IN MY TRAINING to become a primary care physician, I was taught that the best way to elicit a patient’s sexual health history was with a single question: “Do you have sex with men, women, or both?” The remarkably obtuse assumption that a patient would immediately open up to their doctor in this way boggled my mind.
More importantly, this simplistic approach to sex, gender, gender identity, sexual attraction, behavior, and identity pervades the medical community’s perspective of sexual and gender minority (SGM) individuals. Through such questions, binary assumptions are reinforced: male versus female, hetero- versus homosexual versus bisexual. In this respect, medicine today falls short of the realities of people’s lived experiences and the myriad ways in which behavior and sexual identity intersect and affect people’s health and well-being (Streed and Makadon, 2017).
Boxes to Check
What my colleagues and I are addressing in our research and practice are what can be seen as alternative sexualities that go beyond the standard monosexualities of homo- and heterosexual, i.e., the romantic and/or sexual attraction to one sex or gender. These alternative categories can include behaviors, identities, and communities that stand in contrast to, or even in opposition to, socially and culturally dominant sexual orientations. What follows is a partial list of sexualities that we have encountered that fall outside the monosexual paradigm of “gay” and “straight.”
Selected Alternative Sexualities
Androsexual: Being primarily attracted—sexually, aesthetically, and/or romantically—to masculinity.
Asexual: Not experiencing sexual attraction to any sex object. Note this is distinct from celibacy, which is a conscious choice, while asexuality is an intrinsic aspect of a person.
Bisexual: Able to experience sexual and romantic attraction to people of one’s own gender as well as toward another gender.
Demisexual: On the asexual spectrum but tending to experience some sexual attraction in certain situations, such as after one has formed a strong emotional or romantic connection with a partner.
Gynesexual: Being primarily sexually, aesthetically, and/or romantically attracted to femininity.
Pansexual: Tending to experience sexual or romantic attraction to members of all gender and identity expressions. Although similar to bisexual, the term “pansexual” is preferred by some because it doesn’t reinforce the gender binary inherent in the term “bisexual.”
Skoliosexual: Being primarily attracted to genderqueer, transgender, and/or non-binary people.
Of note, researchers and clinicians are encouraged to use the recommended terminology of “homosexual” and “heterosexual” only as adjectives for behaviors, not as nouns to signal identity. A person’s sexual history, behaviors, and feelings may not match their public sexual identity. For example, a cisgender or transgender man who identifies as straight may sometimes have sex with other men, while a cisgender or transgender woman who identifies as a lesbian may have male sex partners at some point in her life. Medical professionals and public health researchers should therefore recognize that self-identifying labels, while important, are not the same as sexual histories, practices, and feelings.
Identifying Nonstandard Sexualities
A major challenge in contemporary research on any sexuality beyond dominant ones (e.g., straight, gay/lesbian) is finding the most inclusive approach to identifying and disaggregating respondents for meaningful comparisons. Large-scale health surveillance instruments have been slowly adding questions about sexual identities, but these are quite diverse, and it is challenging to make comparisons across studies when the response options are different. More than 100 different methods of measuring gender and sexual identities have been identified.
Efforts have been made to more accurately collect data that better identify alternative sexualities. Often these efforts have been informed by the very people who have been previously overlooked. PRIDEnet is a patient-powered research network—part of the Patient-Centered Outcomes Research Institute (pcori)—made up of sexual and gender minority (SGM) people, including members of the lesbian, gay, bisexual, transgender, and queer communities. PRIDEnet was created to help SGM people participate in the clinical research process from beginning to end, from participant advisory councils and focus group testing of questions to community dissemination of research findings. Its participants include more than 14,000 SGM people who participate in the Pride Study by contributing data and participating in its forum.
Within its annual survey of SGM health, PRIDEnet uses an expanded set of options for participant sexual orientation. Through participant feedback, this question provides opportunities to identify multiple sexual orientations (“Check all that apply”), as well as the sharing of unspecified sexualities (“Another sexual orientation”) as write-in options (see Lunn et al., 2019). PCORI’s PRIDEnet Survey in its current form provides the following question and response options:
What is your current sexual orientation? (Check all that apply.)
ο Asexual
ο Bisexual
ο Gay
ο Lesbian
ο Pansexual
ο Queer
ο Questioning
ο Same-gender loving
ο Straight / Heterosexual
ο Another sexual orientation (please specify)
In our own work exploring alternative sexualities, Mickey Eliason and I have noted that gender and sexual identities are complex and multi-faceted concepts. Despite researchers insisting for decades that sex, gender, and sexual identity are independent variables, they are instead messy, overlapping, and interdependent concepts whose meanings evolve over time. The terms that individuals use to label themselves differ according to context and change over the course of their lives, making measurement quite difficult.
To get at this problem, Eliason and I used a two-part question regarding sexual orientation, which allowed for a more nuanced examination of the intersections of gender and sexual identity (Eliason and Streed, 2017). What this technique allowed us to reveal was that individuals who identify as transgender and/or gender diverse were the most likely to select “something else” when disclosing their sexual identity. These respondents tended to be younger, reflecting that this category of “something else” may capture relatively recent changes in perceptions of sexual and gender identities that depart from traditional binary positions.
The two-part question related to sexual orientation, and the options provided, are as follows:
Which of the following best represents how you think of yourself?
(1) lesbian or gay
(2) straight, that is, not lesbian or gay
(3) bisexual
(4) something else
(5) I don’t know the answer
If you answered something else, what do you mean by something else?
(1) You are not straight, but identify with another label such as queer, trisexual, omnisexual, or pansexual;
(2) You are transgender, transsexual, or gender variant
(3) You have not figured out or are in the process of figuring out your sexuality
(4) You do not think of yourself as having sexuality
(5) You do not use labels to identify yourself
(6) You mean something else
Of the eighteen percent reporting their sexual identity as “something else” on the first part of the question, one participant chose the option “You have not figured out … your sexuality,” and none chose “You don’t think of yourself as having sexuality.” The most common response was “You mean something else,” at 57 percent, followed by “You are not straight, but identify with another label,” at 36 percent. The response “You don’t use labels” garnered five percent.
When exploring studies using this two-part question, the findings of the National Health Interview Survey of 2013 (Dahlhamer, et al., 2014) reported that only 0.2 percent of the general population indicated “something else” on the first question, whereas a study of older lesbian/bisexual women (Eliason, et al., 2016) found that seven percent used “something else.” Again, it is noteworthy that transgender and gender diverse individuals accounted for the majority of those who chose to report their sexual identity as “something else.” This raises the question of what they really meant by this response. It appears that we are still not providing inclusive response options for sexual identity questions, and that sexual identities are more complicated that anyone is willing to admit in survey measures. Furthermore, it is likely that federal and other surveys do not reflect terms used by communities of color (e.g., stud, two spirit, same-gender loving), not to mention regional and generational differences in terminology.
The Future of Diversity
What this research suggests is that we do not have a handle on alternative sexualities, i.e., those that fall outside of the standard categories, in the medical field or in public health research. Respondents who answer “something else” pose challenges to analysis and interpretation of data, but should not be discarded or overlooked. Instead, they may represent a subset of the community that views sexuality and gender as fluid and dynamic concepts, not to be defined by a single label.
More discussion about the most inclusive ways to measure sex, gender, and sexual identity in health studies is certainly warranted. Until we have measures that can distinguish among the subtle subsets of the SGM population, we cannot identify potential health risks or sociodemographic disparities for these smaller, but significant, subsets of the larger community. Stigma may be even greater for those who choose “something else” as a sexual identity, who may be misunderstood both by people who identify as both gay and as straight, and their needs may be ignored by healthcare institutions that are increasingly addressing gay and lesbian issues.
References
Dahlhamer, J. M., et al. “Sexual orientation in the 2013 national health interview survey: A quality assessment.” Vital Health Statistics 2(169), 2014.
Eliason, M. J., et al. “The ‘Something Else’ of Sexual Orientation: Measuring Sexual Identities of Older Lesbian and Bisexual Women Using National Health Interview Survey Questions.” Women’s Health Issues, 26 Supplement 1, 2016.
Eliason, M. J., and Streed, C. G., Jr. “Choosing ‘Something Else’ as a Sexual Identity: Evaluating Response Options on the National Health Interview Survey.” LGBT Health, 4(5), 2017.
Federal Interagency Working Group on Improving Measurement of Sexual Orientation and Gender Identity in Federal Surveys, 2016.
Lunn, M. R., et al. “A digital health research platform for community engagement, recruitment, and retention of sexual and gender minority adults in a national longitudinal cohort study—The PRIDE Study.” Journal of the American Medical Informatics Association, 26(8-9), 2019.
Mayfield, J., et al. “Beyond Men, Women, or Both: A Comprehensive, LGBTQ-Inclusive, Implicit-Bias-Aware, Standardized-Patient-Based Sexual History Taking Curriculum.” MedEdPORTAL, 13, 2017.
Streed, C. G., Jr., and Makadon, H. J. “Sex and Gender Reporting in Research.” JAMA, 317(9), 2017.
Carl Streed Jr., MD, MPH, is an assistant professor at the Boston University School of Medicine and research lead at the Center for Transgender Medicine and Surgery.
