torsten Söderbergs Stiftelse, Göran Gustafsons Stiftelse, StratNeuro, and the European Commission (MSCA fellowship awarded to P.T.; 750955). We want to thank all the participants and Martti Mercurio for important technical support.

Open Access funding provided by Karolinska Institute.

Author information

Authors and affiliations.

Department of Neuroscience, Karolinska Institute, Stockholm, Sweden

Pawel Tacikowski, Jens Fust & H. Henrik Ehrsson

Department of Neurosurgery, Univeristy of California Los Angeles, Los Angeles, USA

Pawel Tacikowski

Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

You can also search for this author in PubMed   Google Scholar

Contributions

P.T. and H.H.E. designed the study and wrote the manuscript. P.T. and J.F. collected and analyzed the data. All authors provided revisions and approved the final version of the manuscript for submission.

Corresponding author

Correspondence to Pawel Tacikowski .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Supplementary movie s1, supplementary movie s2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Tacikowski, P., Fust, J. & Ehrsson, H.H. Fluidity of gender identity induced by illusory body-sex change. Sci Rep 10 , 14385 (2020). https://doi.org/10.1038/s41598-020-71467-z

Download citation

Received : 02 September 2019

Accepted : 11 August 2020

Published : 01 September 2020

DOI : https://doi.org/10.1038/s41598-020-71467-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Developmental changes of bodily self-consciousness in adolescent girls.

• Cédric Goulon
• Marie-Hélène Grosbras

Scientific Reports (2024)

Synchronous motor imagery and visual feedback of finger movement elicit the moving rubber hand illusion, at least in illusion-susceptible individuals

• Christopher C. Berger
• H. Henrik Ehrsson

Experimental Brain Research (2023)

Navigating the Cultural Landscape Through Publishing Brands: A Theoretical, Gendered Perspective

• Miriam J. Johnson

Publishing Research Quarterly (2023)

Effects of a virtual gender swap on social and temporal decision-making

• Jasmine T. Ho
• Bigna Lenggenhager

Scientific Reports (2021)

Bodily ownership and agency sensations in a natural state

• Souta Hidaka
• Kyoshiro Sasaki
• Wataru Teramoto

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Sexual orientation and gender identity and expression conversion exposure and their correlates among LGBTQI2+ persons in Québec, Canada

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft

* E-mail: [email protected]

Affiliations Research Chair in Sexual Diversity and Gender Plurality, Université du Québec à Montréal, Montréal, Québec, Canada, Département de sexologie, Université du Québec à Montréal, Montréal, Québec, Canada

Roles Writing – original draft

Affiliation Research Chair in Sexual Diversity and Gender Plurality, Université du Québec à Montréal, Montréal, Québec, Canada

Roles Writing – review & editing

Affiliation Faculty of Law and Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada

Roles Formal analysis, Methodology

Roles Conceptualization, Funding acquisition, Writing – review & editing

Affiliation Département de travail social, Université du Québec en Outaouais, Gatineau, Québec, Canada

• Martin Blais, 
• Fabio Cannas Aghedu, 
• Florence Ashley, 
• Mariia Samoilenko, 
• Line Chamberland, 
• Isabel Côté

• Published: April 6, 2022
• https://doi.org/10.1371/journal.pone.0265580
• Reader Comments

Despite greater acceptance of sexual and gender diversity and the scientific consensus that same-gender attraction, creative gender expression, and transness are not mental illnesses, LGBTQI2+ persons are still commonly told that they can or should change their sexual orientation, gender identity, or gender expression (SOGIE). The aim of this study was to describe the prevalence of SOGIE conversion efforts, including their sociodemographic correlates, among LGBTQI2+ persons.

Using community-based sampling, we assessed SOGIE conversion attempts and involvement in conversion services of 3,261 LGBTQI2+ persons aged 18 years and older in Quebec, Canada.

A quarter of respondents experienced SOGIE conversion attempts, and fewer than 5% were involved in conversion services. Over half of those who were involved in SOGIE conversion services consented to them, but the services’ goals were made clear and explicit to only 55% and 30% of those who engaged in SO and GIE conversion, respectively. The results also suggest that family plays a key role in SOGIE conversion attempts and services utilization, and that indigenous, intersex, transgender, non-binary, and asexual persons, people of colour, as well as individuals whose sexual orientation is not monosexual (i.e., bisexual, pansexual) were more likely to have been exposed to conversion attempts and involved in conversion services.

Conclusions

This study found that the prevalence of conversion efforts is substantial. Interventions to protect LGBTQI2+ people from such attempts should focus not only on legal bans, but also on supporting families who need to be counseled in accepting sexual and gender diversity. Health professionals need to be adequately trained in LGBTQI2+ affirmative approaches. Religious therapists should consult with colleagues and undergo supervision to ensure that their religious beliefs do not interfere with their practice.

Citation: Blais M, Cannas Aghedu F, Ashley F, Samoilenko M, Chamberland L, Côté I (2022) Sexual orientation and gender identity and expression conversion exposure and their correlates among LGBTQI2+ persons in Québec, Canada. PLoS ONE 17(4): e0265580. https://doi.org/10.1371/journal.pone.0265580

Editor: Stefano Federici, University of Perugia: Universita degli Studi di Perugia, ITALY

Received: September 24, 2021; Accepted: March 7, 2022; Published: April 6, 2022

Copyright: © 2022 Blais et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Since the data contain potentially sensitive information about study participants, the Université du Québec à Montréal’ Human Research Ethics Board has only approved storage of the dataset on secure institutional servers. Any requests to access the data can be made to Université du Québec à Montréal’ Human Research Ethics Board ( [email protected] ; reference Ethics Protocol Number #2020-2218).

Funding: This research is supported by funding from the Social Sciences and Humanities Research Council of Canada. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Despite greater acceptance of sexual and gender diversity and the scientific consensus that same-gender attraction, creative gender expression, and transness are not mental illnesses, lesbian, gay, bisexual, trans, queer, intersex, two-spirit (LGBTQI2+) persons are still commonly told that they can or should change their sexual orientation (SO), gender identity (GI), or gender expression (GE). A recent study revealed that two-thirds of youths aged 13–24 years in the US reported that someone had tried to convince them to change their SOGIE [ 1 ]. Such pressures stem from the belief that it is best to be heterosexual and cisgender (i.e., not transgender) and that people should be changed when they do not conform to cisheterosexist norms. The concept of SOGIE change efforts has been coined to describe any direction or advice that intentionally delays or impedes self-acceptance of one’s sexual orientation, gender identity, or gender expression [ 2 – 4 ]. The 2020 edition of the Canadian Sex Now Survey revealed that about 20% of sexual minority men (gay, bisexual, transgender, Two-Spirit and queer) have been exposed to such efforts [ 5 ]. The US Transgender Survey found that 14% of respondents reported lifetime exposure to gender identity conversion efforts [ 6 ].

Conversion therapy refers to more sustained, structured, specific interventions aiming at changing, discouraging, or repressing SOGIE [ 2 – 4 ]. It relies on various techniques, inspired by psychotherapeutic, medical, or faith-based principles (e.g., talk therapy, aversion therapy, hormonotherapy, spiritual guidance) and takes place in various contexts ranging from private or public settings to “gay conversion camps” or religious institutions. Not only are they inefficient, scientifically unsound, and unethical, but they are also known to have adverse effects on survivors [ 6 – 8 ]. It is thus unsurprising that most psychological, medical, and sexual health professional associations have opposed SO conversion efforts for decades, and most of them are now adopting similar responses to GIE conversion efforts [ 9 ]. In December 2020, a ban on SOGIE conversion therapies has been adopted in Québec. This new law targets practices intended to “induce persons to change their sexual orientation, gender identity or gender expression or to repress non-heterosexual sexual behaviour” and applies regardless of age [ 10 ]. Violations are subject to heavy fines, professional discipline, and/or victim compensation. Federally, a criminal ban has been adopted by the Senate [ 11 ]. According to this new law, anyone who advertises, materially benefits from, or causes a person to undergo SOGIE conversion therapy would be liable to imprisonment for up to five years depending on the offence.

Professional associations’ statements are insufficient, as conversion experiences continue to be reported. In the US, about 4% of youths aged 13–24 years have undergone SOGI conversion therapy [ 7 ]. In Canada, three large, non-probabilistic studies have documented SOGI conversion experiences: the Sex Now survey 2011–2012 (N = 8,388) revealed that about 3.5% of Canadian sexual minority men (i.e., gay, bisexual, transgender, Two-Spirit and queer) experienced SO conversion therapy (4.2% in Quebec; [ 4 ]), the Sex Now survey 2019–2020 (N = 9,214) found that 9.9% of participants were exposed to SOGI conversion therapy [ 3 ]; and the Trans Pulse Canada survey (N = 2033) found that 11% of transgender and non-binary people had experienced conversion therapy [ 12 ].

Survivor characteristics

In Canada, men who have sex with men (MSM) who have been exposed to SO or GI conversion efforts or practices were more likely to be gay (compared to bisexual), transgender and non-binary (compared to cisgender), “out” about their sexual orientation (relative to those who were not), younger, immigrants, and to earn an annual personal income of less than $30,000 (compared to those who earn $60,000 or more [ 3 , 4 ]. The TransPULSE study found increasing rates of conversion therapy experiences with age [ 12 ]. In a US cohort of middle-aged and older MSM, Meanley et al. [ 13 ] found lower exposure to conversion therapy among MSM with any college education, but higher exposure among participants who enrolled in the studies post-2001 (compared to those enrolled pre-1987). Among US youths, Green et al. [ 7 ] found a higher prevalence of conversion experiences among gay and lesbian youths (relative to youths identifying as bisexual or as “something else”) and those from low-income families.

Conversion effort exposure appears to be evenly distributed before and after the age of 18 years. Societal, legal, and cultural homo- or trans-negativity is often endorsed by parents of LGBTQI2+ youths [ 14 , 15 ], leading them to seek conversion efforts for their children. Furthermore, these beliefs may lead LGBTQI2+ child(ren) to believe that they would be more accepted if they were heterosexual and cisgender. Growing up with cultural and parental cisheteronormative values is thus likely to influence LGBTQI2+ persons to initiate, be exposed to, or participate in conversion efforts, whether voluntarily or not.

To explore such societal, legal, or cultural contexts, previous studies have relied on variables such as race/ethnicity, age cohort, religious affiliation, or family’s support of SOGIE. Salway et al. [ 4 ] found greater SO conversion therapy prevalence among Canadian Indigenous individuals and other racial minorities (relative to White men), but no differences were found between age groups. The study found that conversion efforts were far more common among trans respondents (12.1% versus 3.5%). Salway et al. [ 3 ] found that the prevalence of SOGI conversion therapy practices was higher among younger generations, immigrants, and racial/ethnic minorities. Meanley et al. [ 13 ] found a greater prevalence of these practices among US middle-aged and older Black MSM (both non-Hispanic and Hispanic) and those of other racial minority groups (compared to non-Hispanic White men), while Green et al. [ 7 ] found a higher prevalence among Hispanic/Latinx youths. In Ryan et al.’s [ 8 ] sample, respondents who were not born in the US were more likely than those born in the US to report having been taken to a therapist or religious leader by their parents to change their SO. Hypothesizing the role of more conservative values, Flores et al. [ 16 ] found lower support for banning conversion therapy among US racial and cultural minority groups. This conclusion supports the finding that ethnic minority parents report greater levels of homonegativity than ethnic majority parents [ 17 ]. Given the between-country variations in attitudes toward SOGIE, we can expect variations in exposure to conversion efforts depending on the country of birth.

Youth who underwent SO or SOGI conversion therapy are also more likely to come from religious families [ 8 ] or to have heard their parents (or caregivers) use religion to justify saying negative things about LGBTQ individuals [ 7 ]. Adamson et al. [ 18 ] found that, in their worldwide sample, about one-fourth of respondents who have been exposed to conversion efforts indicated that they had sought conversion therapy on their own, while the rest of the sample reported that this decision was beyond their control or made on their behalf by their family, religious leaders or community, school, or employer. They also found that most practitioners who led conversion therapy were mental health providers, followed by religious authorities or their associates.

While LGBTQI2+ people in Canada have been subjected to SOGIE conversion efforts, data are still scarce as most studies are limited to sexual minority men and specifically to SO conversion efforts. In Quebec, the only prevalence estimates available come from the Sex Now survey data, which found conversion therapy rates of 4.2% for SO [ 4 ] and 6.8% for SOGI [ 3 ] among Canadian sexual minority men. While little is known about conversion efforts among other sexual orientation groups (e.g., bisexual and pansexual individuals) and across genders and gender modalities (i.e., cisgender or transgender), rates of conversion efforts appear higher among transgender people [ 3 , 4 , 12 , 19 ]. Moreover, as asexuality has only been recently recognised as different from sexual desire disorders [ 20 ], it is likely that persons describing their sexual orientation as asexual are more likely to have experienced sexual orientation conversion efforts or to have sought services to help them change. Also, to our knowledge, data on intersex persons’ experiences with gender identity assignment or modification are also scarce, though such experiences are likely as intersex variations are treated as a medical condition falling under sex/gender (re)assignment. Relying on a large, province-wide community-based survey, the current study describes the prevalence of SOGIE conversion attempts and involvement in conversion services, as well as their sociodemographic correlates, among LGBTQI2+ persons in Quebec.

Participant recruitment

Data on SOGIE conversion experiences were collected as part of the Understanding the Inclusion and Exclusion of LGBTQ People (UNIE-LGBTQ) research project, which aimed to document events during which LGBTQI2+ people (aged 18 years and older) were demeaned, rejected and belittled, or deprived of the full extent of their rights in important life domains. Participants were recruited from September 2019 to August 2020 (before any legal ban on conversion therapy in Quebec or Canada) through the project’ and community partners’ communication channels (emails, listservs, the project website, Facebook pages and groups, Twitter, and LinkedIn), web and printed media, and word of mouth. The survey was administered online and was available in both French and English. Inclusion criteria were understanding French or English, being at least 18 years old, self-identify as LGBTQI2+, and live in the province of Quebec.

Over 6,000 persons accessed the online questionnaire, of which we retained only those who provided a valid Quebec postal code or whose IP address was located in the province (n = 6,095). Participants who did not provide sufficient data to confirm their eligibility or who did not meet the inclusion criteria were excluded (n = 1,115, of which 11 did not consent, 71 were younger than 18, and 85 were not LGBTQI2+). The final sample was composed of 4,980 participants. The present paper is based on the data of the 3,261 respondents who provided information on their exposure to SOGIE conversion attempts or their involvement in SOGIE conversion services. This study was approved by the Institutional Research Ethics Board of the Université du Québec à Montréal (Québec, Canada) (Protocol #2775).

We assessed lifetime involvement in conversion therapy services and lifetime exposure to conversion attempts. Both were measured separately for SO and GIE, as social attitudes and professional guidelines toward sexual diversity and gender diversity are different. The four items used to assess these constructs, and their response options, are presented in Table 1 . The research team created the survey questions based on the scientific literature and by consulting experts on conversion therapy and key informants from community-based organizations.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0265580.t001

Questions on lifetime involvement in conversion services were introduced by explicitly stating the aim of such services. Participants were provided with the following instructions: “The next questions ask about the contacts you may have had with services for which your aim was, for instance, [see Table 1 for specific wording of the aim for SO and GIE] . These services may have been provided by health professionals, spiritual or religious guides, or other types of people. These services may go by various names, including therapy or treatment (conversion, reparative, or corrective), special consultations, spiritual processes, healing or deliverance sessions, or other names you may be familiar with. Answer the following questions in relation to all the services you have been in contact with taken together, whether this was on your own initiative or upon someone else’s request (parent, partner, spiritual advisor, etc.)”. Contrary to these organized efforts, conversion attempts refer to any direction or advice to change someone’s SOGIE, make them conform to cisheterosexist norms, or to prevent them from becoming gay, lesbian, bisexual, or transgender.

We asked those who were involved in conversion services to provide information on their most recent experience: their age at the time, and the type of service provider (response options were: a doctor or psychiatrist; a psychologist; a sexologist; another type of therapist or psychotherapist; a member of the clergy, of a religious group, or of a church; no recollection of the person; other). We also inquired about the goals of the services. For SO conversion, the goals were: “to prevent you from being or becoming gay, lesbian, or bisexual”; “to change your sexual orientation (e.g., toward heterosexuality)”; and “to change how you express yourself in your body (your mannerisms, your ways of speaking, moving, walking, dressing, doing your hair, etc.)”. For GIE conversion, the possible goals were: “to prevent you from being or becoming trans”; “to change your gender identity (e.g., to become cisgender)”; and “to change how you express your gender identity with your body (your mannerisms, your ways of speaking, moving, walking, dressing, doing your hair, etc.)”. The four response anchors were dichotomized: not at all (coded 0); a bit (coded 0); somewhat (coded as 1); and a lot (coded as 1). Respondents also indicated whether they themselves, their parents (or their representatives), or someone else consented to these services and whether their conversion purposes were explicit from the beginning (response options: yes; no).

We also explored six potential motivations to seeking conversion services: 1) “I thought it would be easier for me and for my future if I tried”, 2) “I wanted to become [heterosexual, or cisgender] or to avoid becoming [gay, lesbian, or bisexual, or trans]”, 3) I was afraid of negative consequences if I refused to try (e.g., family rejection, refusal of care, termination of treatment), 4) “I felt that my loved ones would be happy if I did it”, 5) “I could not say no to the person or people who suggested it to me”, and 6) “They convinced me it was a good idea to try”. The response options ranged from 0 (Totally false) to 3 (Totally true).

Additional data on year of birth, intersex variation, sexual orientation, gender modality and identity, race/ethnicity, education, place of birth, household income, parents’ religious attendance, and perceived parents’ attributed importance to religious upbringing were also collected.

Data analysis

Descriptive statistics were computed to summarize the sample’s characteristics. Continuous variables were presented as means and standard deviations, or as medians and intervals defined by the first and third quartiles. For dichotomous variables, their prevalence and 95% exact confidence intervals (CI) were calculated [ 21 ]. For categorical variables, we presented the proportion of each category and the corresponding 95% CI were calculated simultaneously for multinomial proportions [ 22 ]. Chi-square or Ficher exact tests were used to compare the distributions of the lifetime exposure to SOGIE conversion attempts and involvement in conversion services between cisgender LGBQ+ and trans participants. Crude Poisson regression with a robust error variance [ 23 ] was applied to assess the associations between lifetime exposure to SOGIE conversion attempts or service involvement and participant’s characteristics on the prevalence ratio (PR) scale. Analyses were performed using STATA 16.1 and SAS 9.4.

Missing data on the outcome variables followed a monotone pattern reflecting sections order in the online questionnaire, ranging from 34.5% (for conversion services involvement) to 39.7% (for conversion attempts). For both outcomes, weak associations [ 24 , 25 ] were found between the presence of missing data and education (Cramer’s V between 0.12 and 0.13), and between the missingness in SOGIE conversion services involvement and birth cohort (Cramer’s V = 0.12), suggesting that missing data on the outcome variables were not completely random. Participants with a university degree and older participants were more likely to have completed the questionnaire. The percentage of missing values in the analytic sample was below 9% for most variables included in the present paper but exceeded 10% for two variables (parental religious attendance and attitudes). Statistical guidelines suggest that bias is negligeable with less than 10% missingness [ 26 ]. Missing values were not replaced. The significance level was set at p < 0.05.

Participants

Table 2 presents the sample’s characteristics. While most participants were born after 1980, multiple birth cohorts were represented. Most participants described their sexual orientation as gay or lesbian (59%), bisexual (17%), or pansexual (10%). Over 80% of the sample was cisgender (43% women, 40% men), and 17% were transgender or non-binary (12% trans men and non-binary assigned female at birth, 5% trans women and non-binary persons assigned male at birth). Fourteen persons reported intersex variations. Most of the sample was white (89%) but included indigenous people (3%) and people of color (8%). Over half of participants reported a college or university degree (56%), most were born in Canada (87%), and were equally distributed across the four assessed household income brackets. About one-third of respondents reported that their parents never attended religious services and did not attribute any importance to religious upbringing.

https://doi.org/10.1371/journal.pone.0265580.t002

Lifetime prevalence of SOGIE conversion attempt exposure and involvement in conversion services

Overall, 26.4% (95% CI, 24.8% to 28.0%) of respondents have experienced lifetime SOGIE conversion attempts or have been involved in conversion services (see Table 3 ). Cisgender sexual minority participants were more likely to have experienced conversion efforts targeting their SO (20.0%, 95% CI, 18.4 to 21.5) than their GIE (6.2%, 95% CI, 5.3 to 7.2), while trans participants were more likely to have been targeted for their GIE (41.9, 37.5 to 46.4) rather than their SO (25.6%, 95% CI, 21.8 to 29.7). Overall, trans participants were more likely to have been exposed to SOGIE conversion attempts and involved in SOGIE conversion services.

https://doi.org/10.1371/journal.pone.0265580.t003

SOGIE conversion attempts

Over two-thirds of respondents identified family members as responsible for the SOGIE conversion attempts (see Table 4 ), followed by friends and acquaintances, members of the clergy, and relationship (ex-)partners. Ten percent or less of participants identified healthcare professionals as responsible for such efforts. Trans participants were more likely than their cisgender LGBQ+ counterparts to have experienced GIE conversion attempts by friends or acquaintances (28.4%, 95% CI: 22.2% to 35.1% vs 15.3%, 95% CI: 9.8% to 22.2%), relationship (ex-)partner(s) (22.9%, 95% CI: 17.3% to 29.3% vs 11.1%, 95% CI: 6.5% to 17.4%), and healthcare professionals (12.9%, 95% CI: 8.6% to 18.4% vs 2.1%, 95% CI: 0.4% to 6.0%).

https://doi.org/10.1371/journal.pone.0265580.t004

Table 5 reports sociodemographic correlates of SO and GIE conversion attempts. SO conversion attempts were more commonly experienced by respondents who were bisexual, pansexual, and asexual (compared to gay/lesbian), transgender (compared to cisgender), indigenous and racialized (compared to white), and those whose parents were more likely to attend religious services (compared to never ) and to at least somewhat value religious upbringing (compared to not at all ). SO conversion attempts were less common among participants who had a college or university education (compared to less than college), who were born in Canada (compared to those born abroad), and who reported an annual household income of over $30,000 CAD (compared to < $30,000 CAD).

https://doi.org/10.1371/journal.pone.0265580.t005

GIE conversion attempts were more commonly experienced by participants who were born in 1981–1990 and after 1990 (compared to those born before 1955), who reported an intersex variation (compared to endosex respondents), who were bisexual, pansexual, queer, and asexual (compared to gay/lesbian), transgender (compared to cisgender), transmasculine and transfeminine (compared to cisgender women), indigenous and racialized (compared to white), and by participants whose parents extremely valued religious upbringing (compared to not at all ). GIE conversion attempts were less commonly experienced by respondents with a college or university education (compared to less than college) and by those who reported an annual household income of over $60,000 CAD (compared to < $30,000 CAD).

Involvement in SOGIE conversion services

Regarding SOGIE conversion services’ involvement (see Table 6 ), respondents born after 1990 reported the lowest prevalence (2.5%, 95% CI 1.8% to 3.4%), with a gradual increase among older cohorts. Participants born before 1955 were the most likely to have been involved in these services (11.7%, 95% CI, 7.7% to 17.2%) compared to other age cohorts, as were transgender participants (PR = 1.59, 95% CI, 1.10 to 2.30), cisgender men (PR = 1.62, 1.12 to 2.36) and transfeminine participants (PR = 3.28, 1.94 to 5.55) compared to cisgender women, indigenous (PR = 2.10, 95% CI, 1.10 to 4.03) and racialized participants (PR = 2.08, 95% CI, 1.33–3.26) compared to white, and those whose parents attended religious services at least 3 times a year, compared to never , and to value religious upbringing at least somewhat , compared to not at all ).

https://doi.org/10.1371/journal.pone.0265580.t006

Regarding the most recent involvement in SOGIE conversion services ( Table 7 ) results show a wide range in terms of the age at which it took place, with as early as 2 years old and as late as almost 60 years old (median age = 18 years). Over half of occurrences occurred after 2000, with trans participants being more likely to have experienced such involvement after 2009 (57.1, 95% CI: 36.8 to 75.3) compared to cisgender ones (24.8, 95% CI: 16.0 to 36.3). Most commonly, the services were provided by healthcare professionals (doctors, psychiatrists, psychologists, or sexologists), a member of the clergy, another type of professional (e.g., counselors, therapists, teachers, etc.) or, less commonly, by a relative or a family friend. Multiple service providers were identified, which suggests that multiple persons provided conversion services, or that some of them occupied multiple functions (e.g., both a healthcare professional and a member of the clergy, both a sexologist and physician, etc.).

https://doi.org/10.1371/journal.pone.0265580.t007

Among cisgender participants, conversion services’ main goals were to make them heterosexual (69.0%) or to prevent them from being gay, lesbian, or bisexual (62.4%). Among trans participants, the most reported goals were to make them heterosexual (83%), change their gender identity (68.2%) or their gender expression (60.0%), or to prevent them from being or becoming transgender (65.2%).

Among respondents who were involved in SO conversion services, about 52% consented themselves, of whom only 55% were clearly aware of the services’ objectives (see Table 8 ). About 48% reported that their parents (or a family member) consented on their behalf, with over 60% of them indicating that the family member(s) did so with clear awareness of the services’ objectives. An additional one-fifth of participants who were involved in SO conversion services reported that someone other than family consented on their behalf, being cognizant of the services’ objectives in over 80% of cases. The most frequently endorsed reasons for using such services were that they thought it would be easier for them and for their future if they tried, and that they could not say no to the person or people who suggested it.

https://doi.org/10.1371/journal.pone.0265580.t008

Approximately 56% of respondents having been involved in GIE conversion services consented themselves, 30% of whom were cognizant of these services’ conversion goals. Forty percent reported that their family consented for them, with clear awareness of the services’ objectives in 40% of cases. One-fifth of the participants who were involved in GIE conversion services reported that someone other than family consented on their behalf (e.g., physician, member of the clergy, psychologist, friends, school staff, etc.), close to 63% of whom were clearly aware of the services’ objectives. The main reasons endorsed for using these services were to make their lives and futures easier, to please their loved ones, and because they feared negative consequences in case of refusal (e.g., family rejection, refusal of care, termination of treatment, etc.).

This study is the first to report data on lifetime exposure to various forms of SOGIE conversion efforts across all gender identities and modalities and sexual orientation groups in Canada. We used data from a large community-based survey to investigate SOGIE prevalence and correlates among LGBTQI2+ people in the province of Quebec. This study revealed that 4.4% of the sample used SOGIE conversion services, with higher prevalence rates among trans participants (PR = 1.59, 95% CI, 1.10 to 2.30). The overall rate of conversion service involvement was close to those reported for Quebecois MSM in the Canadian Sex Now survey (4.2%, [ 4 ]; 6.8%; [ 3 ]). In the current study, conversion services involvement among transgender participants (6.3%) was lower than that reported in the US Transgender Survey (i.e., 14%; [ 6 ]).

SOGIE modification attempts were far more prevalent than conversion services involvement in the current LGBTQI2+ sample (25%), particularly among trans participants who were about 7 times more likely to report so compared to cisgender participants. In comparison, Salway et al. [ 5 ] report a lower prevalence among sexual-minority men (15% in Quebec, 20% across Canada). Disparities in these estimates may reflect variations in the wording of the phenomenon, such as services involvement, sustained efforts [ 5 ], conversion therapy [ 1 , 7 , 13 ], reparative therapy [ 7 ], attempts or efforts [ 3 ], treatment or cure [ 8 ], or sexual repair/reorientation [ 4 ], as well as geographical variations in the conversion services offered and in the societal attitudes toward sexual and gender diversity across the US and Canada, and in Quebec more specifically.

Correlates of conversion services involvement

It should be noted that licensed healthcare providers were responsible for about half of the current sample’s most recent conversion experiences, and members of the clergy or of a religious group, for about one-third. Over half of participants reported having consented to SOGIE conversion services. These services’ objectives, however, were clear to only 55% of those who engaged in SO conversion and to 30% of those who engaged in GIE conversion, which suggests that the goal of conversion became known to these participants only once after being involved in the process. These numbers are higher than those of a previous study that included participants from over 100 countries and showed that only one-fourth of the sample have sought conversion services on their own, while the rest of respondents declared that the decision was largely outside of their control [ 18 ].

The results also show that other persons were also involved to varying degrees in these decisions (parents, extended family, religious congregation members, or school personnel, including private school personnel, which are assumed to be religious), and that these individuals were more likely than the participants to have been aware of the services’ conversion goals. Overall, conversion services involvement among Quebec LGBTQI2+ persons likely resulted from concerted efforts from their immediate environment. Given that the most frequently endorsed reasons to consent to or comply with these services were the wish for a better future and the fear of rejection, it is also likely that these individuals were swayed by ambient hostility toward sexual and gender diversity, leading them to believe that SOGIE conversion was their best option. The results further revealed that a high percentage of participants, parents, and family members were unaware of conversion services’ goals, suggesting that they may involve deception or manipulation, especially in relation to GIE conversion services. To increase power when exploring for correlates, we merged participants who reported having accessed any SO or GIE conversion services. This decision was supported by our finding that response patterns concerning both services were similar. Contrary to Salway et al. [ 3 ] who found a greater exposure to conversion therapy practices among younger generations of Canadian MSM, we observed a birth cohort effect regarding the accessing of conversion services, with older cohorts being more likely than younger ones to report having done so. This pattern may reflect changes in societal attitudes and professional regulations that oppose SO conversion practices, and only more recently, GIE conversion practices.

Accessing SOGIE conversion services was also more commonly reported by indigenous and racialized participants, as well as by those from more religious families. These findings support those of previous studies, and suggests that these groups may endorse more conservative values and stricter sexuality and gender norms (often imported from a colonial past; see Barker [ 27 ]), which contribute to create a hostile climate toward sexual and gender diversity and to increase the likelihood of seeking SOGIE conversion services [ 15 ]. While there were no variations between sexual orientation groups regarding SOGIE conversion services involvement, we found that transgender persons and those assigned male at birth (cisgender, transgender, or non-binary) presented increased risk. This points to a lower threshold for gender (non-)conformity tolerance toward persons assigned male at birth. Contrary to Salway et al. [ 4 ], low-income participants were not more likely to have been involved in SOGIE conversion services than those with higher incomes.

Correlates of conversion attempts

While our findings regarding SOGIE conversion attempts also confirm the role of sociocultural context, differences between SO and GIE conversion attempts are noteworthy. While SO conversion efforts occurred in similar proportions across birth cohorts, GIE attempts were mainly reported by younger generations. This could reflect socially and politically conservative reactions to increased consultations regarding GIE variations among younger generations [ 28 ]. Such conversion attempts could also be due to more recent cohorts of non-binary and transgender persons coming out earlier due to increasing trans visibility, and while still living in their parents’ homes, which can make them more vulnerable to family pressure and other cisnormative influences.

Both SO and GIE conversion attempts were more commonly reported by less educated and lower income participants, while SO conversion attempts more specifically were more common among those who were from more religious households and who were born outside Canada. These results confirm previous findings about the key role of geographical and socioeconomic factors in creating a social or family context that is hostile to sexual and gender diversity. As Salway et al. [ 4 ] suggested, it is possible that the association between ethnicity and racialized status and SO conversion efforts may be at least partially explained by the mediating effect of socioeconomic factors. Yet, as exposure to SOGIE conversion likely happened before the income and education level measured at the time of the study, it is more likely that exposure to SOGIE conversion efforts has negatively impacted the socioeconomic trajectory, a hypothesis that is also suggested by other authors [ 8 ].

That SOGIE conversion attempts were more commonly reported by individuals who identified as other than gay or lesbian can reflect the greater acceptance and recognition of gay and lesbian persons, while other sexual identities remain misunderstood (e.g., bisexuality and pansexuality) or conceptualized as sexual disorders (e.g., asexuality). Results revealed how cisnormativity can also affect intersex persons, who were more likely than their endosex counterparts to have been exposed to GIE, but not SO, conversion attempts. Moreover, our results showed that, compared to their cisgender counterparts, transgender persons were more exposed to both SO and GIE conversion attempts. Their higher exposure to SO conversion efforts might reflect how gender (non)conformity is often taken as a sign of non-heterosexuality. Unlike conversion services, there were no significant differences in the rates of conversion attempts between trans people assigned male and assigned female at birth.

Strengths and limitations

This study is the first to examine exposure to both SO and GIE conversion attempts and conversion services involvement across multiple sexual orientation groups and gender identities and modalities in a large sample. Yet, this work also has some limitations. First, its cross-sectional, retrospective design is subject to recall bias and prevents any causal inferences. Second, as for any self-selected, non-probabilistic sampling, it is likely that the LGBTQI2+ persons who volunteered to participate are different from those who did not. While we used multiple, diversified recruitment strategies, the results cannot be generalized beyond the present sample. Third, as the SOGIE conversion experiences were elicited using non-validated self-reports, our indicators may not have accurately captured their prevalence.

Despite these weaknesses, this study provides a unique overview of Quebec’s LGBTQI2+ populations’ SOGIE conversion experiences, including women’s (cisgender and transgender). The results highlight that while conversion services involvement was more common among older generations, conversion attempts were more common among younger ones. Our findings also show the increased vulnerability to conversion attempts and service involvement among participants with religious upbringing, indigenous persons and people of colour, intersex, transgender, non-binary and asexual persons, as well as those who did not have a monosexual sexual orientation (bisexual, pansexual).

To protect LGBTQI2+ persons from such attempts and practices, legal bans on conversion practices are an important step as they send a strong message about their unethical and harmful nature. However, they will not be insular to faith-based practices and they will be insufficient to eliminate pressures and practices covertly operating under the guise of exploration. Professionals’ ongoing commitment is sorely needed, professional associations must expand their statements regarding sexual orientation and gender identity and expression practices, and healthcare providers need adequate training in LGBTQI2+ affirmative approaches. Religious counselors should also address the religious beliefs and cisheterosexist assumptions underlying their spiritual guidance or clinical practice. Addressing such biases does not imply deconstructing their religious beliefs, but rather exploring how their faith can impact their clinical practice [ 29 , 30 ]. Moreover, as families play a key role in pressuring children into conversion practices, they need to be supported and counseled in the acceptance of their LGBTQIA+ children. More studies are needed to better understand parental and family characteristics associated with heterosexism and cissexism.

Supporting information

S1 file. alternative language abstract..

https://doi.org/10.1371/journal.pone.0265580.s001

Acknowledgments

The Understanding the Inclusion and Exclusion of LGBTQ People research (UNIE-LGBTQ) is a research partnership of universities, public agencies, semi-public and community-based organizations, and private enterprises dedicating their efforts to better understand situations in which LGBTQI2+ people are demeaned, rejected, and belittled, and deprived of the full extent of their rights in important life domains. We extend our thanks to the research partners as well as to the participants who generously shared their experiences with us.

• 1. The Trevor Project. National Survey on LGBTQ Mental Health. [Internet]. 2019 [cited 2021 Apr 21]. https://www.thetrevorproject.org/survey-2019/
• 2. Ashley F. Model Law–Prohibiting Reparative Practices [Internet]. McGill University; 2020. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3398402
• View Article
• PubMed/NCBI
• Google Scholar
• 5. Salway T, Lachowsky N, Kwag M. Conversion Therapy & SOGIECE in Canada—Sex Now Survey results reveal prevalence of change efforts. Vancouver: Community-based Research Centre. [Internet]. 2020. https://www.cbrc.net/sex_now_survey_results_reveal_prevalence_of_change_efforts
• 10. SQ 2020, c 28 | An Act to protect persons from conversion therapy provided to change their sexual orientation, gender identity or gender expression [Internet]. CanLII; [cited 2021 Dec 6]. https://www.canlii.org/en/qc/laws/astat/sq-2020-c-28/latest/sq-2020-c-28.html
• 11. Government Bill (House of Commons) C-4 (44–1)—First Reading—An Act to amend the Criminal Code (conversion therapy)—Parliament of Canada [Internet]. [cited 2021 Dec 6]. https://www.parl.ca/DocumentViewer/en/44-1/bill/C-4/first-reading
• 12. The Trans PULSE Canada Team. QuickStat #1 –Conversion Therapy. 2019-12-20. [Internet]. 2019. https://transpulsecanada.ca/research-type/quickstats/
• 24. Rea LM, Parker RA. Designing and Conducting Survey Research: A Comprehensive Guide. John Wiley & Sons; 2014. 352 p.
• 27. Barker J. Critically sovereign: Indigenous gender, sexuality, and feminist studies. [Internet]. Critically Sovereign. Duke University Press; 2020 [cited 2021 May 28]. https://www.degruyter.com/document/doi/10.1515/9780822373162/html
• 28. Brady CE, Ernst MM. Pediatric Gender Identity: Consultation on Matters of Identity, Transgender Concerns, and Disorders/Differences of Sex Development. In: Carter BD, Kullgren KA, editors. Clinical Handbook of Psychological Consultation in Pediatric Medical Settings [Internet]. Cham: Springer International Publishing; 2020 [cited 2021 Dec 6]. p. 439–49. (Issues in Clinical Child Psychology). https://doi.org/10.1007/978-3-030-35598-2_33

• Open access
• Published: 04 February 2021

Sexual orientation, gender identity and gender expression-based violence in Catalan universities: qualitative findings from university students and staff

• Elena María Gallardo-Nieto 1 ,
• Aitor Gómez 1 ,
• Regina Gairal-Casadó   ORCID: orcid.org/0000-0003-0093-7912 1 &
• María del Mar Ramis-Salas 2  

Archives of Public Health volume  79 , Article number:  16 ( 2021 ) Cite this article

39k Accesses

10 Citations

11 Altmetric

Metrics details

Hate crimes have raised in Spain and the gender and sexuality-based conflicts persist worldwide which leads to this problem having an effect on health and wellbeing. Following a focus of transforming Higher Education Institutions, this research analysed the problem that affects undergraduate students in six Spanish universities. The research goal is to improve the life quality of lesbian, gay, bisexual, transgender, queer and intersex university students, breaking the silence that exists around the violence that this group suffer in Catalonia, Spain.

Following the Communicative Methodology, this study has identified violence based on sexual orientation, gender identity or gender expression in the target universities and provided guidelines to improve anti-discrimination protocols. A qualitative method has reached experiences of university students, heads of equality commissions, professors and administrative staff regarding this conflict. Focussing on the qualitative research tools, 30 semi-structured interviews were conducted with university students and staff around issues related to the violence against lesbian, gay, bisexual transgender, queer and intersex students: 1) perception of violence and discrimination, 2) institutional measures, 3) actions against violence. An analysis of exclusionary and transformative dimensions was used to identify emergent themes.

We have identified two dimensions for the analysis given their impact in contributing or overcoming violence: exclusionary and transformative. A wide range of forms of violence on the grounds of sexual orientation, gender identity and gender expression perpetrated at universities have been identified as exclusionary facts and described by participants in the study. Equality commissions have not received reports of violence based on sexual orientation, gender identity or gender expression, and university staff shows certain unfamiliarity regarding the measures and politics to prevent and intervene in cases of violence against the lesbian, gay, bisexual, transgender, queer and intersex community. Among the results identified as transformative are the ways through which actions of lesbian, gay, bisexual, transgender, queer and intersex groups against violence and the professors’ commitment to intervene have a relevant impact on student’s wellbeing. An improvement and implementation of anti-discrimination protocols with mandatory applicability has also been documented.

Conclusions

Findings highlight the need of collecting more evidence that contributes to the improvement of protocols, measures and politics to protect all the members of the university community. A better understanding of violence based on sexual orientation, gender identity and gender expression in HEI’s may guide national and international governments to improve the health and well-being of lesbian, gay, bisexual, transgender, queer and intersex persons.

Peer Review reports

Violence based on sexual orientation, gender identity or gender expression is present in our society and within the university community [ 1 , 2 , 3 ]. Numerous international studies have shown that the lesbian, gay, transgender, queer and intersex (LGBTQI+) community have more risk and probabilities to suffer sexual discrimination or harassment during their university trajectory [ 2 , 3 ]. Furthermore, the risk of being object of violence increases in the case of transgender students [ 4 , 5 , 6 ]. National politics and international agendas have given priority to the legislation and regulation to end with LGBTQI-phobia [ 7 , 8 ], even though the risk of suffering sexual harassment is still higher in the case of sexual minorities [ 1 , 6 , 9 , 10 ]. The case of Spanish universities reflects the international panorama in relation to the LGBTQI+ academic community [ 11 ]. Educating in diversity, tolerance and acceptance towards diversity is crucial, but international reports show that this is still a pending issue in Spain [ 12 ]. The lack of literature and research about how this phenomenon affects Higher Education Institutions (HEI’s) is striking and generates a significant silence towards the situation of the LGBTQI+ community and the consequences of LGBTQI-phobia in their personal, academic and health status. As a response to this reality, the research Uni4freedom seeks to contribute to breaking the silence that goes along the LGBTQI+ community at HEI’s, improving the quality of life of the academic community and the struggle against violence based on sexual orientation, gender identity and gender expression in the Catalan context.

The main challenge when studying the discrimination against the diversity of sexual orientations, gender identities and expressions is the diversity of violence manifestations. A change in the ways violence against the LGBT community is manifested, has been shown in the literature in the last years, shifting towards more subtle and unnoticed manifestations [ 6 ]. Verbal forms of violence [ 9 , 13 , 14 ], homophobic jokes [ 10 , 15 , 16 ], anti-LGBT paintings, graffities and threats [ 3 , 13 ], social distance [ 10 , 15 , 17 ], not-inclusive or acceptance spaces [ 18 ] and possible risk of suffering from unprotected forms of sex and AIDS’ contagion [ 19 ] have been identified as advanced forms of violence based on sexual orientation or gender identity or expression. On the one hand, the case of a hostile environment is conditioning the free expression of the felt gender identity and sexual orientation [ 9 , 18 , 19 , 20 , 21 , 22 ]. On the other hand, all these forms and manifestations of violence can generate a response of internalization and normalization of the homophobic actions, perpetuating the violence and affecting negatively in the life quality and wellbeing of the LGBT+ academic community [ 3 , 16 , 22 , 23 , 24 , 25 ].

According to the findings in the scientific literature, violence and discrimination based on sexual orientation and gender identity and expression, has consequences in three spheres of the LGBT university students’ life. Firstly, it affects the health status, both physically and mentally. It has been shown that LGBT students present higher symptoms of depression and anxiety [ 9 , 13 ] and suffer various forms of physical ache [ 10 , 16 ]. Secondly, it affects their academic performance, presenting a lower grade in average in comparison to hetero-cis students [ 26 ]. This difference of academic results has been analysed as an aftereffect of LGBT stigmatization creating difficulty to focus on their studies [ 19 , 27 ], having further consequences in their future possibilities and academic success [ 24 ]. Thirdly, these realities of LGBT-phobia in HEI’s promote exclusionary climates and negatively affects the cohesion and relationality of sexual minority students [ 22 ]. The seen or suffered experiences of harassment or discrimination can generate a feeling of isolation and exclusion [ 6 , 26 ] which can be reinforced by the institutional invisibility of LGBT perspectives and role models [ 13 ].

Evidence shows six different axes to prevent and intervene in front of violence based on sexual orientation and gender identity and expression within university institutions. Visibility of the LGBTQI+ collective and their situation in the university scope is key to prevent LGBTQI-phobia. Besides, generating profound awareness of university members is necessary to be able to face the problem of LGBT-phobia [ 1 , 28 ]. In order to make this awareness effective and reach the whole academic community, the inclusion of LGBT literature in academic curriculums has the highest impact in the reduction of LGBT-phobia [ 18 , 28 ]. Another protective factor for the prevention and intervention in cases of violence based in sexual orientation, gender identity and gender expression is the explicit institutional support towards the LGBTQI+ community through the implementation of politics and strategies towards the reduction of hetero-sexism [ 6 , 9 , 29 , 30 ].

This article presents qualitative evidence about how to overcome this form of gender inequality in a very relevant social institution. We have chosen a qualitative method in order to delve into the complexities of suffering or witnessing violence at HEI’s and the possibilities of intervention that participants identify in their own interpretation. This methodological choice aims to reinforcing the knowledge and contrasting the depth and complexities of the qualitative findings of the project. Very important issues to be considered when preparing policies for the prevention and intervention of LGBTQI-phobia are thus presented . In conclusion, the study aimed to give visibility to the violence based on sexual orientation, gender identity or expression that takes place in HEI’s, and to identify successful practices and decisions for the eradication of this violence.

This article has been focussed it research methodology for social impact. The voices of the end-users of the research have been incorporated in all phases of the research, in order to contribute to the social impact and social transformation of the conflict [ 31 ]. To make that possible, the methodological design is based on the Communicative Methodology of Research (CMR) [ 32 ], which stands out for its capacity to identify successful actions that contribute to overcoming inequality and to generate social policies based on these actions. CM stands out for generating scientific knowledge through the contrast of the scientific evidence (contributed by the researchers) and the contributions of the social agents’ participants in the research, defined as the world of life [ 33 , 34 , 35 ].

The study was designed to understand how, why, in which forms and circumstances this form of violence in HEI’s take place affecting university students’ life, health status and future. Given the scientific evidence on LGBTQI+ violence prevalence and the aims of the research, the main research objective is to improve the quality of life of LGTBIQ university students, breaking the silence that exists about the violence they suffer.

Following the communicative perspective, Uni4Freedom has implemented mixed-methods research [ 34 ] of which the qualitative techniques’ results are presented in this article. Semi-structured interviews Footnote 1 with communicative orientation have composed the fieldwork of the study taking place in six universities of the Catalan region [ 36 , 37 , 38 ]. The fieldwork has been designed in order to, firstly, make an approach and a diagnose of the reality that the LGBTQI+ community faces at Catalan universities and, secondly, delve into the perspective of university staff and professors, exploring the possibilities to implement and propose transformative actions for the inclusion and non-discrimination. The population target of the study is the academic community enrolled in different disciplines within the project’s six partnering Catalan universities Footnote 2 : students, university professors, administrative staff and heads of equality commissions or units at these institutions.

Communicative organization of the research

In order to ensure the social impact of the research, the voices of the LGBTQI+ community and LGBTQI+ organizations have been included in different forms and phases during the study. Their participation has been indispensable, contributing with reciprocity, advice and follow-up to guarantee that the research objectives are met and ensuring ethics’ standards in the methods. The Advisory Board is a follow-up and supervising body which has been formed by representatives of organizations of reference on LGBTQI+ rights in the territory Footnote 3 . In two different stages of the project and face-to-face meetings in 2018 and 2020, this board has debated and reviewed the methodological plan, research technics, findings and proposals grounding the materials in their experience and expertise in LGBTQI+ rights and reality. Their contribution has contributed to comply with ethical principles as well as to ensure the work and results for the improvement of the situation of the LGBTQI+ community at Catalan HEI’s.

We have conducted 12 semi-structured interviews with communicative orientation to LGBTQI+ university staff from the partner universities of the project. Besides, we have conducted 4 semi-structured interviews with communicative orientation to heads of equality units or commissions from the partner universities of the project. And finally, 12 communicative daily life stories with University students have also been done. These technics have followed the communicative orientation of the methodology by facilitating reflective dialogues between participants and researchers about the incidence of violence due to sexual orientation, identity or gender expression faced in their careers as university professor/staff or student. Proposals to make university a more LGBTQI+ friendly space were also gathered from these qualitative work. The distribution of research tools and participants has been as follows:

Research tools

The guidelines of the interviews have been designed following the communicative perspective, attending to the results of the literature review and contrasted with the Advisory Committee. This combination in the design process has allowed us to develop complex guidelines that enable the identification of situations, characteristics and circumstances that either promote or allows to transform situations of violence based on sexual orientation, gender identity or expression at HEI’s. We have identified three sections that have let us build the data collection process of the interviews. In what follows, the structure of the interview under the three sections and some of the questions of the interview’s guidelines are introduced:

To describe and presentgeneral aspects of the research method, theme, exploring different perspectives and ideas in relation to the reality of the situation of the LGBTQI+ community in University.

To study the experience or perception of violence based on grounds of sexual orientation, gender identity or expression at University or spaces related to the institution according to the results of the literature review. The opening question of this section in the case communicative daily life stories with students was the following:

“If you know of any cases of violence due to sexual orientation, gender identity or gender expression, comment on it:

Do you think that the people who suffer from any of these situations are considered victims of violence because of their sexual orientation, gender identity, or gender expression. Why? Why not?

What was your reaction to the situation of violence? Why?

What was the victim’s reaction to the violence or discrimination? Why?

If it was reported to the university, what was the institution’s response? How did they interpret it? How does the institutional response affect the victim’s decisions and behaviors?

What consequences did the fact of reporting have on the aggressor? And on the victim?

Do you know what has to be done in the case of suffering a situation of violence due to sexual orientatio, gender identity or gender expression?”

To approach the perception of institutional strategies to detect, prevent and intervene in cases of LGBTQI-phobia by the research participants attending to their different roles in the community. Two questions from the semi-structured interviews with university staff from this third section were the followings:

“In the section on harassment and discrimination, the inclusion of sexual orientation and gender identity/expression in anti-discrimination policies and the approval of protocols against LGBTI-phobia is considered. Some universities, such as Oxford, Tuft and UCL, have explicit online policies regarding sexual orientation, and other ones have specific policies concerning the trans* community, as well as policies to ensure inclusive language.

Do you think that this would be convenient at your university? Do you think it would be appropriate? Do you think it would be viable? Why? What benefits would it have and how would students experience it?”

“Finally, on training for members of the university community to detect, prevent and act against LFBTI-phobia. Universities like Pennsylvania and Washington train the community to ensure Safe Zones, zones free of any violence, and others like Cambridge and Oxford train the community in successful actions, such as bystander intervention and providing online resources.

Ethical validation

The study has received the ethical validation of the ethical committees of Girona University and Lleida University in 2019. After submitting a detailed protocol for the fieldwork, containing consent forms and interview guidelines, the Ethics and Biosafety Committee of the University of Girona approved the start of the fieldwork. For the second ethical approval, the Committee for the approval of research studies at the Faculty of Nursing and Physiotherapy of the University of Lleida approved the fieldwork plan, consent forms and guidelines for interviews under the ethical requirements of confidentiality and good praxis without any objections.

Consent forms were systematically signed by all research participants and by the researchers implementing the tools, in order to ensure the former’s rights in the research. These forms helped us to protect their right to confidentiality, anonymity, wilfulness, possibility to stop or leave the study at any moment and receive all necessary information for their involvement by the researcher.

Aside of the institutional validation, the research counted with an Advisory Board which supervised, followed-up and advised the research team in three different phases: approval of the literature review, fieldwork plan and preliminary results of the study. This board was composed by members of the LGBTQI+ community, university students and representatives of active organizations for LGBTQI+ rights of the territory Footnote 4 . Their belonging to the targeted community was due to the need of including the voices of the end-users of the research throughout the whole process of the research. The role of the board has been to relate the theory and scientific evidence to the daily reality of the LGBTQI+ community, reinforcing the transformative role of the research through their very contributions in the study.

Data analysis

The analysis chart has been designed to collect contributions from interviews and communicative daily life stories considering all the dimensions and categories selected (Table  1 – Result analysis chart). Dimensions are located in the rows and refer to the two sorts of results depending on their contribution or transformation of the target conflict, referring to the Communicative Methodology. Categories are the concepts that are being used in the research process to analyse the results of the fieldwork and they are located in the columns (Table 1 – Result analysis chart). The categories have been defined through a deductive method of definition, meaning that they have been determined before fieldwork through the study of scientific literature regarding LGBTQI-phobia in HEI’s. The categories resulting from this study are: LGBTQI-phobic violence, actions against the violence and university politics and measures against the violence.

The research team has processed the qualitative results of the fieldwork ensuring the anonymity of the participants in all the phases of the study. Members of the research team have transcribed the interviews and daily life stories verbatim. Then, the research team has coded the transcription by using the numbers of the designed analysis chart (Table 1 – Result analysis chart), identifying results and matches between the targeted categories and dimensions on the transcriptions. We have not made use of any software or program for the systematization of this process.

In this section, we have made an in depth approach to the research target: studying violence against LGBTQI+ community in HEI’s. On the one hand, we have analysed the results that do not contribute to overcoming the problem of violence based in sexual orientation, gender identity or expression, encompassed within the exclusionary dimension. On the other hand, we have analysed the contributions that have an influence in transforming and overcoming the targeted violence in HEI’s, included in the transformative dimension. All of the results presented belong to the research tools and the research participants already mentioned in the fieldwork subsection (Table 2 - Fieldwork distribution).

Violence’s normalization and internalization

Normalization and internalization of LGBTQI-phobia are the most present consequences of the violence in HEI’s. These results show the need to promote measures of awareness-raising to promote respect to diversity. Under this category, we highlight the normalization of violence in the daily discourses at universities as a consequence of the constant violence against the LGBTQI+ community. The normalization of violence is funded on naturalizing discriminatory comments towards the LGBTQI+ community, which can happen even within classrooms, as stated by a LGBTQI+ university professor in an interview:

Then, inside the class, let me think... at the break and when we leave and so on, I’ve seen someone say to another "hey faggot, you didn't get the work done today!" maybe they said that and, I don't know, I have it so incorporated that I don’t realize either.

In this sense, students have also shared in everyday life stories experiences that prove the naturalization of discriminatory discourses towards the LGBTQI+ community, as stated by a female undergraduate and LGBTQI+ student in a communicative daily life story:

Well, I don’t know, if in class or between classes, we are talking, or they are talking, so in a group, and they want to refer to a boy as being a freak or weaker than the rest they refer to him as a faggot.

The LGBTQI+ participant students in the research have claimed the consequences of the normalization of the violence. Following their discourse, they have found that reproduction of homo and lesbo-phobic comments and the self-internalization of the violence are results of having received a LGBTQI-phobic socialization. As a female and LGBTQI+ student expresses in a communicative daily life story:

Many times, I think they overlook these comments because we are used to them. For me what happens to me is like, if one day I hear someone say butch or something, it's not hard for me to pass but I guess I would think that he’s an asshole, you know? But then I would think that, he’s silly and that's it and I wouldn't take it as something personal, but as something more social that looks normal.

Transgender vulnerability in the conflict

Research has shown that transgender people are the most prone to have difficulties and to suffer violence or discrimination at HEI’s [ 4 , 5 , 6 ]. This form of vulnerability in the university context is even more disturbing when the results show the complexity and accumulation of forms of violence that only transgender students suffer. There can be specific circumstances that transgender students live, such as the social transition and the bodily changes, elements that can make their educational process at university even harder when belonging to the LGBTQI+ community. As a transgender student states in a communicative daily life story regarding the transitioning:

Then I made the transition and it's like that, with the medication and that, I was like super confused with many things, I was relocating mental issues, because in the end I didn't know many things either, because the medication numbed me and I don't know. Of course, I did notice suspicion and misunderstanding and a feeling of being something weird, feelings of disgust, by some colleagues and I realized it but well, as I’m saying I tried to ignore it because I have enough problems.

The exclusionary discourses, looks and refusal perception is clear in the voice of the interviewed people, showing the need of promoting measures of awareness raising that advocate the respect to diversity and differences. In this sense, the need of intervention and respect towards the transgender groups is especially relevant, as it has been shown in the interviews’ fragments.

Unfamiliarity of institutional mechanisms and interventions

Secondly, findings on university policies and measures have indicated the lack of actions, university policies and measures to fight violence and, at the same time, they prove the ignorance of professors and staff about the mechanisms to prevent and intervene in cases of LGBTQI-phobia. Furthermore, the lack of cases of violence due to sexual orientation, gender identity or expression reported at equality offices indicates the complexity of this form of violence and the likely unawareness about violence based on the grounds of sexual orientation, gender identity and gender expression by officials at universities. The fact that some Heads of University Equality Offices claim not to have received complaints regarding violence based on sexual orientation, gender identity or expression is relevant, as one experienced worker on an Equality Office shared regarding the cases of LGBTQI-phobia in an interview:

The truth is that no. I have not dealt with any cases at the observatory, no petitions nor expositions have been received of violence based on gender identity or sexual orientation. We haven’t realized it. For me, it hasn’t come directly to me as a teacher or as a colleague. It hasn’t reached me. I know it’s a college reality, but the truth is I can’t say it’s a reality for me because I haven’t seen it.

The figure ‘0’ of cases of violence based on sexual orientation, gender identity or expression at universities can be explained by the lack of mechanisms and abilities by university professors and staff to identify and detect the violence [ 6 , 39 , 40 ]. Moreover, it could also be justified by the attempts to generate safe and friendly spaces for the LGBTQI+ community to make the process of filing a complaint of LGBTQI-phobia easier. As we can see in the following fragment from a communicative daily life story with a transgender student which has already faced the process of name change, he reflects on other possibilities to it within HEI’s:

I think that a trans person should not go through an equality unit to request a name change, right? But I think that this could already be done in a much easier administrative process of administrative, that is, how you do your... You fill out your application for the first time, that is, in that database, what if there were what is called a chosen name?

The lack of knowledge from university professors, staff and officials about measures, resources and officials of reference in cases of LGBTQI-phobia has been stated in the interviews as a constant reality, as mentioned by a female university professor in an interview: “I’m not responsible. I don’t know if within the management team there is someone in charge of this policies in case there is a problem.”

We have identified other indicators apart from unawareness which could respond to the lack of a support network for victims of LGBTQI-phobic violence within HEI’s. Many university policies and educational protocols for the prevention and intervention in cases of violence based on sexual orientation, gender identity or expression have been developed in the last years from Equality Units and Commissions and other spaces towards equality and against discrimination in HEI’s. The ignorance of the international scientific evidence about the existig policies carries a limitation in the struggle against the violence towards the LGBTQI+ community. This is due to the lack of knowledge and training on the measures and the roots of LGBTQI-phobia for the implementation. In order to understand the notions on institutional measures to intervene in conflicts based on sexual orientation, gender identity or expression, we can see an active LGBTQI+ university professor’s discourse where he discusses the thoughts on the transgender name-change process as it follows a fragment of an interview:

The doubt that I was holding is the legal part. Without a doubt the university has to support straight away and if it is necessary to change, it is changed [referring to the name], if you have special needs, it has to be attended, they have to be listened to and we have to see what can be done, of course. What confuses me a little is the legal issue. (…) To the official lists, they appear with the birth name, but they can be changed, and it seems viable, and they are comparable because at the end, that’s the name that they identify with. “I do not identify myself with Antonio José... I identify myself with Toni.” And it seems very comparable. If this person wants to change the name of Maria to Peter because he identifies himself as Peter, so Peter be it and that’s it. What I find most complicated is at a more internal level, for example in the records, that you have the name changed because there would probably be a conflict of legal identity.

In this sense, students agree in recognizing that ignorance complicates the process of identification and support in particular situations of LGBTQI-phobia at universities. For that reason, training and awareness raising on LGBTQI+ issues are both considered very necessary towards turning all university members into agents of change, whether being or not part of the LGBTQI+ community, as a cis-heterosexual female student points out in a communicative daily life story:

I think so, I have not experienced these situations, and I don’t know these type of situations. I'm sure it happened. I think that it should be known both for those who do not know it and for those who suffer it or have seen it, to know that they are not alone that someone is aware of the issue and that they take measures against these situations and that there are those points of help. There are also people who do not want to come out of the closet and they may have problems but they will not ask for help because they have not yet come out of the closet, so it would be good for them to know that there are actions that can help them without anyone knowing anything and keeping their secret. It is an option for those people to have help.

University as a safe space

Secondly, on the variable LGBTQI+ actions against violence findings point at the existence of three protective factors that lead to overcoming violence and discrimination: HEI’s perceived as safer spaces compared to other places, compromise and predisposition of professors to successfully prevent and intervene in cases of violence and university protocols and measures of intervention including all university community. This is due to the role of Equality Units, their familiarity, respect and openness has an important effect in the prevention and intervention of cases of LGBTQI-phobia. We have identified that HEI’s offer a very wide window of possibilities for intervention, acceptance and respect compared to other spaces, as a LGBTQI+ female student points out in a communicative daily life story:

Sexual diversity is more comfortable at university than in other places and that’s why I also think it’s sometimes easier to make more demands within university, right? Because as there is this freedom or this friendly climate, right? Friendly to make claims, to make demands for improvement, so it’s easy to get it and therefore I think that precisely freedom encourages more freedom of expression, right? And more diversity.

Another protective factor within HEI’s towards the LGBTQI+ community and for the transformation of the violence and discrimination is related to the compromise of professors to prevent and intervene. The alliance between students and professors is especially valuable when having the support of a more powerful group within the educational institution in terms of decision and action. This particular support can be offered for different reasons, firstly for the training, awareness and activism in terms of rights by professors. Next, the importance and urgency of intervening in order to transform and stop the conflict based on gender or sexual diversity is made explicit by one of the LGBTQI+ university professors interviewed:

Having just one victim is enough to talk about it and explain that these things are happening, anonymously. If not, we have to orient ourselves differently, lead it in a way that if things happen socially, we try not to let them happen here. Obviously, they shouldn’t take place anywhere. We protect the space; I think we have to find a balance in that so as not to create an alarm.

The compromise to intervene in cases of violence based on sexual orientation, gender identity or expression has been expressed in different forms in the discourses of LGBTQI+ staff. The following case goes one step further as, aside of an open commitment with LGBTQI+ issues, this social conflict is taken into consideration as part of the very teaching praxis. As a result of this, we see how a safer space in the classrooms can be created, by making sexual and gender diversity an issue in the lectures. A LGBTQI+ male professor - committed to openly talking and discussing about matters of gender, sexuality and diversity in class-, talks about the reaction of his students when addressing these issues:

No! Not in class, maybe that's because we criticize it, and make people think and everything is politically correct...to let them see their experiences based on that and then see how they act...of course, in class I guess that they are aware that it would not look very good for them to do joke about it if we are working for them not to do so in their own environments.

When breaking the silence on the issue of LGBTQI-phobia so that the topic becomes a recurring theme in the classroom, students become active upstanders questioning themselves and intervening in cases of violence [ 41 ]. In this sense, another cis-heterosexual university professor highlighted in the interview the need to break the silence and generate mechanisms facilitating that people dare to complain:

It may also be that things are happening and we don’t know it because there aren’t protocols, so this is also a way to encourage people who are going through things to report it. Because violence is always hidden actions. If this is giving them a little encouragement to report and explain what is happening, even if the violence is not physical, that is verbal, that is behavioural, exclusionary...

The value of receptiveness and alliances

Thirdly, on the variable university policies and measures, we have identified evidence of the openness towards sexual and gender diversity by university professors, also considering the need of prevention and intervention plans and measures of high quality in order to transform the reality. This is the case of protocols and measures of intervention generated by the Equality Units at HEI’s that have been interviewed. They highlight the quality and connection with the reality of the LGBTQI+ community of their regulations and intervention measures in their own Units. This is due to the success of negotiation processes between HEI’s and Equality Units, thanks to the sanctions that exist in case of not implementation and to the inclusion of gender identity and sexual orientation perspectives in the regulations. This is introduced by a long experienced worker on the service of the Head of an Equality Office at one participant university in an interview:

We have a regulation for the prevention of gender violence. The difference between regulation and protocol is that all other universities have protocols, ours has sanctions. The others do not have it typed. Our regulation -which was one of the first to be done, but which had two years of negotiation with the University-, is a comprehensive one because it covers the entire university community (officials, staff, professors, students) and it is also a one that entails penalties that many of the university’s protocols do not have. Then what we have done is the adaptation of it, when we already made the regulation, we put for example everything that was harassment due to sex and sexual orientation, we added all the sexual orientation tag.

The interviewees have shown willingness to learn the measures and implement them in the Catalan University contexts, even though if they have not received any training in LGBTQI+ issues. The following fragment refers to a LGBTQI+ male university professor’s interview referring to the measures of trans-inclusion at their institution:

Of course, as the number does not change, so there is no problem, and everything is linked to the ID number and instead you can change the name. I think it’s ok, if there is a real need for it and it is a request from individuals or the community itself, I do not see it difficult and do not see a problem. I think it would bother me to call this person by the name with which they do not feel identified. If they tell me to change the name, I tell them that way, because otherwise there is not an effective dialogue, so I think that if possible, I think it’s perfect and go ahead.

Predisposition and interest by professors have appeared in the qualitative fieldwork together with the claim of needing scientific evidence as well as the inclusion of voices of the own community and of experts in the field. Then they could advise and orientate regarding measures and politics at HEI’s. A university professor claimed it during the interview as follows:

Totally, but I think that the experts here are somehow the ones who have to take the lead because I do not consider myself an expert on the subject, I am a total ignorant, because I find it hard to find the right words to talk about this community, if we are referring to differentiated groups. Mm, I feel I can talk about certain things, but when I think about it, I think that maybe I had not realized it. My normal life is not affected, but there might be other people’s life who is (…) and then if the need exists and the university has the measures to make it feel normal, so that this becomes of normality, then I will be happy to follow any training that is needed because for me it is also an exciting topic, not morbid-like, but to know. Because it is becoming more and more visible.In the same way that this professor commented, another student also claimed the need of measures and politics to have some support in case of suffering violence based on sexual orientation, gender identity or expression. The following statement is a fragment of LGBTQI+ activities and university student’s communicative daily life story, reflecting clearly on the need of feeling institutional protection in order to feel integrated at University:

That people feel safer, better, that they have a real moral and psychological support because until now, they are not considering themselves part of anywhere. Having such a policy would help us a lot to feel that we belong and that we are considered part of something because, of course, we are having to face these LGTB-phobic behaviours and they have to be counteracted with something, right?

Our study demonstrates the urgency of the conflict taking place at HEI’s on the grounds of sexual orientation, gender identity and gender expression. It has also provided us with the scientific evidence and the protagonists’ discourses by bringing to discussion how both dimensions match and complement each other when facing conflicts, needs and discrimination based on sexual orientation, gender identity and gender expression. Furthermore, the study has added relevant knolwedge to previous research with an evidence-based approach and successful cases to improve protocols and strategies for the struggle against the problem of LGBTQI-phobia taking into account the voices of the university community in the Catalan context. Contributing to the previous research on gender violences at Catalan and Spanish universities [ 31 ], our study has gone further in studying the problem of gender violence against the LGBTQI community in HEI’s for the first time in Catalonia. The complementarity of both the generation of evidence and new proposals of avenues for the improvement of current protocols, policies and measures towards the inclusion of the LGBTQI+ community sets a precedent on how to turn HEI’s into more LGBTQI+ inclusive institutions.

Challenges in identifying violence

There is plenty of evidence about how the conflict of violence based on sexual orientation, gender identity or expression is a current reality, which is visible and has become a relevant subject for the development of international policies and agendas in Europe [ 42 ]. Furthermore, the scientific literature describes how this conflict can permeate social institutions, affecting subjects in different spaces, dimensions and degrees. The main challenge identified in the struggle against this social conflict is its identification and detection in institutions, as it has been mutating and changing its form to avoid being detected [ 6 ].

Our study has, not only proven the existance of a variety of forms of direct violence that take place in HEI’s, but it has also identified more subtle and unnoticed forms of violence. Verbal forms of violence, such as homophobic and transphobic comments and jokes, paintings and non-inclusive spaces and classrooms are just the more apparent forms of violence pointed out in the research [ 9 , 10 , 13 , 14 , 15 , 16 , 18 ]. What has made the situation in the Catalan context more complex is the generalized reaction of internalization shown by LGBTQI+ victims and other agents. As the literature highlights, this response of normalization and naturalization of the violence against sexual or gender diversity contributes in the reproduction of the violence against the LGBTQI+ community [ 3 , 16 , 23 , 24 , 25 ].

Besides the reaction of the victims and the LGBTQI+ community, the responses from the rest of institutional agents facing the conflict are especially significant. As mapped by the research, the role of other students and peers [ 27 ], professors and staff is key when approaching the cases of LGBTQI-phobia at university, as the relationality, authority and influence is compelling [ 8 , 20 , 21 , 22 ]. As the findings have shown, their availability, openness and attitude towards the LGBTQI+ community and sex and gender diversity can have an impact on the perception of classrooms and university campuses as free and safe spaces. Additionally, we have found how previous debates or workshops of LGBTQI+ issues at university classrooms can prevent some forms of LGBTQI-phobia from happening. As well, these previous experiences on discussing gender could facilitate processes of social transition, reception of reports of violence or discrimination, improving the perception of the university as a friendlier and safer space. In addition, the heads of Equality Units’ figure entails two different roles: as social agent and worker as well as a representative in terms of equality and non-discrimination in the institution. In any case, this readiness and preparation does not suffice while numbers show that there are no cases of LGBTQI-phobia arriving to institutional instances in some of the participant HEI’s.

Damage on wellbeing of LGBTQI+ students

Given the findings about the prevalence of violence on the grounds of sexual orientation, gender identity and gender expression in Catalan universities, the negative impact on the well-being and life quality of LGBTQI+ students is a fact. If the existence of violence against sexual and gender diversity in university spaces is a reality, the probability of having students suffering physically and mentally, presenting symptoms of depression, anxiety and various forms of physical ache are a worrying reality for the institution [ 9 , 13 , 16 ]. Furthermore, this difficulty affecting only a group of students would generate a gap in the access, quality and academic success compared to the rest of the community due to their health status [ 25 ]. The lack of social cohesion within the university community and students, has a high impact in the present and future of LGBTQI+ students in Catalonia. LGBTQI+ stigmatization also results in impediments for LGBTQI+ students to reach the same academic level and success than the rest of the students [ 19 , 23 , 43 , 44 ].

The findings about the damage of the LGBTQI+ students at University has given visibility to the risk that the LGBTQI+ community suffers which also affects their wellbeing. This evidence indicates that the generation of successful strategies to prevent, detect and intervene in cases of violence on the grounds of sexual orientation, gender identity and gender expression is urgent. This emergency lies on the institutional duty of offering quality higher education for everyone without of any type of discrimination. In order to eliminate any form of discrimination effective anti-discrimination strategies based on scientific evidence need to be developed.

University policies and measures a the LGBTQI-phobia

Given the results about the implemented strategies to fight and prevent forms of violence on the grounds of sexual orientation, gender identity and gender expression, issues on the evaluation, quality and follow-up of these measures are still pending. The evidence shows that the current strategies to fight, prevent and intervene in cases of LGBTQI+ realities in Catalonia are configured as responses to concrete and specific situations. This conception of the LGBTQI+ reality as a transitory conflict and circumstance implies that the forms of intervention planned only take into account the specific conflict, without paying attention to a reality that is present in all the spheres of the university. This can respond to the lack of continuous and more transversal actions that educational systems implement to carry out more equitable actions for the inclusion of LGBTQI+ realities within HEI’s.

Giving visibility and raising awareness of the LGBTQI+ circumstance is a very pressing issue present both in the literature and in the results of the research, as it can prevent different forms of LGBT-phobia. These actions are identified as protective factors in the prevention and intervention of discrimination and violence on the grounds of sexual orientation, gender identity and gender expression, as well as for generating and imporving the LGBTQI+ students’ feelings of belongingness to HEI’s. More in depth, literature and participants have identified the need of training professors and other university staff about LGBTQI+ perspective [ 1 , 28 ]. This could have an impact on the way conflicts and discrimination on the grounds of sexual orientation, gender identity and gender expression is managed with professionals, ensuring safe follow-up and accompaniment processes by educators and staff -who would be trained on the situation of the LGBTQI+ community through scientific evidence-.

In order to translate this process of making LGBTQI+ issues a closer reality to the university community, the inclusion of literature from a LGBT+ perspective in the academic curriculum has been identified as having the highest impact for the reduction of violence and discrimination on the grounds of sexual orientation, gender identity and gender expression [ 20 , 28 ]. Its implementation would require HEI’s to include LGBTQI+ issues horizontally in all university degrees’ classrooms, considering as an institutional duty the need of ensure freedom of living and expressing sexual and gender diversity. Another way of institutionally protecting the LGBTQI+ community is by explicitly supporting the community as has been informed by the literature [ 6 , 9 , 29 , 30 ]. Lastly, the urgency of addressing the transgender issues at universities is present in both the project’s results and literature [ 45 ], highlighting the need of articulating successful practices and accompanying processes to transgender students for the improvement of their health [ 43 ]. This would require that universities start conceiving the transgender reality as a continuous, individual and changing phenomenon that goes beyond the name and gender change in the identification documents, affecting the live of students with different intensity and in different stages and social circles.

Altogether, the complexity of assessing and reviewing the success and impact of university protocols, measures and strategies to intervene is both a scientific and socio-political issue, attending to the changing political circumstances that affects the European and Spanish context. The research limitations that have affected the study have been closely related to the human interactions during the fieldwork, the protection of the anonymity, the search for gender and sexual minority participants and the issues of visibility and public recognition of participants. For that reason, we have worked very hard in the ethical framework and approval to ensure everyone’s safety, respect, confidentiality and support during and after the fieldwork. Otherwise, the qualitative method and results of the study have also set limits on the applicability and transferability of the findings. Although quality-centred findings do not offer results that can be generalized to the whole Catalan university community, they have allowed us to delve into the reality of the Catalan HEI’s through the discourses of university staff and students.

Following our research goal of improving the quality of life of LGBTQI+ university students, through the CM and breaking the silence that exist about this sort of violence, the study identified protective and exclusionary factors likely to have a high impact in the quality of life of University LGBTQI+ students in the Catalan region. This innovative and transformative focus has provided the dialogue-based methodology on the study of the conflict of gender and sexual diversity in the most relevant educational institution.

The need of studying the conflict of LGBTQI-phobia at universities lies on the importance of higher education in the lives of students and in their future possibilities. It also falls on the strong impact of suffering violence and discrimination for several years while the right of living one’s sexual orientation, gender identity and gender expression freely is not guaranteed. All of this shows how gender and sex norms permeate educational institutions [ 46 , 47 ], making visible the current positioning of Catalan HEI’s against LGBTQI-phobia and towards a more inclusive and diverse university community.

New avenues and research targets on this matter could contribute to identifying other needs and axes of actions that could be essential in the struggle against LGBTQI-phobia. On the one hand, investigating the positioning of professors in the classrooms and their previous training on gender and LGBTQI+ perspective with a base on scientific evidence could open new lines of research for the prevention of violence. Furthermore, the inclusion of LGBTQI+ literature to be addressed in classrooms and the impact of normalizing gender and sex diversity in educational institutions would also be relevant. Our study highlights the importance of the alliance of university professors in the struggle against LGBTQI-phobia as upstanders in the conflict, an issue that must be paramount in new research lines and actions against violence on the grounds of sexual orientation, gender identity and gender expression. On the other hand, studying the case of transgender needs and trajectories in HEI’s is still a pending issue. Tackling the need to underst transgender identities and non-binary gender expressions within the institutional framework would contribute to detect and explain forms of violence yet to be identified as well as the strategies to counter these.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Interviews had an approximate duration of 40 min and the place was chosen by both participant and researcher. Interviews were normally implemented in public spaces which allowed the researcher to generate an atmosphere of trust, such as cafeterias or university offices. The materials result of the interviews were the manual transcriptions made by members of the research team of the Uni4Freedom project. Then, the analysis took place as it follows in the Data Analysis subsection.

The partner universities of Uni4Freedom are: Rovira i Virgili University; University of Barcelona; University of Girona; University of Lleida; Ramón Llull University and University of Vic.

Participant entities and organizations on the Advisory Board:

Col·lectiu H2O · Gais, Lesbianes, Bisexuals i Transsexuals del Camp de Tarragona.

SAI Tarragona - Servei d’Atenció Integral a les Diversitats Sexuals i de Gèneres de Tarragona.

Xarxa Solidària de Vctimes de Violència de Gènere a la Universitat.

Gènere Lliure.

Col·lectiu de gèneres i sexualitats dissidents (GSD).

The participant entities in the Advisory Committee have been:

- Col·lectiu H2O (Gais, Lesbianes, Bisexuals i Transsexuals del Camp de Tarragona).

- SAI Tarragona - Servei d’Atenció Integral a les Diversitats Sexuals i de Gèneres de Tarragona: suport social, informació i atenció piscològica i jurídica.

The participant universities in the study are:

Rovira i Virgili University.

Girona University.

Lleida University.

Vic University.

Barcelona University.

Ramón Llull University.

Abbreviations

Communicative Methodology

Higher Educational Institution

Community of lesbian, gay, bisexual, transgender, queer, intersexual and other groups with non-conforming and dissident identities, orientations or expressions

Costa AB, Peroni RO, de Camargo ES, Pasley A, Nardi HC. Prejudice toward gender and sexual diversity in a Brazilian Public University: prevalence, awareness, and the effects of education. Sex Res Soc Policy. 2015;12(4):261–72.

Article   Google Scholar  

McGinley M, Wolff JM, Rospenda KM, Liu L, Richman JA. Risk factors and outcomes of chronic sexual harassment during the transition to college: examination of a two-part growth mixture model. Soc Sci Res. 2016;60:297–310.

Rankin SR. Campus climates for sexual minorities. New Dir Stud Serv. 2005;111(Special Issue: Gender Identity and Sexual Orientation: Research, Policy, and Personal):17–23.

Google Scholar  

Coulter RWS, Rankin SR. College sexual assault and campus climate for sexual- and gender-minority undergraduate students. J Interpers Violence. 2017;35(5–6):1351–66.

Goodrich KM. Lived experiences of college-age transsexual individuals. J Coll Couns. 2012;15(3):215–32.

Hong JS, Woodford MR, Long LD, Renn KA. Ecological covariates of subtle and blatant heterosexist discrimination among LGBQ college students. J Youth Adolesc. 2016;45(1):117–31.

Council of Europe C. Discrimination on grounds of sexual orientation and gender identity in Europe [Internet]. Paris; 2011 p. 134–134. Available from: https://www.coe.int/t/Commissioner/Source/LGBT/LGBTStudy2011_en.pdf . Accessed 26 Jan 2021.

ILGA-Europe. Annual Review of the Human Rights Situation of Lesbian, Gay, Bisexual, Trans, and Intersex People in Spain covering the period of January to December 2018 [Internet]. 2018 p. 1–2. Available from: https://ilga-europe.org/sites/default/files/spain.pdf . Accessed 26 Jan 2021.

Ellis SJ. Diversity and inclusivity at university: a survey of the experiences of lesbian, gay, bisexual and trans (LGBT) students in the UK. High Educ. 2009;57(6):723–39.

Woodford MR, Han Y, Craig S, Lim C, Matney MM. Discrimination and mental health among sexual minority college students: the type and form of discrimination does matter. J Gay Lesbian Ment Health. 2014;18(2):142–63.

Gallardo Nieto, E. M., Gómez González, A., Gairal Casadó, R., & Ramis Salas, M. del M. (2020). Sexual orientation, Gender Identity and Gender Expression-Based Violence in Catalan Universities: Qualitative Findings from University Students and Staff Research Square https://doi.org/10.21203/rs.3.rs-97327/v1 .

Ávila R. LGBTQI inclusive education report [internet]. Brussles: IGLYO (International Lesbian, Gay, Bisexual, Transgender, Queer & Intersex Youth & Student Organisation); 2018. Available from: https://web.unican.es/unidades/igualdad/SiteAssets/guia-de-recursos/acoso/IE-Full-Report-May-18.pdf . Accessed 26 Jan 2021.

Alessi EJ, Sapiro B, Kahn S, Craig SL. The first-year university experience for sexual minority students: a grounded theory exploration. J LGBT Youth. 2017;14(1):71–92.

Roffee JA, Waling A. Rethinking microaggressions and anti-social behaviour against LGBTIQ+ youth. Safer Communities. 2016;15(4):190–201.

Jewell LM, Morrison MA. “But There’s a Million Jokes About Everybody . . .”: Prevalence of, and Reasons for, Directing Negative Behaviors Toward Gay Men on a Canadian University Campus. J Interpers Violence. 2010;25(11):2094–112.

Woodford MR, Howell ML, Kulick A, Silverschanz P. “That’s so gay”: heterosexual male undergraduates and the perpetuation of sexual orientation Microagressions on campus. J Interpers Violence. 2013;28(2):416–35.

Hamilton L. Trading on heterosexuality - college women’s gender strategies and homophobia. Gend Soc. 2007;21(2):145–72.

Evans NJ, Broido EM. The Experiences of Lesbian and Bisexual Women in College Residence Halls. J Lesbian Stud. 2002;6(3–4):29–42 1.

Mohammadi Gharehghani MA, Khosravi B, Irandoost SF, Soofizad G, Yoosefi LJ. Barriers to condom use among female sex Workers in Tehran, Iran: a qualitative study. Int J Women's Health. 2020;12:681–9.

Lapinski J, Sexton P. Still in the closet: the invisible minority in medical education. BMC Med Educ. 2014;14(1):171.

Rankin SR, Hesp GA, Weber GN. Experiences and perceptions of gay and bisexual fraternity members from 1960 to 2007: a cohort analysis. J Coll Stud Dev. 2013;54(6):570–90.

Rothmann J. The (de)professionalisation of the gay male academic identity: locking the closet door on south African university campuses. South Afr Rev Sociol. 2016;47(4):40–59.

Clarke V. Wearing a gay slogan t-shirt in the higher education classroom: a cautionary tale. Fem Psychol. 2016;26(1):3–10.

Kheswa JG. Exploring the Impact of Discrimination on the Psychological Well-being of Lesbian Students at South African University Campus. Rupkatha J Interdiscip Stud Humanit. 2016;VIII(2):148–55.

Martin-Storey A, August EG. Harassment due to gender nonconformity mediates the association between sexual minority identity and depressive symptoms. J Sex Res. 2016;53(1):85–97.

Woodford MR, Kulick A. Academic and social integration on campus among sexual minority students: the impacts of psychological and experiential campus climate. Am J Community Psychol. 2015;55(1–2):13–24.

Jackman K, Kreuze EJ, Caceres BA, Schnall R. Bullying and Peer Victimization of Minority Youth: Intersections of Sexual Identity and Race/Ethnicity. J School Health. 2020;90(5):368–77.

Deniz C. Reconceptualization sexuality and rethinking homophobia in metropolitan campus spaces. J Crit Educ Policy Stud. 2017;15(1):228–51.

Waldo CR, Kemp JL. Should I come out to my students? An Empirical Investigation. J Homosex. 1997;34(2):79–94.

Article   CAS   Google Scholar  

Garvey JC, BrckaLorenz A, Latopolski K, Hurtado SS. High-impact practices and student–faculty interactions for students across sexual orientations. J Coll Stud Dev. 2018;59(2):210–26.

Puigvert L, Valls R, Garcia Yeste C, Aguilar C, Merrill B. Resistance to and transformations of gender-based violence in Spanish universities: a communicative evaluation of social impact. J Mix Methods Res. 2017;13(3):361–80.

Valls Carol R, Padrós M. Using dialogic research to overcome poverty: from principles to action. Eur J Educ - Wiley Online Libr. 2011;46(2):173–83.

Pulido C, Elboj C, Campdepadrós R, Cabré J. Exclusionary and transformative dimensions: communicative analysis enhancing solidarity among women to overcome gender violence. Qual Inq. 2014;20(7):889–94.

Flecha R, Soler M. Communicative Methdology: successful actions and dialogic democracy. Curr Sociol. 2014;62(2):232–42.

Puigvert L. Preventive socialization of gender violence: moving forward using the communicative methodology of research. Qual Inq. 2014;20(7):839–43.

Vidu A, Schubert T, Muñoz B, Duque E. What students say about gender violence within universities. Qual Inq. 2014;20(7):883–8.

Denzin NK, Lincoln Y. The SAGE handbook of qualitative research. Los Angeles: SAGE; 2017.

Denzin NK. The reflexive interview and a performative social science. Qual Res. 2001;1(1):23–46.

Duhigg JM, Rostosky SS, Gray BE, Wimsatt MK. Development of heterosexuals into sexual-minority allies: a qualitative exploration. Sex Res Soc Policy. 2010;7(1):2–14.

Coleman K. The Difference Safe Spaces Make: The Obstacles and Rewards of Fostering Support for the LGBT Community at HBCUs. SAGE Open. 2016;6(2) Available from: http://journals.sagepub.com/doi/10.1177/2158244016647423 . Accessed 26 Jan 2021.

Valls R, Puigvert L, Melgar P, Garcia-Yeste C. Breaking the silence at Spanish universities: findings from the first study of violence against women on campuses in Spain. Violence Women. 2016;22(13):1519–39.

United Nations. Discriminatory laws and practices and acts of violence against individuals based on their sexual orientation and gender identity [Internet]. United Nations. Human Rights Council; 2011 p. 25. Available from: https://www.ohchr.org/documents/issues/discrimination/a.hrc.19.41_english.pdf . Accessed 26 Jan 2021.

Nicolazzo Z. Trans* in college. Transgender students’ strategies for navigating campus life and the institutional politics of inclusion. Sterling, VA: Stylus Publishing; 2017.

Horn SS, Schriber SE. Bullied and punished: exploring the links between bullying and discipline for sexual and gender minority youth. J Res Adolesc. 2020;30(1):1–18.

Sherman ADF, Clark KD, Robinson K, Noorani T, Poteat T. Trans* community connection, health, and wellbeing: a systematic review. LGTB Health. 2020;7(1):1–14.

Zhang L, Osberg L, Phipps S. Is all bullying the same? Arch Public Health. 2014;72(1):19.

Ferfolja T, Asquith N, Hanckel B, Brady B. In/visibility on campus? Gender and sexuality diversity in tertiary institutions. High Educ [Internet]. 2020 [cited 2020 Jul 8]; Available from: https://doi.org/10.1007/s10734-020-00526-1 .

Download references

Acknowledgements

The authors would like to thank the research participants and collaborators for their important contribution in the study. In particular, we would like to thank to ACUP for their advice and support in all phases of the research. We would also like to acknowledge the support in the data collection to the Advisory Council and all entities participating in it: Col·lectiu H20, SAI Tarragona and Xarxa Solidària de Victimes de Violència de Gènere a la Universitat. We also want to thank the University consortium that enabled the project to take part, formed by Rovira i Virgili University, Lleida University, Girona University, Vic University, Barcelona University and Ramon Llull University. To conclude, we would like to thank all the project collaborators which contribute significantly in data collection and transcription tasks of the fieldwork.

The research leading to these results has received funding from the RecerCaixa program (2017ACUP00235).

Author information

Authors and affiliations.

Universitat Rovira i Virgili, Tarragona, Spain

Elena María Gallardo-Nieto, Aitor Gómez & Regina Gairal-Casadó

Universitat de Barcelona, Barcelona, Spain

María del Mar Ramis-Salas

You can also search for this author in PubMed   Google Scholar

Contributions

The first author EMGN contributed to the data collection and writing of the manuscript along with other project collaborators. The second author AGG contributed with the methodological review of the manuscript. The third author RGC participated in the analysis of the results of the study. The fourth author MMRS contributed to the review of the manuscript offering feedback on editing and stylistic issues. All the authors read and approved the manuscript.

Corresponding author

Correspondence to Regina Gairal-Casadó .

Ethics declarations

Ethics approval and consent to participate.

All study protocols were approved by the Ethics Committee of Girona University on December 19th of 2018 and the Committee for the approval of research studies of the Nursing and Physiotherapy Faculty of Lleida University on May 17th of 2019. As well, all participants gave assent to complete the research tools. Development and monitoring of these protocols involved a study advisory group, which included LGBTQI+ academic community and LGBTQI+ organizations of the local territory.

Consent for publication

Consent procedures permitted use of verbatim quotations from participants in suitably anonymised form.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Gallardo-Nieto, E.M., Gómez, A., Gairal-Casadó, R. et al. Sexual orientation, gender identity and gender expression-based violence in Catalan universities: qualitative findings from university students and staff. Arch Public Health 79 , 16 (2021). https://doi.org/10.1186/s13690-021-00532-4

Download citation

Received : 10 November 2020

Accepted : 18 January 2021

Published : 04 February 2021

DOI : https://doi.org/10.1186/s13690-021-00532-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Discrimination
• Social problem
• Health education
• Universities
• Sexual orientation
• Gender identity

Archives of Public Health

ISSN: 2049-3258

• General enquiries: [email protected]

Select Your Interests

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing
• Download PDF
• Share X Facebook Email LinkedIn
• Permissions

Draft Guidance on Reporting Gender, Sex, Gender Identity, Sexual Orientation, and Age in Medical and Scientific Publication—Call for Review and Comment

• 1 Executive Managing Editor, JAMA and the JAMA Network
• 2 Deputy Managing Editor, JAMA Network
• 3 Managing Editor, JAMA
• 4 Editor in Chief, JAMA and the JAMA Network
• Editorial Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals Annette Flanagin, RN, MA; Tracy Frey, BA; Stacy L. Christiansen, MA; AMA Manual of Style Committee JAMA

As we have previously acknowledged, 1 terminology, usage, and word choice are critically important in medical and scientific publication, particularly when describing people. Inclusive language recognizes diversity and conveys respect, but noninclusive language may convey bias toward or against persons or groups based on their assumed or self-identified characteristics or demographics and must be avoided. Guidance on use of terms to describe gender, sex, gender identity, sexual orientation, and age in medical and scientific publication must address and balance challenging concepts and goals to promote clarity, inclusiveness, respect, and fairness. People should not be reduced to or limited by a single characteristic, as any characteristic likely intersects with other demographic characteristics and aspects of identity. However, consistent terminology is needed to describe characteristics, individuals, and populations, especially in reports of medical and health research as well as review and opinion articles. Although researchers and scholars, editors, journals, publishers, and others have improved the assessment and reporting of gender, sex, age, and other sociodemographic factors in research and scholarly publication, 2 - 20 more work is needed to expand and clarify the role and reporting of these characteristics in medical and health research and publication.

The AMA Manual of Style: A Guide for Authors and Editors 21 provides extensive guidance on use of inclusive language for authors and editors who write, edit, and publish in the medical and scientific literature. This includes specific guidance regarding usage and reporting of demographic characteristics of individuals and groups. As was done with the reporting of race and ethnicity in medical and science journals, 1 the committee of the AMA Manual of Style has developed updated guidance on reporting gender, sex, gender identity, and sexual orientation as well as age. This draft guidance recommends use of accurate terms when reporting individual or population characteristics or to describe the evolving range of identities as currently understood and to avoid a reductionist description, or “labeling,” of people with a single characteristic. The guidance is intended to advise authors and editors on the clear, fair, respectful, and consistent use of inclusive language. The draft guidance includes the following sections:

Overview of Inclusive Language Considerations for Gender, Sex, Gender Identity, and Sexual Orientation

Concerns and Controversies in Health Care and Research

Glossary and Definitions for Terms Associated With Gender, Sex, Gender Identity, and Sexual Orientation

Examples of Commonly Used Terms

Guidance for Reporting Sex and Gender in Research Articles

Presenting Data in Tables and Figures

Collective Terms for Describing Gender, Gender Identity, and Sexual Orientation

Pregnancy and Parenting

Grammar and Punctuation Usage for Gender, Sex, Gender Identity, and Sexual Orientation

Gender-Neutral Terms

Personal Pronouns

Summary Guides for Recommended Terms When Reporting Gender, Sex, Gender Identity, and Sexual Orientation and Age

During the past year, we have iteratively and extensively revised the previous guidance based on research, review of numerous resources, and discussion by the committee members, as well as invited independent review and critical assessments of leading gender, inclusivity, and equity scholars, researchers, and advocates who provided thoughtful input and represented diverse voices and who did not always agree with one another. We now invite wider public review and comment on this draft guidance. The draft guidance can be found at https://jamanetwork.com/pages/draft-guidance and will be available for review and comment until September 30, 2024. Following this public review and comment process, we will revise and publish as guidance from the AMA Manual of Style . As is our practice, this guidance will be published with the understanding that it is not static and will be reviewed and updated as needed.

Corresponding Author: Annette Flanagin, RN, MA, JAMA and JAMA Network ( [email protected] ).

Conflict of Interest Disclosures: Three of the authors (Christiansen, Flanagin, and Frey) serve as committee members for the AMA Manual of Style .

See More About

Flanagin A , Frey T , Christiansen S , Bibbins-Domingo K. Draft Guidance on Reporting Gender, Sex, Gender Identity, Sexual Orientation, and Age in Medical and Scientific Publication—Call for Review and Comment. JAMA. 2024;332(8):e2416646. doi:10.1001/jama.2024.16646

Manage citations:

© 2024

Artificial Intelligence Resource Center

Cardiology in JAMA : Read the Latest

Browse and subscribe to JAMA Network podcasts!

Others Also Liked

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Environ Res Public Health

It’s a Man’s World: A Qualitative Study of Gender and Sexuality amongst Australian Gay Men

Jack thepsourinthone.

1 School of Health Sciences, Western Sydney University, Penrith, NSW 2751, Australia; [email protected] (T.D.); [email protected] (A.A.)

Tinashe Dune

2 Translational Health Research Institute, Campbelltown Campus, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia

Pranee Liamputtong

3 College of Health Sciences, VinUniversity, Gia Lam District, Hanoi 100000, Vietnam; [email protected]

4 Health Equity Laboratory, Adelaide, NSW 2560, Australia

5 Oral Health Services, Sydney Dental Hospital, Sydney Local Health District, NSW Health, Sydney, NSW 2010, Australia

6 Discipline of Child and Adolescent Health, The Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Parramatta, NSW 2145, Australia

Associated Data

The data associated with the paper are not publicly available but are available from the corresponding author upon reasonable request.

Currently, research explicitly examining masculinity and internalized homonegativity is sparse, and even sparser studies are those using qualitative methods. To address this, this study aims to explore: how gender norms are constructed and experienced amongst gay men; and how gender and sexual identity are experienced in relation to masculine norms amongst gay men. A sample of 32 self-identified gay men aged 22–72 years ( M = 34.34, SD = 12.94) participated in an online semi-structured interview on masculinity and homosexuality. The study used Zoom to facilitate the online interviews as it offered privacy, accessibility, ease of use, and voice recording, among other benefits. Thematic analyses revealed gay men’s understandings of masculinity, femininity, and sources of pressure to conform. Furthermore, gay men emphasize the conflict experienced between heteronormative gender and sexuality norms, which highlights the term homosexual male as an oxymoron.

1. Introduction

Gender norms are a pervasive social structure that provide prescriptions that both guide and constrain an individual’s behavior (e.g., men ought to be strong) [ 1 , 2 ]. They operate under a framework in which behavior is gendered, generalized, strictly scripted, and socially governed in order to avoid derision [ 3 ]. Bradley [ 4 ] notes that heteronormative masculinity is defined by the exclusion and oppression of its outgroup actors—women and gay men—who threaten its very essence. Although women may resist hegemonic femininity and adopt more masculine traits (e.g., butch, tomboy) without comparatively much hostility, men who adopt more feminine traits often experience social backlash from strangers, friends, and even family members—notably fathers [ 4 ]. Despite current social trends, social dichotomization between femininity and masculinity continues to exist [ 5 , 6 ]. This suggests a rigidity in male gender norms, as compared to female gender norms, whereby social trends favor divergences from traditional gender norms for females but not for males. One such example includes the general social acceptance of women wearing either pants or dresses while men only wear pants. In this paper, we therefore draw particular attention to masculine–heteronormative gender norms—specifically, what is perceived to be masculine, how non-heteronormative men relate to masculinity, and its attributing role in the lives of non-heteronormative men.

1.1. Masculinity and Homosexuality: Literature Review

The current literature maintains that heteronormative masculinities depict gay men as being more feminine than their heterosexual counterparts and affect perceptions of their gender and sexual identity [ 7 , 8 , 9 ]. Phrases such as “that is so gay” or “no homo” are often used as a form of social regulation to deter unscripted expressions of masculinity [ 10 ]. However, not only do phrases like these reflect society’s perceptions of homosexuality, but they also reflect heterosexist ideals. As a consequence of these heterosexist ideals, gay men often experience negative attitudes towards their own sexuality—internalized homonegativity [ 11 ]. Internalized homonegativity has been noted to relate to depression, poor wellbeing, sexual discrimination, shame, body dissatisfaction, eating disorders, and suicidal ideation, and results in more extreme and unbearable states of mind in men than women [ 12 , 13 , 14 , 15 , 16 , 17 ]. Phrases such as “I am a man, therefore I may not love a man” [ 18 ] and “you can’t be a man and be gay” [ 7 ] are common concepts that gay men are regularly confronted with. Additionally, anti-effeminacy and homophobic sentiment has been argued to be cyclically perpetuated by victims of gender/sexuality harassment [ 19 ]. Minority stress theory argues that homonegative and heterosexist social environments contribute to gender and sexuality diverse individuals’ experiences of chronic stress [ 20 ]. As such, it is imperative that the role of gender norms (specifically, masculinity) on non-heteronormative individuals’ experiences of gender and sexual identity be addressed to alleviate minority stress, improve mental health, wellbeing, and quality of life, and reduce heteronormative pressures.

Among gay men, homosexual masculinity is often referred to as “straight-acting” masculinity and is argued to be an emulation of heteronormative masculinity—and, arguably, heterosexuality [ 21 , 22 ]. The term straight-acting bears heterosexist overtones, and using this identifier in place of masculine suggests an ideology that masculinity is a state of being exclusive to heterosexuality. HWhile heterosexual masculinity is perceived as an authentic and natural gender performance, whereas homosexual masculinity is perceived as a costumed drama [ 23 ]; “homosexual men are more like women…Even the most masculine gay man is a bit sissy” [ 24 ]. The social construction of masculinity, therefore, generates a reified oxymoron out of the phrases “homosexual male” and “gay man”, whereby both terms are perceived as direct oppositions of each other.

The strain gay men may experience in their efforts to be as heteronormatively masculine as possible, despite their homosexuality, is perpetuated by prejudice and discrimination in all areas of life that serve to govern socially acceptable expressions of masculinity. For example, gay men who are overly concerned with gender norms and masculine body ideals are argued to be compensating for their feelings of internalized homonegativity and inferiority [ 8 , 25 , 26 , 27 ]. Furthermore, individuals who have experienced harassment due to childhood gender non-conformity are more likely to experience later adult life body shame and bear anti-effeminacy prejudice towards others [ 19 , 28 ]. This is evident in discriminative social practices in classifieds and dating applications that exclude effeminate men [ 25 , 29 , 30 , 31 ]. As a result, gay men who have internalized heteronormative masculinity and the strict rules therein participate in policing other gay men, as well as themselves through compensatory behavior, as a means of minimizing gay men’s effeminacy stereotypes [ 19 ]. It can be further argued that the discrimination between straight-acting and effeminate gay men, particularly within personal advertisements, normalizes, and even glorifies, the divisive social practice. These dynamics thus perpetuate heteronormative masculinity, (hyper)masculine gender norms, and further contribute to gender-related strain and internalized homonegativity.

1.2. The Australian Social Environment

The social environment of gender and sexuality diverse groups, within a Western context, is rapidly evolving [ 32 ]. It is only within the past century that more positive attitudes have emerged. In 1957, psychologist Evelyn Hooker challenged the mainstream view of homosexuality being a disorder [ 33 ]. In 1973, the Diagnostic Manual of Mental Disorders no longer classed homosexuality as a disorder. This was subsequently followed by changes within the World Health Organization’s International Classification of Diseases in 1990 [ 34 ]. However, progress within Australia has been slow. The campaign to decriminalize same-sex sexual conduct in Australia began in the 1970s, but it was not until 1997 that it became legal in all Australian states [ 35 ]. Furthermore, it was only within the last five years—December 2017—that Australia passed the Marriage Amendment (Definition and Religious Freedoms) Act 2017, which legalized marriage between same-sex couples [ 36 ].

Prior to this, discrimination against gender and sexuality diverse groups was common, with arguments of gay and lesbian relationships being unnatural [ 36 ]. Similarly, the period leading up to the amendment saw a rise in homophobic and transphobic harassment and assault [ 37 ]. Sentiments such as “I was really scared, I don’t feel as safe as I used to” was common among gender and sexuality-diverse individuals [ 37 ].

1.3. Theoretical Framework

As this paper explores the role and relationship between factors that influence how masculinity is internalized and experienced in line with (non)heteronormative gender norms, a holistic theoretical lens is needed to interpret the data collected. We therefore engage with the principles of socio-ecological theory [ 38 , 39 ]. Doing so will allow for a multidimensional view of the interactions and relationships between a wide range of factors within a person’s environment. Socio-ecological theory supports this as it helps to identify constructs, interactions, and experiences between an individual and various levels of their environment. Flanders et al. [ 40 ], for example, argued that the use of the framework allowed for an explicit analysis of the gender socialization process through each level of the individual’s environment. It helps to provide additional and holistic insights into the social intricacies and dimensions of gender and sexuality, including how they shape and are shaped by the individual and their environment, which other studies tend to overlook.

Socio-ecological theory emphasizes the agency of both the individual and the influence of their environment, as each shapes and is shaped by each other [ 38 , 39 ]. This includes both informal and formal environments such as:

• The microsystem—family and close social networks;
• The mesosystem—major settings (e.g., school, church, work);
• The exosystem—other social structures that, although do not contain the individual, encompass their immediate setting;
• The macrosystem—broader social structures and ideologies.

Importantly, social structures such as gender norms continue to exist and take shape according to those who use them [ 41 ]. Based on a synthesis of literature, Figure 1 depicts a preliminary conceptual model of the typical ecological environment for a gay man and highlights various areas heteronormative masculinity pervades and exerts an influence. Beginning from the macro level of a gay man’s social ecology, heteronormative masculinity permeates the psychology of how they perceive themselves, others, and the world and extends to the micro- and meso-systems that enforce heteronormative gender and sexual identities through interactions with friends and family members (microsystem), as well as strangers and colleagues (mesosystem) [ 7 , 19 , 25 , 29 , 30 , 31 , 42 ]. Moreover, the interactions between the individual and their micro-, meso-, and exo- systems arguably contribute further to the issues presented [ 8 , 19 , 43 ]. It can, therefore, be argued that the role of heteronormative masculinity on a gay man’s life cannot be examined in isolation but, rather, as a complete system of factors, each contributing to the manufacturing of internalized homonegativity. The present study seeks to explore and identify the factors within each level of the socioecological model that influences gay men’s identity, expressions, and experiences of masculinity and gender norms in the context of (non)heteronormativity.

Socio-ecological map of an Australian gay man [ 44 ].

Currently, research explicitly examining masculinity and internalized homonegativity is sparse [ 16 , 24 , 45 ] and even sparser are studies examining internalized homonegativity qualitatively [ 13 ]. This paper is based on a larger body of work titled “It’s a Man’s World”, which explores masculinity and internalized homonegativity amongst gay men. The study, therefore, aims to qualitatively explore this under-examined area and develop a stronger understanding of the relationship between masculinity and internalized homonegativity within a sample of Australian gay men. The research aims to explore:

• How gender norms are constructed and experienced amongst gay men; and
• How gender and sexual identity is experienced in relation to masculine norms amongst gay men.

It is expected that the findings will contribute to the identification of the underlying issues surrounding internalized homonegativity (e.g., gender norms) and gaps for further research in the area.

2. Materials and Methods

2.1. research design and instruments.

Few studies have examined masculinity and internalized homonegativity qualitatively [ 13 ]. This study, therefore, intended to use an under-examined methodology within the field. With considerations of previous studies [ 7 ], semi-structured interviews were utilized. The interview focused on men’s experiences (or lack thereof) of internalized homonegativity, the factors that contribute to their experiences, and the impact it may have on their health and wellbeing. As such, topics for discussion were centered on: experiences of childhood harassment for gender non-conformity, notions of homosexuality as feminine, pressure to be straight-acting/masculine, reactions to gender non-conformity (e.g., anti-femme), and negative feelings about being gay. Table 1 contains the interview guide used. The research design and ethical considerations were initially reviewed by a panel of three experts in the field, as well as receiving further review and approval by the Western Sydney University Human Research Ethics Committee (Approval No.: H12044).

Interview Question Guide.

All interviews were conducted via Zoom version 3.5.4 (Zoom Video Communications, San Jose, CA, 2017). A close-ended self-administered demographics questionnaire was also utilized to ascertain participant’s background information—age, gender, ethnicity, religion, post code, and from what device were they accessing in order to participate (e.g., laptop).

Using Zoom for Data Collection

The online environment is an invaluable resource in research, as it offers a safe and inclusive space, allowing for researchers to make visible that which is difficult to study or non-existent in traditional environments [ 46 , 47 ]. As such, we used Zoom, an online conferencing program, to collect the data. This software tool was utilized for two reasons: (a) it allowed for the interview to be recorded without the aid of additional software or equipment, and (b) it offered privacy in that it did not require the participant or researcher to add each other to their contacts—a common feature in online conferencing and social media. This allowed for the researcher to reach out and include underrepresented samples, geographically and/or socially isolated individuals, individuals who are unable to or prefer not to attend in person [ 48 , 49 , 50 ]. Gay men, for example, may not wish for their identities to be disclosed, and online environments, therefore, allow for such populations to participate in research with lower risks to their anonymity [ 48 ]. Furthermore, Zoom is argued to be more favorable among both participants and researchers over face-to-face, telephone, and other videoconferencing technologies when conducting interviews [ 51 ]. Other benefits of this particular software include convenience, ease of use, cost effectiveness, data management, interactivity, security, unique features such as video recording, and its ability to facilitate personal connections between users [ 51 ]. In this study, a personal computer with a reliable internet connection, web camera, and Zoom installed was used to facilitate the interview.

2.2. Participants

Participants from the It’s a Man’s World study were initially recruited via advertisements through lesbian, gay, bisexual, transgender, and/or intersex (LGBTI) networks (e.g., LGBTI Alliance of Australia, Queensland Aids Council), social media (e.g., Facebook, Twitter, Instagram), dating applications (e.g., Grindr), flyers placed across Western Sydney University campuses, and word of mouth. The researcher’s contact details were included within the advertisements in order for individuals to express interest in the study. Participants from the It’s a Man’s World study were given the option to also express interest in the current research and provide their contact details. A pool of 253 individuals self-identifying as gay men expressed interest in the current study after participating in the initial It’s a Man’s World study. All individuals were contacted through email after, and of these, only 32 individuals followed up by arranging an interview. No interviews were cancelled or turned down, and no participants withdrew from the study.

Between March and July 2017, and months prior to the legalization of same-sex marriage in Australia, a sample of 32 self-identified gay men aged 22–72 years ( M = 34.34, SD = 12.94, median = 30) living in Australia (NSW = 90.63%, QLD = 3.13%, VIC = 3.13%, WA = 3.13%) participated in online interviews focusing on masculinity and homosexuality—this time period was marked with high contention and discussion around LGBTI issues. Among the sample, 3.13% identified as Aboriginal, 6.25% as East Asian, 6.25% as Southeast Asian, and the remainder as Caucasian (85.38%). Additionally, most of the sample identified with no religion (68.75%), followed by those identifying as Christian (18.75%), Buddhist (6.25%), and other (6.25%). Gay men, compared to lesbian women, are argued to be most adversely affected by heteronormative constructions of masculinity and femininity and are more prone to resultant health and wellbeing complications [ 8 , 16 , 52 ]. As such, the study’s aim and scope focused solely on gay men, and individuals of other genders and sexualities were excluded (e.g., transgender, bisexual, etc.). Each interviewee received a AUD 30 digital gift card as compensation for their time and inconvenience.

2.3. Procedure

Following initial contact, JT forwarded details of the study to the participants, including a participant information sheet, a participant consent form, instructions on how to install and use the Zoom program, and the time of the scheduled interview. On the day of the interview, participants were required to click on the link included in the email correspondence which automatically runs the Zoom program with the appropriate conference room for the present study. Audio recording was then enabled on Zoom once consent had been given, and JT commenced a semi-structured interview using the interview questions as a guide.

2.4. Analysis

Following data collection, interviews were transcribed verbatim and inserted into Quirkos . Quirkos is a visually intuitive data management software that assists researchers in the coding and analyses of qualitative data [ 53 ]. Quirkos assisted in organizing topical responses and emergent substantive categories. Thematic analysis method was used to analyze the data. It was conducted by ascertaining codes, patterns, and substantive categories within participants’ accounts in relation to the study’s aims [ 54 ]. Coding was conducted by JT, and emerging themes were discussed by all authors (JT, TD, PL, and AA).

Pseudonyms were assigned to participants where direct quotes were used to maintain participant anonymity. Four distinct themes emerged from the gay men’s stories: Understanding Masculinity, Understanding Femininity, Gay Men and Gender Expression, and Sources of Pressure. The themes of Understanding Masculinity and Understanding Femininity relate to gay men’s perceptions and understanding of masculine and feminine gender norms, respectively. Similarly, the theme of Gay Men and Gender Expression relates to how gay men relate to, perform, and express gender and gender norms. Furthermore, Sources of Pressure relates to sources of pressure and expectation of performing/expressing gender norms.

3.1. Understanding Masculinity

When asked about masculinity, participants described masculinity using a range of characteristics and discussed it in relation to several systems (e.g., micro-, meso-, exo-, and macro-systems). Physical characteristics were one of which participants commonly referred to. For instance, muscularity, fitness, body weight, body height, deep voice, and body hair were quite common. Body weight was suggested to equate to masculinity; “I was never really a masculine person anyway. I’m as skinny as a stick… It’s actually interesting that I just conflated masculinity with body types” (Ernest, 26).

Other participants also described masculinity using lifestyle choices and behaviors. These included maintaining an active lifestyle, going to the gym, owning sports cars, trucks, or utes (utility vehicles), skills (e.g., repairing), ways of dressing, and even favored music genres. For instance, one participant characterized masculinity as “someone that goes to the gym and drives a big beefy car” (Anthony, 23) while another stated “being masculine is driving big trucks or being manly, rugged, and knowing how to fix things around the home” (Harry, 32).

Certain ways of communicating, expressing, interacting, and thinking were also associated with masculinity. Participants tended to describe masculinity as being less emotional, less affectionate, proud, egotistic, narrow-minded, misogynistic, and even homophobic. Generally, participants commonly described masculinity as restrictive. For instance, “not talking about your emotions… maybe suppressing the desire to just act a little bit femme and a bit softer sometimes” (Finn, 33) and “a limited range of topics that you can speak about with other men or even in general, in public, or in social situations” (Aaron, 24). Masculinity was also described as “having a really big sense of pride and ego” (Nathan, 26) and to place a limit to their behaviors: “I had a lot of trouble with the idea of specific types of music that I felt like I shouldn’t be listening to because of a need to be masculine” (Aaron, 24).

3.2. Understanding Femininity

Similarly, participants tended to describe femininity using lifestyle choices and behaviors, for instance, mannerisms, interest in fashion/shopping, ways of dressing, and certain behaviors. Largely, femininity was associated with femaleness and behaving “girly or acting like a girl” (Ernest, 26), camp, or flamboyant. One such example includes “wearing maybe bright colors or tight clothing or revealing clothing” (Melvin, 30). Gossiping was another behavior that participants described as feminine.

In terms of communicating, expressing, interacting, and thinking, femininity was commonly described as emotional, open, freeing, less serious, and empathetic. One participant expresses the positive impact femininity has on their gender expression; “For me it feels more free. I feel like I can be expressive. I can throw my hands around and I can dress in crazy ways. I can really be emotional. I can just really react in a strong emotional way to things. If someone tells me something I can be like ‘My god’. You can just really express yourself and you don’t have that limit on expressing yourself” (Nathan, 26).

3.3. Gay Men and Gender Expression

3.3.1. enacting feminine gender norms.

When asked about how gay men relate to the constructs of masculinity and femininity, a mix of responses were given. Some participants described gay men as being typically feminine and others as typically masculine. In the case of the former, participants expressed notions of femininity as a norm for gay men; “I think it’s also that gay men feel less inclined to have to live up to masculine ideas” (Aaron, 24) and “I thought maybe being feminine actually becomes a way for gay men to fit into a community and find a community and if you don’t fit into that maybe it’s a bit isolating” (Nathan, 26). This norm for gay men to adhere to feminine norms is further explained by one participant’s struggles to be welcomed by the gay community in their city; “You might see the whole scene and realize I don’t really fit in here and feel kind of crap. If you’re not popular or look a certain way or fit into that kind of homogenous 2010 kind of gay scene, then you might feel a bit shit about yourself so you reshape yourself to look and act in a certain way so that you fit in” (Finn, 33).

From the interviews, participants expressed experiencing prescriptions and expectations to enter more female-dominated careers, speak, behave, and dress a certain way, as well as participate in recreational activities deemed appropriate and congruent with their sexuality. Gay men are often compared to or described as being more like women: “People are more likely to make derogatory comments or call you a girl or call you one of the girls or assume you relate better to women than to men or assume you’re bad at sports. I think it also shows in subtle ways to being left out of certain things because you’re not as highly valued” (Melvin, 30). Another participant expressed, “A lot of the time, people’s response whether they be gay or straight… might be that the effeminate straight guy is clearly a closet case… whereas with femme gay guys, it’s just one of those things where people are like ‘Yeah, that is just how gay guys act’” (Finn, 33). Participants also expressed concern over the blurred line between gender identity and sexual identity: “When I introduce myself to some people, they go ‘I never would have thought you were gay’ or ‘Are you sure?’… Am I too masculine to be gay?” (Cooper, 26).

3.3.2. Enacting Masculine Gender Norms

On the other hand, however, some participants expressed pressure to behave masculine, as well as negative social cues when behaving effeminately. For instance, one participant compared anti-effeminacy reactions in relation to straight and gay men: “I feel like with straight people it’s not so much a thing…Some guys might find it a little bit confusing and off-putting but I feel like gay guys are kind of worse about it” (Finn, 33). Similarly, another participant argued that “there is a toxic nature around what is seen as attractive in the gay male world and I feel that it usually favors fitness and muscles more” (Cooper, 26) and “to act like a woman is somehow a negative thing”.

Similarly, masculinity has been described to bear weight in the hierarchy of gay men and social status. For instance, one participant stated: “These buff, gym going, bearded hair dudes are sort of dominating the space and going ‘Well you’re actually too feminine. I’m masculine, so I’m more important than you. I’m more valid than you are’. It’s interesting to navigate that, because the way that society sort of pushes these more masculine sort of men, I feel they’re not as gay, if that also makes sense” (Cooper, 26). While others expressed “I think masculinity is viewed as a benchmark in which people are judged. The more masculine someone is, the better they are” (Ernest, 26) and “The more masculine you are, the higher up you are” (Melvin, 30). This form of ostracization and discrimination is described as being more common than other overt forms of discrimination: “Rather than pointing and calling names… now we simply exclude them. You’re not behaving straight enough for me and therefore I’m going to exclude you out and I only want to meet straight acting men. It’s not portrayed as a personal preference; it’s portrayed as somehow being better than the alternative” (Tyler, 51).

In examining the discrepancy between expectations of various gender norms among sub-communities/groups, the phenomena were described as self-perpetuating, cyclical, and, at times, further reinforcing and exaggerating such norms. One participant noted: “I think that sometimes we reinforce our own gender stereotypes by finding the other people that make us feel comfortable and then we build on that by bouncing off each other, and I think that happens for both straight acting and I think that happens for effeminate men as well. They’ll find themselves a group of people who behave in the same way. Having done so, they then feel more comfortable in behaving even more extreme in whatever behavior it is, be it spitting on the ground or be it having short shorts and jumping around and squealing. We support our own perceptions by finding people who make those perceptions comfortable” (Tyler, 51).

3.3.3. Public and Outward Presentation

Others also discussed the stigmatization of male effeminacy, the fear of publicly presenting femme, and the use of masculinity as a defense mechanism. For instance, one participant described the use of heterosexual/masculine self-presentation as a form of defense mechanism: “I could be dressed in just a straight passing outfit, walking like normal…and I’ll still be afraid that they will perceive that I’m gay or not super masculine” (Aaron, 24). Similarly, another participant asserted that “if there was some kind of bikie who walked in and looked as scary as all hell, then I’d probably just try to be as normal as possible” (Ernest, 26). Similarly, “I think it’s wanting to conform… there’s a reason why men would be in the closet, it’s because they think it’s something that’s undesirable, to be a gay man” (Phillip, 23).

Outward presentation of femininity is often described as an indicator of gayness. One participant expressed; “People are surprised when they find out that you’re gay or whatever and they’re like ‘I didn’t realize you were gay. Wow’, like that whole surprise, which underlying that is the implication that people should be readily identifiable based on how they act or whatever. I mean how are you going to find out that I’m gay unless I tell you that I like to bang dudes” (Finn, 33). Similarly, another participant expressed: “I was a lot more flamboyant when I was younger and it was actually brought to my attention via a couple of people saying, ‘People think you are gay’. They didn’t say, ‘You are gay and that’s okay’. They said, ‘It doesn’t matter if you are but people think you are’” (Phillip, 23). This is further depicted by one participant’s anecdote; “I think a lot of people get quite annoyed by flamboyancy and public displays of affection and, ‘I’m fine with what you do in your own bedroom kind of thing but don’t let me have to see it or know about it’” (Phillip, 23). These indicators of gayness may even include the most subtle of social nuances/physical details, for example, “I feel as if though the policing is of gender and of demonstration or performance of gender, but there’s an undertone there. It’s dad saying ‘Cut your fingernails because they’re too long’, but what he’s not saying in words, reading between the lines, he’s still saying ‘Stop looking so gay’” (Cooper, 26).

3.4. Sources of Pressure

When asked about sources of pressure, expectation, and inheritance of gendered norms, gay men described a plethora of sources stemming from all four systems (i.e., macro-, exo-, meso-, and micro-systems). For instance, one participant highlights the pervasive nature of gender norms through one’s society: “As much as I detest society says we’re supposed to think and feel, I do believe that does transcend into what I do, think, and feel sometimes, no matter how much I resist it” (Harry, 32). Other sources included: fathers, male figures, mothers, religion, school, authority figures, television, and movies. Furthermore, external pressures are described to permeate through to one’s own cognition: “I wouldn’t be able to drive a bright pink Barina down the main street of [city]. I couldn’t have the guts to do that, as ridiculous as that is. It’s a car. But I still, in my head, do feel the pressure of society saying I still have to act a certain way or do a certain thing or behave in a way and a manner in context rather than doing exactly what I want to do” (Harry, 32). One participant describes the lifelong process of gender socialization: “We grow up in a world where from the minute a child is born, they’re told that they have to behave in a certain way, and if they step outside of those rules, they’re punished. From such an early age, they’re told non-normative genders, non-normative sexualities are bad things” (Ernest, 26).

Additionally, participants often emphasized that the impact of such agents could occur through either direct or indirect interactions with the individual. For instance, one participant highlighted that “You don’t even have to have it directly put on you, you just have to hear it and be a witness to it happening to other people to start learning that that is the way things are” (Aaron, 24, Caucasian). Similarly, another participant emphasized the unspoken nature of gendered norms and the expectations of how (gay) men ought to be; “There’s an awful lot that we don’t appreciate that children pick up on as an unspoken” (Tyler, 51).

4. Discussion

The paper has identified areas of gay men’s social environments that influence their sense of gender, sexuality, experiences of gender norms, and the impact it may have on their health and wellbeing. Figure 2 provides an overview of the results in accordance with their respective level on the socio-ecological model.

Socio-ecological map of an Australian gay man within the present study.

Gay men in the present study tended to emphasize physical characteristics and certain lifestyles (e.g., tradespersons) when describing masculinity. Like muscularity, a larger body weight bears with it a larger physical presence. This is consistent with traditional notions of masculinity, which include strength and dominance [ 1 ]. Such descriptors depict a physically strong, proficient, and skillful individual—typical of a blue-collar worker. Additionally, these characteristics may also be argued to depict activity as opposed to passivity—commonly attributed to masculinity [ 55 ] and dominance, both physically and socially/symbolically (e.g., owning a ute/truck may suggest manual/physically demanding occupations while owning a sports car may suggest wealth/affluence). Social structures existent in an individual’s exo- and macro-systems (e.g., masculinity) are argued to both shape, as well as are shaped by, individuals [ 41 ]. Within the previous examples, participants described instances whereby certain lifestyles influence what is perceived as masculine. However, the reverse was also be observed in a participant’s anecdote whereby constructs in one’s macrosystem impedes on one’s personal choices (i.e., choice of leisure activity).

Results also revealed ways in which masculine norms impeded on gay men’s ways of communicating, expressing, and thinking. This is consistent with extant literature highlighting masculine norms to include restrictive emotionality, restrictive affectionate behavior between men, success, power, competition, and primacy over women [ 56 , 57 ]. This demonstrates how masculinity influences how individuals interact with others within their micro- and meso-systems—specifically, it depicts an impediment on one’s relationships with others.

Within one’s exosystem, there exists the stereotype that gay men are more effeminate [ 7 , 9 ]. This stereotype affects how gay men perceive and relate to their own gender and sexual identities. Gay men within the present study revealed pressure and expectation to abide by feminine norms lest they be ostracized. This suggests that gender norms are reversed for gay men. While masculine gender norms may play a role in impacting gay men’s gender identity, feminine gender norms exert a pressure onto gay men due to their sexual identity. That is, masculine norms exert an influence over gay men due to their identity as a man while feminine norms exert an influence over gay men due to their identity as being gay. As such, gay men experience a discrepancy between their gender and sexual identities and feel compelled to perform their gender as what is typically viewed as feminine/gay. This force from agents within one’s meso- and micro-systems is argued to impact how gay men perceive themselves, as well as how they interact with others in their environment.

The present study’s results also revealed strain exerted by other gay men through the ostracization of feminine gay men and the veneration of masculine gay men. This is consistent with current literature, which emphasizes the discriminative social practices which exclude effeminate gay men [ 22 , 25 , 29 , 30 , 31 ]. These findings demonstrate the negative effect structures within an individual’s macro- (masculinity) and exo-systems (heteronormative gender norms) have on the individual and their interactions with their micro- and meso-systems through day-to-day social interactions, dating, and even how they present themselves to others. This hierarchy and valuation of masculinity is often described as part of straight-acting culture whereby passing as heterosexual was coveted. Additionally, this ritualized legitimization of gender among gay men demonstrates the influence agents within the meso- and micro-systems have in the construction of broader social structures [ 41 ].

Extant literature highlights the pressures received from friends and family members (e.g., fathers) in their microsystem, as well as strangers and colleagues within their mesosystem [ 4 , 25 , 29 , 30 , 31 ]. Gay men, hence, experience pressure from all areas of their environment, including themselves through the internalization of such norms. Similar to the literature, gay men within the present study emphasized both the direct and indirect nature of gender norm acquisition through direct interactions with others as well as through observations and imitation [ 2 ].

Participants within the present study also described instances of conformity to masculine norms, passing, and altering their public behavior/appearance. Behavior such as this is common among sexual minority individuals who experience fear and/or distress regarding both actual and anticipated discrimination and/or harassment. Gay men often expressed negative reactions to their public presentation. This suggests that individuals and society have a specific conception of how a gay man should outwardly appear/present. This example demonstrates not only that gayness has a physical appearance but also implies that one ought to avoid appearing this way. This derision of outward gayness highlights a particular notion prevalent within one’s society that, regardless of acceptance, homosexuality should remain in the closet.

The constructs of gender and sexuality norms are described to be systemically and cyclically perpetuated through macro- and exo-level systems such as one’s society, culture, religion, traditions, educational institutions, and media. This is consistent with current theories that maintain one’s overarching social structures, systems, and institutions play a part in fostering and perpetuating such norms [ 38 , 39 , 41 ]. Additionally, individuals describe these norms as being regulated and enforced by agents within their meso- and micro-level systems, with whom they may have either direct or indirect contact. These agents include: mothers and fathers, relatives, friends, peers and acquaintances, individuals within one’s community, and even strangers. These results are consistent with other similar studies [ 4 , 25 , 29 , 30 , 31 ]. Additionally, the degree of pressure, regulation, and enforcement placed on the individual by these agents may vary. Phrases such as “that is so gay” are argued to be a form of social regulation to deter unscripted expressions of masculinity [ 10 ]. For instance, gay men in our study experienced conflicting and competing expectations from agents within their meso- and micro-systems. It was often described that gay men were expected to conform to masculine norms due to their identity as a man but were also expected to conform to feminine norms due their sexual identity. This often led to gay men experiencing a strain and conflict between their identities. This further maintains the notion of the term homosexual male being oxymoronic. Whether gay men adhere to one set of norms or the other, they risk ostracization due to one of their identities.

This paper suggests that there exists a strain experienced by gay men in relation to masculinity, in that it impedes on their relationship and forms of communicating with others within their micro- and meso-environments. Additionally, it argues that gay men experience a conflict between their identities as both a man and a gay man. Current heterosexist and heteronormative constructs of gender norms tend to dichotomize masculinity and homosexuality. As such, an oxymoron is created by the term gay man and arguably creates a strain uniquely experienced by gay men. This strain is described to impede on one’s relationships and their ability to actualize their potential. It is suggested that future research endeavor to examine this conflicting strain experienced by gay men and to examine whether it is an experience unique to gay men or shared amongst other non-heteronormative identities. Doing so will arguably aid in better understanding and accommodation in relieving gay men’s experiences of strain.

Limitations and Recommendations

Some limitations of the study need to be pointed out here. Although the study only recruited participants identifying as gay men, we received interest from men identifying with other identities (e.g., bisexual). The present study is limited in that it only examines the effect of heteronormative gender norms on only one group (gay men). Future studies are recommended to examine other non-heteronormative identities in order to ascertain the broader spectrum of how gendered norms impact non-heteronormative individuals and whether these impacts are unique to particular sexual identities or are a shared experience. Specifically, there exists sparse research examining gender norms among bisexual men and little to no research utilizing trans and gender-diverse men [ 58 ]. Gender norms also impact heterosexual men in similar ways. Although there is a plethora of research on how conformity to masculine norms affect men’s health (see gender role conflict theory, gender role strain paradigm, and precarious manhood theory) and wellbeing, there is relatively limited research on non-conformity among straight men [ 42 , 59 , 60 ]. Future studies may wish to explore this avenue and/or employ a comparative study between heterosexual and LGBTI identities.

Additionally, the present study was limited in that the majority of participants identified as Caucasian and non-religious. Studies have revealed that men of diverse ethnicities and those high in religiosity are affected differently by gender and sexuality norms [ 61 , 62 ]. Future studies are recommended to examine a diverse sample consisting of different ethnicities and religious identification and to employ a comparative approach.

The year 2022 marks five years since the legalization of same-sex marriage within Australia through the Marriage Amendment (Definition and Religious Freedoms) Act 2017. The social environment within Australia, as well as globally, has changed over the years in regard to gender and sexual diversity [ 63 , 64 ]. The literature suggests that attitudes towards gender and sexual diversity improve following legislative change—specifically among those in support of it (i.e., LGBTI individuals, allies) [ 65 ]. Furthermore, online conferencing technologies have drastically improved as well through the increased use and accessibility of programs such as Zoom, including added features such as live closed-captioning, transcription, and breakout rooms [ 66 , 67 ]. As such, it is recommended that future studies examine heteronormative gender norms among LGBTI individuals (notably, from an Australian perspective) and to adopt a qualitative online conferencing approach. The increased usage and accessibility of such technologies will, arguably, support the implementation of this under-utilized methodology within the field and may also innovate new methodologies (e.g., online conference focus groups)

Many policies within Australia are informed by the determinants of the health model [ 68 , 69 , 70 ]. For example, the Australian Department of Health specifically highlights the importance of sex, gender, and socioeconomic characteristics (e.g., education, employment, income) as determinants of good health [ 71 ]. The socio-ecological model follows a similar structure and, by adopting both models, healthcare workers and researchers may ascertain specific areas that need to be addressed. The present study identified areas/sources of strain for gay men in each level of the socioecological environment. As such, the results aid policymakers map out sources of strain and allow for them to address them appropriately.

5. Conclusions

Sparse are current studies explicitly examining masculinity and internalized homonegativity [ 16 , 24 , 45 ], and even sparser are those employing the qualitative approach [ 13 ]. We addressed this gap by qualitatively examining Australian gay men’s perspectives on heteronormative gender norms (e.g., masculinity) and their experiences of being gay, identifying conflicts between their gender and sexual identities (i.e., gay man being an oxymoronic term), and the impact it has within varying socio-ecological systems. Our findings contribute to the furthering of the sociological understanding of LGBTI and men’s health and recommend future studies to further explore this topic in other LGBTI populations. Attitudes towards gender and sexuality diverse identities have also changed (notably following the legalization of same-sex marriage in Australia five years ago). As such, recommendations are made for future studies to replicate the study following the recent surge in usage of online conferencing technology.

Author Contributions

Conceptualization, J.T. and T.D.; data curation, J.T.; formal analysis, J.T.; funding acquisition, J.T. and T.D.; investigation, J.T.; methodology, J.T.; project administration, J.T.; supervision, T.D., P.L. and A.A.; writing—original draft, J.T.; writing—review and editing, J.T., T.D., P.L. and A.A. All authors have read and agreed to the published version of the manuscript.

This research was funded by the School of Health Sciences, Western Sydney University, Research Training Scheme (RTS).

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Western Sydney University Human Research Ethics Committee (Approval No.: H12044).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.