Abstract and Keywords
Sexual orientation is a multidimensional phenomenon involving a person’s sexual attraction, sexual behavior, and sexual orientation identity. Sexual orientation patterns may remain consistent or fluctuate over time. Although heterosexual attractions, behaviors, and identities appear to be the dominant manifestations of sexual orientation, other sexual expressions exist. The causes of sexual orientation are still not completely understood; however, evidence suggests that biological factors play a strong role. Sexual development is an important part of human development, and there are parallel and differing developmental tasks and trajectories for those who are heterosexual and those who are queer. Non-heterosexual sexualities are often stigmatized, which contributes to homophobia and heterosexism. There is a continuing history in the mental health professions of efforts to change the sexual orientation of people who are queer, despite evidence of harm and ethical mandates. Researchers and service providers should assess sexual orientation because it is one of many important characteristics in the lives of individuals.
Sexual orientation refers to how a person is positioned on three dimensions of sexuality: sexual attraction, sexual behavior, and sexual orientation identity. Sexual attraction refers to a person’s physical and emotional attractions to others, which involves felt sensations within a person based on another person who is the focus of desire. Sexual behavior refers to physical intimacy and sexual activity between people. Sexual orientation identity refers to a person’s conception of their personal identity and group affiliation based on who they are sexually or romantically attracted to and/or who they are engaging in sexual behavior with. The term sexual identity is sometimes used to refer to sexual orientation identity, but this is not always the case. Sexual identity has also been used to refer to one’s identity in terms of being male or female, as well as identities related to variations in sexuality (e.g., polyamorist, swinger, and “dom” or “sub” in bondage, discipline, and sadomasochism [BDSM]).
Complexity and Fluidity in Sexual Orientation
Sexual orientation is a complex. It involves three components: it is shaped by biological, psychological, and sociocultural factors. And it manifests as psychophysiological, behavioral, and psychosocial phenomena in people’s lives and in society. Whereas sexual attraction is psychophysiological and sexual behavior is behavioral, sexual orientation identity is both a mental and social phenomenon. The mental aspect of sexual orientation identity centers on a person’s conception of who they are as a sexual being. Sexual orientation identities are also sociocultural because they provide a means for group affiliation and the formation of subcultures. Sexual orientation identities are also socially constructed. In the West, the terms “heterosexual” and “homosexual” were coined in the 1860s by Karl Maria Kertbeny (Katz, 1995). Over time, certain connotations were placed upon these identities, they became integrated into language and communication systems, and individuals were expected to embody these identities as part of their personal and social lives. In contemporary societies, there exists a set of socially defined sexual orientation identities. Individuals are often socialized from birth to have an assumed orientation (e.g., heterosexual), but individuals may also choose a different identity that better aligns with their personal sexual experiences during the life course. This can be complicated by stigma because some identities are more socially stigmatized than others (e.g., gay versus heterosexual). The extent to which a person identifies with a particular sexual orientation identity is shaped by their sexual desires and behaviors, individual socialization experiences around sexuality, and the attributes and meanings connected with the socially constructed sexual orientation identities. Given these multi-influential biopsychosocial factors, there is not always exact alignment along the dimensions of sexual orientation for every individual. For example, a person may feel attracted to men and women, only engage in sexual behavior with women, and self-identify as heterosexual.
Another aspect of complexity about sexual orientation is that it is not static. For example, a person’s attraction to another may change over time; it may shift from being nonexistent to being strong to being moderate. And, at one time, a person may feel attracted to one gender and then later feel attracted to other genders as well. In terms of sexual behavior, the activities a person engages in with another may change and vary in frequency over time. For example, sexual partners may initially engage in outercourse or non-penetrating/non-enveloping sexual activity (e.g., frottage, mutual masturbation, deep kissing, and cuddling), then oral sex, and then penetrating/enveloping sexual intercourse over the duration of a sexual relationship. In addition, sexual orientation identity may also change over time. For example, data from the National Longitudinal Study of Adolescent to Adult Health show that 18% of women and 6% of men changed their sexual orientation identity between two waves of data collection, a six-year period (Savin-Williams, Joyner, & Rieger, 2012). Some participants who identified as bisexual later identified as gay/lesbian or heterosexual, some participants who identified as gay/lesbian later identified as bisexual, and some participants who identified as heterosexual later identified as bisexual or gay/lesbian. Indeed, there is fluidity when it comes to sexual orientation; however, many individuals’ sexual orientation patterns remain consistent over time.
Diversity in Sexual Orientation
There is much diversity in the expressions of sexual orientation. A discussion of this diversity first requires a brief overview about sex and gender because these constructs are tied to sexual orientation. Sex refers to distinctions of being male, female, or another sex (e.g., intersex and transsexual) based on biological characteristics, which include sexual anatomy, genetics, and hormones. In the United States, sex is assigned at birth: male or female. This practice ignores the natural variation in sex characteristics present at birth as exemplified by intersex babies (Kaneshiro, 2015), as well as variation that occurs over the life course, such as changes in hormone levels and anatomical characteristics that many people who are transgender or transsexual pursue so that their bodies reflect their gender identity (Teich, 2012). Gender includes a person’s gender identity, which is their internal sense of being a man, woman, or another gender (e.g., transgender and genderqueer) regardless of biological sex, as well as gender expression, which is how a person demonstrates or performs their gender through clothing, hairstyle, speech, behavior, and appearance. Gender expression is often understood as existing on a bipolar gradient with masculine and feminine on each end; however, what is considered masculine and feminine is socially constructed. And, many people do not conform to traditional gender stereotypes in their appearance and behavior (i.e., gender non-conforming, gender-variant, or gender non-binary). Table 1 shows some terms and definitions associated with sexual orientation that reflect diversity in sex, gender, and sexuality.
Table 1. Sexual Orientation-Related Terms and Definitions
Category and Term
A person typically characterized by an XY genome, reproductive organs that include a penis and testicles, and higher levels of the hormone testosterone
A person typically characterized by an XX genome, reproductive organs that include a vagina, and higher levels of the hormones estrogen and progesterone
A variety of biophysical manifestations where a person’s genome or sexual anatomy do not fit the typical definitions of male or female
A subset of transgender people who pursue medical interventions to change their sex characteristics so that they match their gender identity
A person whose birth sex aligns with their gender identity (e.g., male and man, or female and woman)
A person whose sex assigned at birth does not align with their gender identity; many gender identities fall under the umbrella term of transgender
A person who has multiple genders (e.g., man and woman, bigender, and pangender), no gender (e.g., agender and genderfree), or movement between genders (e.g., genderfluid)
A person whose gender identity is connected to maleness and/or masculinity.
A person whose gender identity is connected to femaleness and/or femininity
Sexual Orientation Identity
A person who is sexually attracted to people of the opposite sex or gender
A person who is sexually attracted to people of the same sex or gender
A female or woman who is sexually attracted to other females or women
A person who is sexually attracted to males and females or men and women
A person who is sexually attracted to people of multiple sexes or genders
Pansexual or Omnisexual
A person who is sexually attracted to people of all sexes or genders
A person with a lack or low level of sexual attraction to anyone
A person who is uncertain who they are sexually attracted to
An umbrella term for people of diverse sexualities who are not heterosexual; an alternative identity to the traditional non-heterosexual identities such as gay, lesbian, or bisexual
A person who is sexually attracted to males, men, and/or masculine people
A person who is sexually attracted to females, women, and/or feminine people
A person who is sexually attracted to people who are transgender or genderqueer
Data about variation in sexual orientation is often limited because questions and response options are constructed with an assumption of sex and gender as binary (i.e., male or female and man or woman). In reality, sex and gender entail diverse manifestations. Nationally representative U.S. data on the three dimensions of sexual orientation will be presented next. These data are from the 2011–2013 National Survey of Family Growth and include adults aged 18 to 44.
Sexual attraction. Among women, 81% were attracted only to the opposite sex, 12.9% were mostly attracted to the opposite sex, 3.2% were equally attracted to both sexes, 1.6% were mostly or only attracted to the same sex, and 1.2% were not sure (Copen, Chandra, & Febo-Vazquez, 2016). Among men, 92.1% were attracted only to the opposite sex, 4.1% were mostly attracted to the opposite sex, 0.9% were equally attracted to both sexes, 2.3% were mostly or only attracted to the same sex, and 0.7% were not sure.
Sexual behavior. In terms of behavior, 95.3% of women and 93.5% of men had engaged in opposite-sex sexual behavior (Copen et al., 2016). On the other hand, 17.4% of women and 6.2% of men had engaged in same-sex sexual behavior.
Sexual orientation identity. Among women, 92.3% identified as heterosexual, 1.3% identified as gay/lesbian, 5.5% identified as bisexual, and 0.9% did not respond or did not know (Copen et al., 2016). Among men, 95.1% identified as heterosexual, 1.9% identified as gay, 2% identified as bisexual, and 1% did not respond or did not know.
Sexual orientation identity has often been thought to exist as a trinary where a person is heterosexual, bisexual, or homosexual; however, this classification ignores and oversimplifies the realities of peoples’ sexual experiences. Given that these identities are socially constructed, new terms have come into use while others have fallen out of use. For example, fewer people self-identify as homosexual in contemporary U.S. society; individuals are more likely to use the terms gay or lesbian. In addition, the term same-gender-loving is often used in the African American community instead of homosexual, gay, or lesbian. Other recent identity terms include those that are non-monosexual; the terms polysexual, pansexual, and omnisexual have come into use, perhaps due to understandings that there are multiple sexes and genders. The term mostly heterosexual is also being used more and may be fitting for those who feel that they are somewhere between feeling heterosexual and bisexual. Asexual is another overlooked, yet evident, sexual orientation identity for people who do not feel strongly attracted to anyone. Historically, queer was often used as a derogatory term but has been reclaimed in the 1990s and 21st century. Individuals may self-identify as queer, and queer is often used as an umbrella term to refer to the diverse array of non-heterosexual identities. Queer may be preferred over acronyms such as LGBT because many identities can fall under the queer umbrella, and it avoids the “alphabet soup” problem of an ever-changing acronym. Sexual minorities is also an umbrella term used to refer to various non-heterosexual identities; however, it has a subordinate connotation because a group of people are being defined in relation to heterosexuals who are the majority group.
In addition, many sexual orientation identities may feel problematic for people who are transgender, genderqueer, or intersex. For example, a lesbian is typically understood as a female or woman who is attracted to other females or women. Thus, the identity is anchored based on the sex or gender of the person with the desire. Some people who are transgender, genderqueer, or intersex may feel that they are neither male nor female or neither a man nor woman. Thus, other terms have come into usage that do not require a person’s sex or gender as an anchor for their attraction: androsexual, gynesexual, and skoliosexual. These terms only relate to the sex or gender of the person or people who are the focus of desire. Finally, those who feel uncertain about their sexual orientation may identify as questioning. Indeed, there is much diversity when it comes to sexuality. Sexual orientation identities are often mutually exclusive social identity categories that may seem limiting when juxtaposed with the unique and sometimes changing experiences and diversity of peoples’ sexual attractions and behaviors. It is likely that new sexual orientation identities will come into usage to better describe individuals’ unique sexual experiences and also provide for group affiliation based on commonalities.
Causes of Sexual Orientation
A combination of genetic, hormonal, and environmental factors is thought to shape a person’s sexual orientation. The etiology of heterosexuality is almost never questioned because it ensures reproduction and the survival of our species. On the other hand, the etiology of homosexuality has been the focus of sociopolitical debate and empirical inquiry. Existing evidence from twin and genetic studies shows that a person’s genes contributes to their sexual orientation. Studies of monozygotic or nearly genetically identical twins show concordance rates of 30% to 75% (Alanko et al., 2009; Bailey, Dunne, & Martin, 2000; Bailey & Benishay, 1993; Bailey & Pillard, 1991; Bailey & Pillard, 1995; Bailey, Pillard, Neale, & Agyei, 1993; Boomsma, Busjahn, & Peltonen, 2002; Dawood, Bailey, & Martin, 2009; Johnson, Turkheimer, Gottesman, & Bouchard, 2009; Kendler, Thornton, Gilman, & Kessler, 2000; Kirk, Bailey, Dunne, & Martin, 2000; Whitam & Diamond, 1986; Whitam, Diamond, & Martin, 1993). In other words, both twins were either heterosexual or homosexual up to 75% of the time. This finding was also evidenced when twins grew up in different families (Eckert, Bouchard, Bohlen, & Heston, 1986; Whitam et al., 1993). If sexual orientation was completely determined by genes, the concordance rate for monozygotic twins would be 100%. In terms of genetic scan studies, although findings from one study indicated the possibility of a “gay gene” (Hamer, Hu, Magnuson, Hu, & Pattattucci, 1993), these findings have not been replicated completely; however, subsequent research does indicate that multiple genes are involved in the heritability of same-sex attraction (Hu et al., 1995; Jannini, Burri, Jern, & Novelli, 2015; Mustanski et al., 2005; Rice, Anderson, Risch, & Ebers, 1999; Sanders et al., 2015).
There is also evidence that hormonal fluctuations in utero may interact with genes and influence a person’s sexual orientation. For example, researchers found that girls who were exposed to high levels of androgens in utero were more likely to be same-sex oriented (Dittmann, Kappes, & Kappes, 1992; Hines, Brook, & Conway, 2004; Meyer-Bahlburg, Dolezal, Baker, & New, 2008; Zucker et al., 1996). In terms of men, research shows that gay men have generally more older brothers than heterosexual men (Blanchard, 2001, 2004; Blanchard & Bogaert, 1996, 2004; Blanchard & Ellis, 2001; Bogaert, 2003, 2006; Cantor, Blanchard, Paterson, & Bogaert, 2002; Schwartz, Kim, Kolundzija, Rieger, & Sanders, 2010). The likelihood that a male will be same-sex oriented increases with each older brother he has. This fraternal birth order (or “older brother effect”) is thought to result from an in-utero maternal immune response that stems from having several male pregnancies.
Theories about childhood socio-emotional experiences with parents and sexual orientation have also been put forth. These assertions include that having a dominant or possessive mother and a distant or absent father contributes to homosexuality among men, and that having a harsh or distant mother and a discordant relationship with one’s father contributes to female homosexuality. However, there is a lack of evidence for such claims, and existing research discredits these family upbringing theories (Beckstead, 2012; Isay, 2009; Peplau & Garnets, 2000; Rosario & Schrimshaw, 2014). Although the family environment does influence the way a person’s sexuality is expressed, a causal relationship between parent-child relationships and sexual orientation has not been evidenced.
Research shows that 95% of gay men and 84% of gay/lesbian women felt that they had little to no choice regarding their sexual orientation (Herek, Norton, Allen, & Sims, 2010). Biological factors play a major role in determining a person’s sexual attractions. However, societal and cultural factors shape how individuals enact or express their sexual desires in terms of sexual behaviors, relationships, and identities. In many societies and cultures, there is great pressure toward heterosexuality and stigma attached to all other sexualities, which can curb the sexual expression of individuals.
Sexual Orientation and Human Development
Sexual development is an aspect of human development. Puberty begins for most people between the ages of nine and 12 and involves many changes: biophysical maturing of the body, self-consciousness about one’s body, and the advent of sexual desires. Sexual activity is rare during this period—only 2% of adolescents have had sex by age 12 (Finer & Philbin, 2013). However, masturbation becomes more common during this time, and adolescents may engage in kissing or dating. Sexually playful behavior may also occur during childhood and early adolescence: this may involve showing one’s genitals to a friend, looking at others’ genitals, and even touching a friends genitals. However, this is not necessarily related to sexual orientation and is typically driven by curiosity (de Graff & Rademakers, 2006). Sexuality often flourishes during the teenage years; interest and engagement in sexual activity advances during this time (Hall & Rounds, 2013). By age 19, over 70% of adolescents have had sex (Finer & Philbin, 2013). Strong sexual feelings are often accompanied by strong romantic feelings associated with initial romantic interests and relationships. Sexuality continues to play a strong role in people’s personal lives and relationships through adulthood and into older adulthood.
Sexual orientation development among queer people has been a focus of study, perhaps because it is viewed, treated, and may manifest differently than the development of the heterosexual majority. Research on sexual milestones among queer people shows parallels with adolescents in general (e.g., emergence of sexual desire and behavior), as well as different developmental tasks and pathways (e.g., coming out to oneself and others). Table 2 shows empirical findings related to sexual milestones among queer people.
Table 2. Sexual Milestones in the Development of Lesbian, Gay, and Bisexual People
Mean Age (SD)
First awareness of same-sex sexual attraction
Calzo, Antonucci, Mays, and Cochran (2011); D’Augelli (2002); D'Augelli, Grossman, and Starks (2008); D’Augelli and Hershberger (1993); D’Augelli, Hershberger, and Pilkington (1998); Diamond (1998); Drasin et al. (2008); Dubé and Savin-Williams (1999); Fisher (2012); Floyd and Bakeman (2006); Floyd and Stein (2002); Grossman, Foss, and D’Augelli (2014); Katz-Wise et al. (2017); Maguen, Floyd, Bakeman, and Armistead (2002); Martos, Nezhad, and Meyer (2015); Pew Research Center (2013); Rosario et al. (1996); Savin-Williams (1995); Savin-Williams and Diamond (2000)
First same-sex sexual activity
Calzo et al. (2011); D’Augelli and Hershberger (1993); Diamond (1998); Dubé and Savin-Williams (1999); Floyd and Stein (2002); Grov, Bimbi, Nanín, and Parsons (2006); Katz-Wise et al. (2017); Maguen et al. (2002); Rosario et al. (1996); Savin-Williams (1995); Savin-Williams and Diamond (2000)
Self-identifying as lesbian, gay, or bisexual
Calzo et al. (2011); D’Augelli (2002); D'Augelli et al. (2008); D'Augelli and Hershberger (1993); D’Augelli et al. (1998); Diamond (1998); Dubé and Savin-Williams (1999); Grossman et al. (2014); Grov et al. (2006); Herek, Norton, Allen, and Sims (2010); Katz-Wise et al. (2017); Martos et al. (2015); Parks and Hughes (2007); Pew Research Center (2013); Rosario et al. (1996); Savin-Williams and Diamond (2000)
First same-sex relationship
Initially coming out to someone else as lesbian, gay, or bisexual
Calzo et al. (2011); D’Augelli (2002); D’Augelli et al. (2008); D’Augelli and Hershberger (1993); D’Augelli et al. (1998); Drasin et al. (2008); Dubé and Savin-Williams (1999); Fisher (2012); Floyd and Bakeman (2006); Floyd and Stein (2002); Grossman et al. (2014); Grov et al. (2006); Herek et al. (2010); Maguen et al. (2002); Martos et al. (2015); Parks and Hughes (2007); Pew Research Center (2013); Savin-Williams and Diamond (2000)
Sexual orientation identity development is a particularly important developmental trajectory for queer people. Many theoretical models of identity development for queer people have been formulated with varying levels of empirical support (Eliason & Schope, 2007). These are primarily sequential linear stage models, which can be useful for service providers in terms of understanding particular issues that clients may be facing and responding with developmentally appropriate interventions. However, these models may oversimplify the complex realities of queer clients and ignore diversity in sexual trajectories. Nonetheless, Eliason and Schope (2007) identified several relevant themes among the models:
• Differentness: Many queer people report feeling different from the norm during childhood and/or adolescence.
• Confusion: Growing up and being socialized in a culture with compulsory heterosexuality can lead to feelings of confusion when non-heterosexual feelings emerge.
• Exploration: Feeling confused may lead to sexual exploration with oneself and with others to resolve any sexual dissonance and gain understanding about one’s sexuality.
• Disclosure: Disclosing information about one’s sexuality to others is on ongoing process, which includes decisions about if, when, and how to come out to whom or in what settings.
• Labeling: There is often pressure to adopt a particular sexual orientation identity that best fits one’s sexual feelings and behaviors; labels may feel restrictive or exclusive, or they may bring a sense of identity coherence.
• Cultural Immersion: Individuals may engage and deepen ties with the queer community and queer culture.
• Distrust of the Oppressor: Queer people often develop a deeper awareness about heterosexist oppression and may feel anger, distrust, disappointment, or rejection toward people who perpetuate oppression or leave systems of oppression unchallenged.
• Degree of Integration: Sexual orientation is just one of many identities each person has; integrating one’s sexual orientation identity with one’s other identities and throughout one’s life can lead to a balanced and holistic sense of self, but particular identities may come to the forefront at different times depending on life circumstances.
• Internalized Oppression: Given that queer people grow up and are socialized in a culture that is generally heterosexist, it is perhaps unavoidable to internalize negative societal views about queer sexualities, which can negatively impact how one views oneself and the queer community.
• Managing Stigma: Negative views about queer people permeate many societies and queer individuals will confront this stigma within their families, neighborhoods, schools, workplaces, religious communities, governmental systems, and other social organizations and institutions.
• Identity Transformation: Change in sexuality occurs for many people over the life course, which entails adjustment issues for the individual and their social relationships.
• Authenticity: For many queer people, the sexual orientation identity development process involves moving from shame, hiding, secrecy, and denial to acceptance, openness, and authenticity.
Prejudice and Discrimination Based on Sexual Orientation
Many groups are socially stigmatized, which involves an overall negative view of people who possess a certain characteristic or are a member of a particular group. In many societies, queer sexualities and people are stigmatized (Herek, 2015). This sexual stigma fuels the social system of oppression related to sexual orientation known as heterosexism. Heterosexism refers to attitudes, beliefs, actions, institutional structures or practices, and policies that advantage heterosexuality and disadvantage queer desires, behaviors, identities, relationships, individuals, and communities. Homophobia refers to the negative attitudes of individuals toward queer people. Thus, homophobia is one part of heterosexism. Indeed, heterosexism exists on several levels in society.
At the individual level, heterosexism can be internalized among queer people and heterosexual people. Internalized heterosexism involves negative attitudes and beliefs about queer sexualities, people, and communities (e.g., queerness is unnatural, deviant, abnormal, immoral, and unhealthy). Data from the General Social Survey show that about half (49%) of respondents felt that same-sex sexual relations were wrong to some extent (National Opinion Research Center, 2014). Attitudes and beliefs often find expression in behavior. A person’s actions represent another element of individual heterosexism. A nationally representative U.S. survey demonstrated that 58% of queer people had been subjected to slurs or jokes, 30% had been threatened or physically attacked, 23% received poor service at a business, and 39% were rejected by a friend or family member because of their identity (Pew Research Center, 2013). Heterosexist actions may also be subtle or unintentional (e.g., microaggressions) and indirect (e.g., passing on a rumor that someone is queer).
Heterosexism is also institutionalized, which involves laws and policies, organizational practices, and institutional systems that disadvantage queer people. This form of heterosexism can be found in many social institutions, including schools, neighborhoods, workplaces, service settings, religious communities, and mass media. In secondary schools, nearly 70% of queer students indicated that queer history, people, and events were excluded from class lessons; 23% of students reported that they were prevented from wearing clothing regarding queer issues (e.g., rainbow flag T-shirt), and 18% were prevented from attending a school dance with a same-gender date (Kosciw et al., 2014). In terms of laws, queer people are still not legally protected from housing discrimination or employment discrimination throughout the United States despite evidence that they are disproportionately affected (Friedman et al., 2013; Sears & Mallory, 2011). There is also evidence of problematic attitudes (Dorsen, 2012; Hall, Kresica, & McDougald, 2014; Sabin, Riskind, & Nosek, 2015) and hostile or insensitive actions of helping professionals toward queer clients/patients (Eliason & Schope, 2001; Hayman, Wilkes, Halcomb, & Jackson, 2013; Scherzer, 2000). This may stem from health and human service professional programs failing to adequately prepare students to provide sensitive and effective services to queer clients/patients. For example, 70% of medical school deans rated the quality of their schools’ coverage of queer-related content as fair or poor (Obedin-Maliver et al., 2011). Further, 41% of social work programs did not adequately prepare students to provide competent services to queer people (Martin et al., 2009). In addition, many of the largest religious organizations in the United States officially oppose same-sex marriage (e.g., American Baptist Churches, Assemblies of God, Church of Jesus Christ of Latter-Day Saints, National Baptist Convention, Orthodox Jewish Movement, Roman Catholic Church, Southern Baptist Convention, and United Methodist Church; Masci & Lipka, 2015). A national U.S. study found that 29% of queer people said they were made to feel unwelcome at a place of worship (Pew Research Center, 2013). In terms of mass media, queer people and issues are often excluded in mainstream outlets or are represented negatively, stereotypically, or superficially (Fisher, Hill, Grube, & Gruber, 2007; Gross, 2001; Raley & Lucas, 2006).
The National Association of Social Workers (NASW, 2008) code of ethics states that “social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of . . . sexual orientation.” The code further states that “social workers should act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class on the basis of . . . sexual orientation.” Thus, social workers are called to not only abstain from engaging in discrimination based on sexual orientation but also to actively challenge and deconstruct the system of oppression known as heterosexism.
Sexual Orientation Change Efforts
There is a history of medical and mental health professionals pathologizing queer sexualities and using castration, electroconvulsive shock therapy, hormonal treatment, lobotomies, and psychiatric institutionalization to “treat” or “cure” people who exhibited non-heterosexuality (Herek, 2010; Silverstein, 1996). Contemporary sexual orientation change efforts (SOCE) include reparative therapy, conversion therapy, ex-gay therapy, and transformational religious ministries. Practitioners have used an array of techniques to try and change clients’ sexual orientations (American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation, 2009). For example, aversive conditioning has been used, which involves the induction of nausea, vomiting, or paralysis while showing clients homoerotic images. Other aversive pairings included electric shocks and snapping oneself with an elastic band on the wrist. Other techniques included cognitive reframing of homoerotic desires and redirecting thoughts, heterosexual affection training with reinforcement, and teaching heterosexual dating skills.
Findings from a comprehensive report that reviewed 83 published studies showed that any completed research supporting SOCE was limited and insufficient and that SOCE were often harmful to clients (American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation, 2009). Negative mental health outcomes among clients who underwent SOCE include depression, anxiety, suicidal ideation, psychosomatic symptoms, alcohol abuse, anger, confusion, grief, disappointment, guilt, hopelessness, self-hatred, decreased self-esteem, feeling dehumanized, feeling untrue to oneself, self-blame, sense of having wasted time and resources, and feeling angry and betrayed by the provider (American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation, 2009). SOCE among clients are also associated with interpersonal problems including loss of sexual feeling, problems with emotional and sexual intimacy with partners, increase in high-risk sexual behaviors, loss of queer friends and potential romantic partners, decreased authenticity with others, deterioration in relationships with family, loss of social support, loss of faith, social isolation, and hostility and blame toward parents (American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation, 2009).
In the 21st century all of the nation’s leading medical and mental health professional associations have categorically rejected SOCE, including the NASW. “NASW condemns the use of SOCE or so-called reparative therapy by any person identifying as a social worker or any agency that identifies as providing social work services” (NASW, 2014). Social workers should abstain from involvement in SOCE directly as practitioners, as well as indirectly by not referring clients to other practitioners or programs that engage in SOCE.
Measuring and Assessing Sexual Orientation
Asking questions about sexual orientation for the purposes of understanding clients or collecting data from research participants is a sensitive matter but should not be avoided. Questions about race/ethnicity, sex/gender, and age are routinely asked by service providers and researchers, yet inquiries about sexual orientation are often not made. Intake forms, surveys, and questionnaires should include one or more questions about sexual orientation. Table 3 shows some examples of questions that could be used to assess or measure sexual orientation. The selection of questions will depend on the nature of one’s service setting or one’s research focus. Fixed-choice questions are commonly used and have advantages, such as less respondent burden and efficient classification for researchers or evaluators. However, typical fixed-choice questions do not take into account the diversity of sexual orientation, and limited response options may alienate respondents with less common sexual orientation identities as well as people who are transgender, genderqueer, or intersex. Open-ended questions allow for inclusivity, and respondents can precisely describe their orientation in their own words. However, this does entail more respondent burden and challenges for classifying respondents into groups. Table 4 shows questions about characteristics related to sexual orientation that could also be included on intake forms, surveys, and questionnaires.
Table 3. Questions for Measuring or Assessing Sexual Orientation
Primarily Open-Ended Questions
Sexual orientation identity
Do you consider yourself to be:
Heterosexual or straight
Gay or lesbian
What is your sexual orientation identity? ___________________
Who have you had sex with?
Both men and women
I have not had sex
What types of sexual activities have you engaged in? Check all that apply.
I have not had sex
People are different in their sexual attraction to other people. Which best describes your feelings?
Only attracted to females
Mostly attracted to females
Equally attracted to females and males
Mostly attracted to males
Only attracted to males
People can be sexually attracted to people of one or more genders. What gender(s) are you attracted to? _________________________
Table 4. Questions for Measuring or Assessing Dimensions Related to Sexual Orientation
What was your sex designated at birth?
Other (please specify): _______________
What is your gender identity (e.g., man, woman, transgender, transman, transwoman, genderqueer, two-spirit, etc.)? ________________
Are you currently in a romantic or sexual relationship?
If “yes,” what is the gender of your romantic/sexual partner?
Concern about sexuality
Do you have any concerns related to your sexuality?
Intersectionality: Sexual Orientation and Other Identities
A person’s sexual orientation identity may intersect with other identities, which entails layers of oppression and/or privilege for any given individual. For example, there may be a compounding effect of oppression for individuals who have multiple socially disadvantaged identities (e.g., a queer woman of color). Alternatively, there may be a buffering effect for those who have a combination of disadvantaged and privileged identities (e.g., a queer white male). Indeed, there is much heterogeneity in the queer community, although there are universal experiences, such as coming out and facing heterosexist oppression. Both researchers and service providers should consider the multitude of identities (e.g., age, race/ethnicity, immigrant/citizenship status, socioeconomic status, sex, gender, sexual orientation, ability/disability status, and religious/spiritual/moral orientation) and their associated social systems of privilege and oppression (e.g., ageism, racism, nativism, classism, sexism, cisgenderism, heterosexism, ableism, and religism), which shape the biopsychosocial circumstances that imbue the lives of individuals and communities.
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