Healthy Sexuality Cuts a Wide (Sometimes Confusing) Swath

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Last week, a man reached out to me wanting to talk about his attraction to transgender women. He said he had been trying to repress and/or change this attraction for over a decade, to no avail, eventually giving in with pornography and occasional in-person encounters. He told me that he’d looked for support at the local LGBT center, the local trans support center, on several online forums, and even from a therapist—all without meaningful success.

The fact that this man, so desperately searching for affirmation and assistance, is struggling to find that, even in places where one would typically expect to receive it in abundance, tells me that however advanced we think we are in the 21st century, there remains a tremendous amount of confusion, misinformation, and judgment when it comes to gender identity, sexual orientation, and sexual expression.

The actual and simple truth is that healthy sexuality is not a one-size-fits-all proposition, even though many people—including an alarming number of psychotherapists—treat it that way. In an attempt to promote a greater understanding of healthy sexuality, especially healthy sexuality that varies from the “norm” (whatever the “norm” might be), I am posting some basic definitions and information.

Gender Identity

• Gender identity: The degree to which a person self-identifies as male or female (or something in-between). Gender identity can differ from a person’s biological gender at birth, though typically it does not. Gender identity shows up relatively early in life and is fundamentally fixed over the lifespan. Children as young as five will talk about gender identity issues, saying things like, “Everyone thinks I’m a boy, but I don’t feel like a boy.”
• Cisgender: When your birth gender and gender identity match.
• Transgender: When your birth gender and gender identity do not match.
• Intersex: Individuals born with any of several variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals that do not fit the typical definitions for male or female bodies. It is estimated that 1.7 percent of the population are born intersex; many are “assigned” a gender through surgery at birth.
• Gender expression: The degree to which society might identify a person as masculine or feminine (regardless of that person’s biological gender and gender identity). Some people express themselves via a mix of masculine and feminine gender; these individuals are referred to as androgynous, genderfluid, or undifferentiated. Often, it is assumed that feminine or androgynous men are gay and that tomboyish or androgynous women are lesbian. In actuality, gender expression and sexual orientation are unrelated.
• Gender dysphoria: A psychological condition evidenced by a significant, longstanding level of discontent with one’s biological birth sex or the gender roles associated with that sex. You can have gender dysphoria without wanting to change your physical gender. If so, this is a matter of gender expression, not gender identity.

Sexual Orientation

• Sexual orientation: The gender (or genders) to which a person is sexually and romantically attracted. The American Psychiatric and American Psychological Associations both say that sexual orientation exists on a continuum from completely heterosexual to completely homosexual, and the vast majority of people are somewhere in between, living in a gray area of multiple attractions. That said, most (but certainly not all) people self-identify as either heterosexual or homosexual.
• Heterosexual: Attracted to the opposite gender.
• Homosexual: Attracted to the same gender.
• Bisexual: Attracted to both males and females.
• Gynandromorphophilic: Attracted to transgender women.
• Skoliosexual: Attracted to non-binary individuals, including transgender men and women.

Varieties of Sexual Expression

• Solo sex: Masturbation (generally our first and often our most consistent form of sex).
• Partner sex: Typically begins with adolescent experimentation—although sexual abuse, porn, and similar technologies can disrupt that.
• Group sex: Sex with multiple partners at the same time.
• Chemsex: Pairing substance use with sexual behavior.
• Kink: A “non-conformist” sexual interest—whether something someone engages in often, or something they might use once in a while to spice up their sex life.
• Fetish: A deep and abiding (maybe primary) sexual desire focused on an object (like leather or stiletto heels), a ritualized behavior, a body type, or a body part. (A fetish is similar to a kink, but a kink is something you can take or leave, while a fetish is a significant, possibly primary part of your arousal template.)
• Paraphilia: Sexual desires taken to an extreme, resulting in negative consequences. Paraphilias are not considered psychologically problematic unless they cause distress or consequences for the individual.
• Abusive sex: Occurs when you use someone for sexual gratification without regard for the effects on that other person. Overt sexual abuse can be hands-on or verbal. Covert sexual abuse is the surreptitious, indirect, sexualized emotional use/abuse of a child by a parent, stepparent, or any other long-term caregiver.
• Sexual offending: Clinically, sexual offending is defined as non-consensual sexual activity. The legal definition can look much different and will vary depending on the jurisdiction.

It's important to note that psychological gender identity and sexual orientation are relatively fixed along the lifespan. Physical markers of one's sex can be altered with surgery. At the same time, individuals can add to (uncover previously hidden) elements of their arousal template.

But psychological gender identity and a person’s basic sexual orientation cannot be changed, and therapists should never attempt to do such work, as it is likely to be counterproductive (shaming) rather than helpful. The proper therapeutic approach when working with clients who struggle with their gender identity or sexual orientation is to help them understand and accept their thoughts and feelings as a healthy and normal part of who they are—no matter what their family, friends, religion, and society-at-large choose to say.