research paper about gender and sexuality

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• BJPsych Bull
• v.45(5); 2021 Oct

Sex, gender and gender identity: a re-evaluation of the evidence

Lucy griffin.

1 Priory Hospital Bristol, Bristol, UK

Katie Clyde

2 Southern Health NHS Foundation Trust, Hampshire, UK

Richard Byng

3 Faculty of Health, University of Plymouth, UK

Susan Bewley

4 Department of Women & Children's Health, King's College London, UK

Associated Data

For supplementary material accompanying this paper visit http://dx.doi.org/10.1192/bjb.2020.73.

In the past decade there has been a rapid increase in gender diversity, particularly in children and young people, with referrals to specialist gender clinics rising. In this article, the evolving terminology around transgender health is considered and the role of psychiatry is explored now that this condition is no longer classified as a mental illness. The concept of conversion therapy with reference to alternative gender identities is examined critically and with reference to psychiatry's historical relationship with conversion therapy for homosexuality. The authors consider the uncertainties that clinicians face when dealing with something that is no longer a disorder nor a mental condition and yet for which medical interventions are frequently sought and in which mental health comorbidities are common.

In 2018 the Royal College of Psychiatrists (RCPsych) issued a position statement to promote good care when dealing with transgender and gender-diverse people that relates to ‘conversion therapy’. 1 In this article we reappraise the phenomenology of gender identity, contrast ‘treatments’ for homosexuality with those for gender non-conformity, analyse the relationship between gender dysphoria and mental disorders with particular reference to the younger cohort of transgender patients, and ask how psychiatrists can address distress related to gender while upholding the central tenet of ‘first do no harm’.

Homosexuality and conversion therapy

Male homosexuality was outlawed in the UK in 1865 until the Sexual Offences Act 1967 decriminalised sexual acts between men. During that time, homosexuality was shameful, stigmatised and conceptualised as a mental disorder. Psychiatry was instrumental in its treatment, which continued even after the legal change. 2

Attempts to ‘cure’ same-sex desire included psychotherapy, hormone treatment and various behavioural interventions. These interventions are now considered ‘conversion’ or ‘reparative’ therapy. 3 One high-profile failure for such ‘treatments’ was Alan Turing. After being found guilty of gross indecency in 1951, he was prescribed oestrogen, which rendered him impotent and caused gynaecomastia. He died by suicide in 1954. 4

Conversion therapies lost popularity as evidence emerged of their ineffectiveness, 5 coupled with more tolerant social attitudes. Homosexuality was removed from the World Health Organization (WHO) ICD-10 classification in 1992. In 2014, the RCPsych published a position statement explicitly rejecting conversion therapy and supporting a ban. 6 Same-sex orientation is regarded as a normal, acceptable variation of human sexuality.

Enshrined in the Equality Act 2010, lesbians and gay men in the UK now enjoy the same civil rights as heterosexuals in terms of healthcare, marriage and raising of children, and equal employment. Although they enjoy equal status and increased visibility in most Western societies, there remain countries and cultures where same-sex practice is taboo or criminal, and where people still seek treatment.

Beyond sexual orientation

In recent years, increasing links have been forged between lesbian and gay communities and those representing other gender identities. Stonewall describes ‘any person whose gender expression does not conform to conventional ideas of male or female’ as falling under the umbrella term ‘trans’. 7

Definitions have evolved beyond those included in the 1992 ICD-10 under ‘gender identity disorders’, with which psychiatrists might be familiar. 8 Transsexualism was widely understood to mean ‘a desire to live and be accepted as a member of the opposite sex, and an accompanied discomfort of one's anatomic sex’. 8 Underlying mechanisms are poorly understood, although there are similarities and overlaps with both body dysmorphia and body integrity identity disorder. 9 , 10 Sufferers might embark on social and medical intervention to help them ‘pass’ as the opposite sex. Historically, a diagnosis of gender dysphoria would have been required for doctors to intervene in this group. 11

Transgender, however, has become a much broader category ( Fig. 1 ). New terminology reflects a conceptual shift from clinical disorder to personal identity. 12 Crucially, gender dysphoria is no longer integral to the condition. The World Health Organization has renamed ‘gender identity disorder’ as ‘gender incongruence’ and reclassified it as a ‘condition related to sexual health’ rather than retaining it in the chapter pertaining to ‘mental and behavioural disorders’, 13 a somewhat discrepant placement, reflecting a political rather than scientific decision-making process.

A page from The Gender Book 12 (reproduced with permission of www.thegenderbook.com ).

By contrast, DSM-5 has removed ‘gender identity disorder’, renaming it ‘gender dysphoria’. It is possible to meet the criteria for a diagnosis of gender dysphoria within DSM-5 without experiencing body dysphoria relating to primary or secondary sexual characteristics, 14 and the American Psychiatric Association emphasises that ‘not all transgender people suffer from gender dysphoria’. 15

The following is from the 2018 ICD-11: 16

‘Gender incongruence of childhood is characterized by a marked incongruence between an individual's experienced/expressed gender and the assigned sex in prepubertal children. It includes a strong desire to be a different gender than the assigned sex; a strong dislike on the child's part of his or her sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the experienced gender; and make-believe or fantasy play, toys, games or activities and playmates that are typical of the experienced gender rather than the assigned sex.’

Definitions are inadequate in explaining how anyone experiences the gender of the opposite sex. Without further explanation of ‘toys, games or activities’ that are typical of each sex, this is left to parents, teachers and doctors to determine. The inference might be that gender-congruent behaviours have some objective existence and not fulfilling them might indicate a ‘trans’ identity. Children who do not conform to social norms and expectations come to dislike their sexual characteristics: that embodiment of their gender dissonance.

There is a lack of consensus demonstrated as to the exact nature of the condition. Questions remain for psychiatrists regarding whether gender dysphoria is a normal variation of gender expression, a social construct, a medical disease or a mental illness. If merely a natural variation, it becomes difficult to identify the purpose of or justification for medical intervention.

Conversion therapy relating to gender

The RCPsych gives a description within the position statement of ‘treatments for transgender people that aim to suppress or divert their gender identity – i.e. to make them exclusively identify with the sex assigned to them at birth’. 1 Conversion therapy is described as ‘any approach that aims to persuade trans people to accept their sex assigned at birth’. It goes on to include ‘placing barriers [to] medical transition’. Unfortunately, the statement does not define ‘approach’ beyond alluding to psychoanalytic or behavioural talking therapies. Thus, conversion therapy for transgender people appears conflated with that for homosexuality. Furthermore, there is little evidence that it is taking place in the UK. 17 Historically, a diagnosis of gender dysphoria was required before medical intervention; 10 this is a part of standard gatekeeping that is now being criticised as a ‘barrier’ instead of regular safe medical practice. 2 Now, a self-declaration of being ‘trans’ appears to be indication enough for a patient to expect their doctor provide a range of complex medical treatments, with no evidence of dysphoria being required. 18

The position statement 1 could also be read as suggesting that full medical transition is an ultimate goal in gender-diverse patients, rather than considering a range of possible goals, which might include limited interventions or reconciliation with one's own (sexed) body. With regard to conversion therapy in children, the statement does not refer to desistance; evidence suggests that the majority of children left alone reconcile their identity with their biological sex; the feelings of 60–80% of children with a formal diagnosis of gender dysphoria remit during adolescence. 19 – 21

Definitions of sex, gender and gender identity

Gender theorists propose that all people must have a gender identity; it is not waivable. For those people whose internal identity aligns with their sex, the word cisgender and ‘cis’ terminology are used. Those whose identity is wholly that of the opposite sex are described as transgender or ‘trans’. However, there are other identities for those whose internal sense lies somewhere between or outside a neat fit into either gender-binary category. Fluidity and fluctuation in gender identity is also recognised, with categories such as ‘non-binary’, ‘gender-fluid’, ‘genderqueer’, ‘pangender’ and ‘genderfuck’ all recorded by clinicians at the UK's Gender Identity Development Service (GIDS) for under-18-year-olds. 22 The social networking site Tumblr presently describes over 100 different genders. 23 Without a strong male or female identification, ‘agender’ becomes itself another gender identity.

Some consider gender identity to be fixed and absolute, with some neuroscientists asserting that it develops in utero in the second-trimester brain. 24 , 25 However, there is little to no convincing evidence to support fundamental differences between the brains of females and males. 26 If one's ‘internal sense of being a man or a woman’ no longer refers to a ‘man’ or ‘woman’ as defined by biological sex 27 then the definition of gender identity risks becoming circular.

Within current debates, if gender identity becomes uncoupled from both biological sex and gendered socialisation ( Box 1 ), it develops an intangible soul-like quality or ‘essence’. As a pure subjective experience, it may be overwhelming and powerful but is also unverifiable and unfalsifiable. If this identity is held to be a person's innermost core concept of self, then questioning the very existence of gender identity becomes equated with questioning that person's entire sense of being, and consequently risks being considered a threat to the right to exist, or even as a threat to kill. Behaviours such as ‘misgendering’ or ‘dead-naming’ are understood by proponents of gender theory to be destructive, debasing and dehumanising. 28 This might explain why the prevailing discourse has become as sensitive and at times inflammatory as it has.

Sex, gender and gender identity

Humans are sexually dimorphic: there are only two viable gametes and two sexes, whose primary and secondary sexual characteristics determine what role they play in human reproduction. Sex is determined at fertilisation and revealed at birth or, increasingly, in utero . The existence of rare and well-described ‘disorders (differences) of sexual differentiation’ does not negate the fact that sex is binary. The term ‘assigned at birth’ suggests a possibly arbitrary allocation by a health professional, rather than the observed product of sexual reproduction.

Gender describes a social system that varies over time and location and involves shaping of a set of behaviours deemed appropriate for one's sex. It operates at an unconscious level via strong social norms, yet is also rigidly enforced by coercive controls and sometimes violence. 18 The ‘rules’ exist regardless of how individuals feel about them. Gender can thus be perceived as oppressive and potentially painful to all people of both sexes within patriarchal societies, the dominant form of social structure across most, although not all, of the globe. Feminist theory holds that gender operates as a hierarchy, with men occupying the superior position and women the subordinate. As long as this hierarchy exists, all women are harmed to some extent, whether or not they conform to their sex stereotypes. 19

Gender identity

If sex refers to biology, and gender to socialisation and role, then gender identity may be viewed as the psychological aspect. The American Psychological Association defines it as ‘someone's internal sense of being a man or a woman’. 20 Gender identity is thus distinguished from biological sex and gendered socialisations. 21

Nonetheless, notions of gender identity are still contested and raise some ethical questions for professionals working at the interface of physical and mental disorder. Most psychiatrists reject Cartesian dualism, whereby the mind is something imprisoned inside the body, or the ‘ghost in the machine’. 29 How should doctors consider the body? We are born as, and die as, a body; we are our bodies. How can someone be born in the wrong body? Many patients bring a ‘wrong’ or ‘wronged’ body to their doctor; these may be traumatised, wounded, diseased or disliked bodies. How should doctors react when someone informs them that, although they inhabit the body of a man, they are in all other respects female? We must deal with all our patients with compassion but also make safe medical decisions when demonstrable material reality is at odds with a patient's subjectivity.

Children and adolescents

The Gender Identity Development Service (GIDS), Britain's only specialised gender service for children and adolescents and based at the Tavistock Centre, London, has recorded a 25-fold rise in referrals since 2009, most marked in biological girls (‘assigned female at birth’), who make up the majority of referrals presently ( Fig. 2 ). 30

Referral rates to the Gender Identity Development Service at the Tavistock Centre (Tavistock and Portman NHS Trust) in London between 2009 and 2019. 30

Despite gender dysphoria no longer falling within the remit of mental illness in ICD-11, there is a substantial body of evidence of increased levels of mental illness among adults, usually attributed to societal responses to gender non-conformity or ‘minority stress’. 31 De Vries et al measured psychiatric comorbidity among those referred to a child and adolescent gender clinic in The Netherlands and also found increased rates of depression, anxiety and suicidal ideation in this younger group. 32 However, a potentially worrying picture regarding causes and consequences emerges from more recent research in this young, increasingly natal-female population.

Kaltiala-Heino et al examined referrals to an adolescent gender identity clinic in Finland over a 2-year period, finding high rates of mental health problems, social isolation and bullying ( Fig. 3 ). 33 Most bullying pre-dated the onset of gender dysphoria and was unrelated to gender incongruence.

Referrals to an adolescent gender identity clinic in Finland over a 2-year period (from 2011–2013). 33

Similarly, in the UK, Holt et al 34 found that associated difficulties were common in children and adolescents referred to the GIDS in London ( Fig. 4 ). Same-sex attraction was particularly common among natal females, with only 8.5% of those referred to the GIDS describing themselves as primarily attracted to boys. This raises important questions about current societal acceptance of young lesbians even within youth LGBTQ+ culture. It is possible that at least some gender-non-conforming girls come to believe themselves boys or ‘trans masculine non-binary’ as more acceptable or comfortable explanations for same-sex sexual attraction, 35 a kind of ‘internalised homophobia’. Autism spectrum disorders are consistently overrepresented in referred children and adolescents. 36

Referrals to the Gender Identity Development Service at the Tavistock Centre (Tavistock and Portman NHS Trust) in London between 1 January 2012 and 31 December 2012. 34 ASD, autism spectrum disorder.

The RCPsych's position statement acknowledges these elevated rates of mental illness within the transgender population, 1 but appears to attribute them primarily to hostile external responses to those not adhering to gender norms (or sex-specific stereotypes). 37 , 38 A deeper analysis of mental illness and alternative gender identities is not undertaken, and common causal factors and confounders are not explored. This is worrying, as attempts to explore, formulate and treat coexisting mental illness, including that relating to childhood trauma, might then be considered tantamount to ‘conversion therapy’. Although mental illness is overrepresented in the trans population it is important to note that gender non-conformity itself is not a mental illness or disorder. As there is evidence that many psychiatric disorders persist despite positive affirmation and medical transition, it is puzzling why transition would come to be seen as a key goal rather than other outcomes, such as improved quality of life and reduced morbidity. When the phenomena related to identity disorders and the evidence base are uncertain, it might be wiser for the profession to admit the uncertainties. Taking a supportive, exploratory approach with gender-questioning patients should not be considered conversion therapy.

Suicide, self-harm and current controversies

Transgender support groups have emphasised the risk of suicide. After controlling for coexisting mental health problems, studies show an increased risk of suicidal behaviour and self-harm in the transgender population, although underlying causality has not been convincingly demonstrated. 39 Then, expressed in the maxim ‘better a live daughter than a dead son’, parents, teachers and doctors are encouraged to affirm unquestioningly the alternative gender for fear of the implied consequences. There is a danger that poor-quality data are being used to support gender affirmation and transition without the strength of evidence that would normally determine pathways of care. One 20-year Swedish longitudinal cohort study showed persisting high levels of psychiatric morbidity, suicidal acts and completed suicide many years after medical transition. 40 These results are not reassuring and might suggest that more complex intrapsychic conflicts remain, unresolved by living as the opposite sex.

Established risk factors for self-harm and suicidal behaviour appear to be age related (younger trans patients are at higher risk) and include comorbid mental health problems, particularly depression, and a history of sexual abuse. 39 Thus, all new patients of any age warrant thorough assessment and formulation using a biopsychosocial model; the best evidence-informed interventions should be provided. If this is followed by an individual desisting it should not be considered conversion therapy. That term should perhaps be reserved for coercive treatments.

Best psychiatric practice avoids oversimplification of the causes and treatment of suicidal behaviour and self-harm. Preliminary data from a small ‘before and after’ pilot study of the use of puberty blockers at the Tavistock Centre in selected children found a reduction in body image problems in adolescents following a year of puberty suppression. However, positive effects were offset by increases in self-harm and suicidal thoughts. 41 Surprisingly, this unpublished study was deemed a success such that prescribing of puberty blockers was introduced as standard practice and commissioned with scaling up of services. There was no development of alternative psychological approaches, nor were randomised controlled comparisons made.

Evidence suggests that almost 100% of children commencing puberty blockade go on to receive cross-sex hormones. 42 This requires further interrogation to ascertain whether the high figures are due to robust, effective selection and gatekeeping or to a less palatable interpretation that preventing physical and sexual maturation crystallises gender dysphoria as a first step on a cascade of interventions. 43 The GIDS remains under intense scrutiny regarding research criticisms. 44 Although in the early 2000s it was criticised for being too conservative and not offering puberty blockers, there appears to have been a volte-face made in response to external pressure, 45 without the publishing of robust data showing that this intervention is effective and safe.

Puberty blockers are known to affect bone and, possibly, brain development. They put users at risk of developing osteoporosis 46 and are associated with reductions in expected IQ. 47 They are described as ‘buying time’ for adolescents to make up their mind about whether to proceed with transition. Long-term effects are not known, but infertility appears inevitable when cross-sex hormones are introduced shortly after puberty blockers. 48 Loss of sexual maturation will also be associated with lack of adult sexual function, although it is unlikely that a pre-pubertal child can truly understand this side-effect at the time of consent.

Those seeking transition are a vulnerable population who suffer from high levels of suicidality, psychiatric morbidity and associated difficulties. Medical and surgical transition is sought to relieve these psychiatric symptoms. Plausibly, there is an initial reduction in distress following transition, although no controlled trials exist. Therefore, the long-term outcome of medical and surgical transition in terms of mortality and quality of life remains unknown. No long-term comparative studies exist that satisfactorily demonstrate that hormonal and surgical interventions are superior to a biopsychosocial formulation with evidence-based therapy in reducing psychological distress, body dysphoria and underlying mental illness.

Clinical implications

It is unclear what the role of psychiatry is in the assessment and treatment of gender dysphoria, now that it is no longer considered a diagnosable mental illness, and whether there is still a place for a routine psychosocial assessment. It could be argued that patients should be deterred from gender intervention pathways while comorbid mental illness is treated ( Fig. 5 ). Without long-term follow-up data, it is not possible to identify those who might reconcile with their sex and those who might come to deeply regret their medical and/or surgical transition. Moreover, it is not transparent where ultimate and legal responsibility for decision-making lies – with the patient, parents (if the patient is a child), psychologist, endocrinologist, surgeon or psychiatrist.

Are these scenarios examples of good clinical practice or conversion therapy?

Psychiatrists understand that human development is necessary, but not always comfortable. Puberty, although a normal physiological process, is associated with particularly high levels of psychological and bodily discomfort. Psychiatrists’ role is to journey with patients as change is navigated and to provide support through sharing uncertainty and difficult decision-making. But in the current climate, psychiatrists may be unsure whether addressing psychological and social antecedents will lead to accusations of conversion therapy. Attempts to reconcile a sufferer's discomfort with their actual body would be good practice in other conditions involving body image disturbance, such as anorexia nervosa.

The magnitude of any benefits of medical and surgical transition is not clear. Follow-up studies are sparse, and with the new cohort of adolescents, clinicians step even further into the unknown. 49 These young people are not comparable to adult, mainly male-to-female, research participants on whom existing empirical clinical guidelines were based. Doctors are now questioning the wisdom of gender-affirmation treatment of children and young people, citing poor diagnostic certainty and low-quality evidence. 50 A recent review of evidence for the use of gender-affirming hormones for children and adolescents states that these drugs ‘can cause substantial harms, including death’ and concludes ‘the current evidence base does not support informed decision making and safe practice’. 51

Among a plethora of online videos by teenagers proudly displaying their mastectomy scars a worrying increase in detransitioner testimonies can now be found 52 ( Fig. 6 ). These are mainly young women who have rejected their trans identities and are reconciling with their birth sex.

Reasons given for detransitioning in a female detransition and re-identification survey run between 16 and 30 August 2016 and shared through online social networking sites. 52

Feminist concerns

In theory, universal human rights should not pit disadvantaged groups against one another, but in practice, disputes occur. Women's rights activists point to persistent global inequalities, sex discrimination and violence against women and girls. They are concerned that ignoring sex as a reality risks no longer being able to name, measure and ameliorate sex-based harms. Endorsing old sex and gender stereotypes in an attempt to validate young patients may inadvertently shore up outdated notions of how men and women should look and behave. There is no reason to believe that women have an innate love of pink and wearing high heels and find map-reading difficult, any more than men have a natural leaning towards blue and playing football and make excellent leaders.

Inherent in the notion of ‘gender identity’ is that there already exists a specific subjective experience of being a man or a woman. However, there cannot be a significant intrinsic experiential difference between male and female human beings when we cannot know what those differences are. One cannot possibly know how it feels to be anything other than oneself. Medicine may be in danger of reinforcing social norms and reifying a concept that is impossible to define over and above material biological reality. At present, many health, social, educational and legal policies are being adapted to give gender primacy over sex. 53 – 57

Conclusions

Language that confuses or conflates sex and gender identity, while appearing inclusive, might have the unintended consequence of closing down the means to understand complexity and respond appropriately to patients’ emotional and material reality. The medical profession must be compassionate, accept differences and fight for those who are marginalised and discriminated against.

However, viewing transgender as a fixed or stable entity, rather than a state of mind with multiple causative factors, closes down opportunities for doctors and patients to explore the meaning of any discomfort. Being gender non-conforming, or wishing to opt out of gender altogether, is not only not indicative of mental disorder – it is, in many ways, an entirely rational response to present capitalist reliance on rigid gender norms and roles. However, when multiple medical interventions are required on an otherwise healthy body or doctors are expected to deny the concept of sex or the sexed body, the situation becomes less coherent. The notion of conversion therapy for those seeing themselves as transgender relies on another binary – that of ‘cisgender’ and ‘transgender’ – being set, closed, biologically anchored categories without overlap, rather than a more plausible hypothesis that one's gender identity is flexible, informed by one's culture, personality, personal preferences and social milieu.

The push for early bodily modification and hormones by some transgender patients is a cause for concern. New services, modelled on commissioning guidance from NHS England for adults of 17 years and above, will allow for self-referral, preclude psychological formulation or therapeutic intervention as standard practice, and recommend hormonal intervention after two appointments. 58 This will further scale up hormonal and surgical interventions in young patients, who will miss out on pubertal development and necessary mental health treatment in their quest for interventions that may harm and that they may later regret.

In the rapidly moving and politicised debate, psychiatrists look to the RCPsych for guidance. Those providing and interpreting the scanty evidence from published research need to be independent and impartial, using best-quality measures rather than ideology. It is confusing to liken open-minded working with young patients as they figure out who they are to conversion therapy. Holding an empathic neutral middle ground, which might or might not include medical transition, should not be equated with this. Psychiatrists need to feel empowered to explore the meaning of identity with their patients, treat coexisting mental illness and employ a trauma-informed model of care when appropriate.

The General Medical Council's Good Medical Practice demands of clinicians compassion, shared decision-making and safeguarding of young people's open futures. 59 The counterargument to unquestioning gender affirmation is that the process of medical transition may itself prove to be another form of conversion therapy, creating a new cohort of life-long patients dependent on medical services and turning at least some lesbian and gay young people into simulacra of straight members of the opposite sex. Psychiatry sits on this knife-edge: running the risk of being accused of transphobia or, alternatively, remaining silent throughout this uncontrolled experiment. Respectful debate, careful research and measurement of outcomes are always required.

Acknowledgements

We consulted a trans woman and a detransitioner for this article. We thank them for their input.

About the authors

Lucy Griffin , MBBS, BSc, MRCPsych, is a consultant psychiatrist at The Priory Hospital Bristol, UK. Katie Clyde , MBChB, MRCPsych, DGM, is a consultant psychiatrist with Southern Health NHS Foundation Trust, Hampshire, UK. Richard Byng , MB BChir, MRCGP, MPH, PhD, is a general practitioner and Professor of Primary Care Research at the University of Plymouth, UK. Susan Bewley , MD, FRCOG, MA, is Professor (Emeritus) of Obstetrics and Women's Health, Department of Women & Children's Health, King's College London, UK.

Author contributions

L.G.: undertook a search and analysis of the literature, and conceived and wrote the paper. K.C.: undertook a search and analysis of the literature, and contributed to the drafting of the paper. R.B.: participated in the conception and evolution of the analysis, critically reviewing the paper and suggesting amendments incorporated into the final paper. S.B.: participated in the conception and evolution of the analysis, critically reviewing the paper and suggesting amendments incorporated into the final paper.

Declaration of interest

Supplementary material.

• 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

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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

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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).

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Elena María Gallardo-Nieto, Aitor Gómez & Regina Gairal-Casadó

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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.

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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.

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Consent procedures permitted use of verbatim quotations from participants in suitably anonymised form.

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Studying Gender and Sexualities with Qualitative Methods

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• Volume 41 , pages 333–335, ( 2018 )

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Avoid common mistakes on your manuscript.

Sometimes things just happen. In reviewing the manuscripts we had in the queue for the September issue, we realized that beyond any conscious intention half of them had to do with gender and/or sexualities. That is actually not surprising since about a third of the submissions we receive focus on gender and/or sexualities. In fact, we have always had to make sure that at least one of our editorial assistants was a GSS scholar, able to identify and locate viable reviewers.

Qualitative Sociology does not focus on publishing in specific research areas or sociological subfields. So why do we receive so many GSS submissions? We believe it is because qualitative methods lend themselves to studying the building blocks of gender expression and sexual identities—the interactional, the discursive, and the performative—and how these buttress systems of inequalities. Quantitative methods do a great job of detecting and measuring the effects of gender bias and discrimination in employment, education, and other domains of social life. But qualitative methods are particularly suited to unpacking the “how” of gender and sexualities—the layers of practices, discourses, histories, and identities that constitute and are constituted by them.

Gender and sexuality encompass (often binary) sets of categories related to the meanings assigned to assumed reproductive capacities made explicit in the everyday and inscribed into the unconscious, as well as the malleable and fluctuating content of those categories. Focused but open-ended participant observation, qualitative interviewing, and ethnographic readings of documents and archives can show us how people resist, remake or reify these categories, challenging or reproducing the inequalities that structure them. Qualitative methods can reveal the complicated and reciprocal processes through which assumptions about gender and sexuality guide interactions, become embedded in institutions, and differentially affect life chances.

In this issue, Rania Salem shows how the Egyptian middle class reproduces inequality through active constructions and reconstructions of gendered expectations around marriage. Salem shows how “waithood”—the process whereby young people wait to marry because they do not have the education, employment or material well being to form a new household—results not simply from a scarcity of resources, but depends on gendered constructions of the division of labor and consumption practices that provide assurance to a bride’s family that a man will provide for his dependent wife after the wedding. Matrimonial transactions, then, adhere to norms and ritualized situations that signal actors’ dedication to dominant ideals of masculinity and femininity and the unequal roles they will come to occupy within marriage.

In a world in which there have been undeniable formal gains in gender equality, qualitative research can unpack and explain persistent inequalities. Examining the role of women in Italian mafias, Felia Alum and Irene Marchi push back against analyses that suggest that taking on high level positions in an organization—here, the mafia—signals that women have become empowered. They show this only happens at moments of crisis and that, while women gain status in the organization, they effectively do so by default. Wives, mothers and daughters serve as a sort of “reserve army” when men are killed, imprisoned, incapacitated or threatened. They suggest the term exploitation is closer to the mark than emancipation. By decoupling “rising in the ranks” from empowerment, the authors show that increased gender parity does not necessarily signal egalitarian gender relations. Chelsea Wahl and Stephen Ellingson provide a classic portrait of gender discrimination, looking at the contradictory way that the jazz world is simultaneously built upon a culture of meritocracy and gender essentialism. Women musicians may be initially accepted, but they are tested and evaluated in ways that men are not and may require the support of a well-established man in the scene; more often than not, assumptions about what women are physically capable of limits how far they can make it in the industry. When they seek more established roles in the jazz world they are often marginalized or pushed into feminized roles (as singers, for example). They push back by working with the discourse of meritocracy, fighting for established positions in the jazz world.

Alin Frantsman-Spector and Avihu Shoshana show that resistance is not the only response to discrimination and marginalization. They look at the obligatory therapy to which prisoners’ wives are subject in Israel in order to obtain benefits for their children and imprisoned husbands. At first they resist the discourse of “vulnerable femininity” social workers foist upon them. But eventually they adopt an attitude of “strategic passing” in order to get what they need from state representatives. Over time the women learn to navigate social workers’ discourse in order to obtain medical and financial benefits, suggesting that even in submission there is room for agency. However, as the authors show, in acquiescing to a discourse that is not their own to protect and provide for their families, prisoners’ wives are made to engage in the reproduction of symbolic violence and gender (as well as ethnic) inequalities.

Both the Kelly and Gouchanour article as well as the piece by Frantsman-Spector and Shoshana demonstrate other “interactions” well captured by qualitative methods: the interactions between distinct yet interconnected systems of discrimination (class, race, ethnicity, and so on) that produce inequalities within gender categories as well as between them. Kimberly Kelly and Amanda Gochanour reveal how largely white evangelical anti-abortion activists “blackwash” abortion decisions. In trying to convince Black women not to have abortions, they do not seek to address the structural discrimination that puts Black women in the position of having an unwanted pregnancy. Rather, they appeal to racial stereotypes portraying them as abandoned by their communities and duped by abortion providers. Gowri Vijayakumar’s article is instructive in considering how gender expression and sexual identities intersect to produce and impede activism in India. Vijayakumar shows that, while the formation of collective identity plays a crucial role in social movements, constructing a collective identity among sex workers is contingent on various factors, all of which revolve around the ways cis and trans women experience sex as work, including the different constraints they face in openly identifying as sex workers.

These articles vividly demonstrate how qualitative sociology can reveal the stubborn inequalities that still define our world in the 21st century. These inequalities cannot be fully understood without studying in context, the practices, discourses, histories, and identities they are made of.

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Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use

• Shirin Heidari 1 ,
• Thomas F. Babor 2 ,
• Paola De Castro 3 ,
• Sera Tort 4 &
• Mirjam Curno 5  

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An Erratum to this article was published on 24 June 2016

Sex and gender differences are often overlooked in research design, study implementation and scientific reporting, as well as in general science communication. This oversight limits the generalizability of research findings and their applicability to clinical practice, in particular for women but also for men. This article describes the rationale for an international set of guidelines to encourage a more systematic approach to the reporting of sex and gender in research across disciplines.

A panel of 13 experts representing nine countries developed the guidelines through a series of teleconferences, conference presentations and a 2-day workshop. An internet survey of 716 journal editors, scientists and other members of the international publishing community was conducted as well as a literature search on sex and gender policies in scientific publishing.

The Sex and Gender Equity in Research (SAGER) guidelines are a comprehensive procedure for reporting of sex and gender information in study design, data analyses, results and interpretation of findings.

Conclusions

The SAGER guidelines are designed primarily to guide authors in preparing their manuscripts, but they are also useful for editors, as gatekeepers of science, to integrate assessment of sex and gender into all manuscripts as an integral part of the editorial process.

Sex and gender are important determinants of health and well-being. Sex refers to a set of biological attributes in humans and animals that are associated with physical and physiological features including chromosomes, gene expression, hormone function and reproductive/sexual anatomy [ 1 ]. Sex is usually categorized as female or male, although there is variation in the biological attributes that constitute sex and how those attributes are expressed.

Gender refers to the socially constructed roles, behaviours and identities of female, male and gender-diverse people [ 1 ]. It influences how people perceive themselves and each other, how they behave and interact and the distribution of power and resources in society. Gender is usually incorrectly conceptualized as a binary (female/male) factor. In reality, there is a spectrum of gender identities and expressions defining how individuals identify themselves and express their gender. A glossary of terms is provided in Appendix 1 to define the meaning of sex, gender and related terms.

Sex and gender interactions influence health and well-being in a variety of ways. They both impact environmental and occupational risks, risk-taking behaviours, access to health care, health-seeking behaviour, health care utilization, and perceived experience with health care, and thus disease prevalence and treatment outcome. In addition, it is well-known that pharmacokinetics and pharmacodynamics of pharmaceutical agents differ between sexes, resulting in differential adverse event profiles and further impacting treatment outcomes. Thus, sex and gender are critical determinants of health [ 2 ].

Sex and gender bias in the conduct of research

Despite recognition of the importance of sex and gender in most areas of research, important knowledge gaps persist owing to the general orientation of scientific attention to one sex or gender category and because of a misconception that disaggregation of sex does not apply to other living organisms that can be classified by sex [ 3 – 6 ].

The gap in the representation of women in studies on human subjects has been well-documented [ 1 ]. A review of cardiovascular treatment trials included in Cochrane Reviews reveals that only 27 % of the total trial participants in the 258 clinical trials were women [ 7 ]. More importantly, among trials recruiting both men and women, only one third reported a gender-based analysis [ 8 ]. More than 79 % of animal studies published in Pain over a 10-year period included male subjects only, and only 4 % studied sex differences [ 9 ].

The underrepresentation of women in research can result in adverse consequences. Among the ten prescription pharmaceuticals withdrawn from the US market between 1997 and 2001, eight caused greater harm to women than men [ 10 ]. More recently, the US Food and Drug Administration (FDA) issued a safety communication, recommending half a dose of zolpidem for women, due to greater susceptibility to the risks of the drug [ 11 ]. Sex- and gender-based analysis, in all of these cases, would have provided sufficient information to guide dosing and applicability of drugs in men and women prior to approval.

Failure to conduct sex and gender-based analysis occurs in a range of disciplines. In the field of engineering, lack of consideration of differences in the physiology and anatomy of males and females in developing car seats has resulted in higher risk for whiplash injuries among female car occupants compared with men [ 12 , 13 ].

Although the term “gender gap” has most often been applied to women, the benefit that sex- and gender-based analysis has for our understanding of men’s health should also be noted. Despite the increasing representation of male and female subjects in research and reporting of sex-specific and gender-specific data, these examples indicate that existing policies have not been enforced [ 3 ]. Lack of interest in sex and gender differences may not only be harmful but also present missed opportunities for innovation. Understanding the underlying differences and similarities, exploring applicability, uptake and impact of technological innovations and getting deeper insight into cognitive variability will undoubtedly lead to more innovative approaches and better solutions to meet the needs of society.

The role of journal editors and editorial policies

Editors play an important role as gatekeepers of science, including the articulation of an ethical framework that influences the conduct of research. With an ever-increasing volume of information being published, concerns over the quality of publications have lead journal editors, publishers and professional associations to implement detailed guidelines. Ethical review procedures are now universally applied in human and animal research, in part because of journal requirements. The impact of journal policies on compliance to mandates has been clearly demonstrated in such diverse areas as clinical trial registration [ 14 ] and the reporting of systematic reviews after introduction of PRISMA guidelines [ 15 ]. Another illustration is the gradual adoption of the Consolidated Standards of Reporting Trials (CONSORT) statement, which has led to improved reporting of randomized controlled trials [ 16 , 17 ]. Following CONSORT and PRISMA, many other reporting guidelines have been developed, including the ARRIVE guidelines for animal research [ 18 ].

Although policy implementation and enforcement continue to be a critical challenge, journals could play an important role in advancing the quality and transparency of reported data by promoting sex- and gender-specific analysis of research data as a matter of routine. In a 2011 workshop on “Sex-specific reporting of scientific research,” convened by the US Institute of Medicine, a number of key issues were identified that journals and journal editors should address in order to improve gender-sensitive reporting of research [ 3 ], including the appropriateness of sex-specific data analyses and the absence of journal policies recommending sex and gender considerations in research design and reporting.

On the basis of the available evidence, a committee of the US Institute of Medicine in 2010 recommended that the International Committee of Medical Journal Editors (ICMJE) and other editors adopt a guideline that all papers reporting the results of clinical trials analyse data separately for men and women. The ICMJE has since published more robust guidance on sex and gender reporting, recommending that researchers include representative populations in all study types, provide descriptive data for sex and other relevant demographic variables and stratify reporting by sex [ 19 ].

Adequate inclusion of sufficient numbers of men and women (and other sub-populations) in research, along with appropriate analysis and transparent and complete reporting of research data, require a concerted effort among funders, researchers, reviewers and editors [ 20 ]. Although editors typically enter the research process late, after the research has already been concluded and the data analysed, they can still play an important role in ensuring effective, transparent and complete sex and gender reporting.

In recent years, several reviewers of sex and gender issues in scientific research have made recommendations regarding the best ways to address the problems that have been identified. Doull et al. [ 21 , 22 ] proposed that the methodology of systematic reviews and of sex- and gender-based analyses be refined and synchronized to enhance the collection, synthesis and analysis of evidence for decision-making, and they developed an appraisal tool for systematic reviews and adapted it to evaluate primary studies and protocols for new research [ 22 ]. Nowatski and Grant [ 23 ] provided a rationale for gender-based analysis, which is designed to identify the sources and consequences of inequalities between women and men and to develop strategies to address them. The Clinical Orthopedics and Research journal published an editorial on gender and sex in scientific reporting in 2014, including a set of recommendations [ 5 ].

Editorial associations, publishing houses, funding agencies and public interest organizations have also taken an interest in sex and gender issues. The Canadian Institutes of Health Research implemented a requirement in 2010 that all grant applicants respond to mandatory questions about whether their research designs include gender and sex [ 24 ]. Advances made in the inclusion of women as research participants in the USA can be attributed in large part to the actions taken at the NIH in 1993 that stipulated women and minorities should be included in phase 3 clinical trials so that valid analyses of differences in intervention effects could be performed [ 25 ]. More recently, the NIH announced plans to require grant applicants to describe how they will balance of male and female cells and animals in preclinical studies, unless sex-specific inclusion is unwarranted [ 6 ].

Despite a greater recognition of the importance of sex and gender considerations in research and scientific publishing, progress has been slow in some areas of science and further work is needed to build on preceding efforts by journals, journal editors and learned societies. As noted by Nieuwenhoven [ 26 ], vigorous approaches are needed to stimulate scientists to integrate sex and gender aspects into their research. For example, there is no overarching set of recommendations that provides guidelines for better reporting of sex and gender in scientific publications across disciplines. To address this need, the present article describes the development of a set of international guidelines to encourage a more systematic approach to the reporting of sex and gender in research across disciplines.

The European Association of Science Editors (EASE) established a Gender Policy Committee in 2012 and tasked it to develop a set of guidelines for reporting of Sex and Gender Equity in Research (SAGER). A panel of 13 experts (eight females, five males) representing nine countries were selected by the Chairperson of the GPC (Dr. Heidari). Eight members were senior editors for a variety of biomedical journals, and the remaining individuals had expertise on gender research and scientific publishing.

An internet survey of 716 journal editors, scientists and other members of the international publishing community was first conducted to gather information about existing sex and gender policies and opinions about the need for such policies. The survey focused on four policy areas: (1) instructions for authors that require or encourage disaggregation of data by sex or gender when feasible; (2) gender policies concerning the composition of editorial staff and boards; (3) policies that strive for gender balance among peer reviewers and (4) guidelines that ask reviewers to assess manuscripts for inclusion of sex-disaggregated data and gender analysis. The survey targeted four groups: EASE members; members of the International Society of Addiction Journal Editors (ISAJE); a random sample of 100 journals selected from the 8607 names in the Thomson Reuters SCI Expanded database of journals and an open sample in which any concerned individual could complete the survey. In total, 716 respondents took part in the survey, representing 338 unique journals and 114 unique publishing houses.

In addition to the survey, several other methods were used to identify policy options and expert recommendations. First, keyword searches were conducted (e.g. “sex” + “instructions for authors”) to identify journals that had specific policies on sex and gender. In addition, we scanned the websites of surveyed journals that explicitly expressed concerns about sex and gender knowledge gaps in science and the sex and gender reporting policies of peer-reviewed journals already known to the Gender Policy Committee.

Over a 3-year period, the Committee worked through a series of teleconferences, conference presentations and a 2-day workshop to develop its recommendations. Once the draft guidelines were developed, dissenting views were considered at editors’ meetings in Blankenberge, Belgium, and Split, Croatia. In addition, the draft guidelines were circulated to 36 experts in sex and gender research; any comments received were incorporated into the document where relevant.

Survey findings

The average proportion of respondents in each of the four samples who reported having sex and/or gender policies at their journals was 7 %. Respondents from countries where men and women are more equal (lower GII) were more likely to report that these policies are in place.

In the random sample of 100 journals and the EASE and ISAJE groups, a majority (75 %) were unsure or unwilling to introduce sex and gender considerations as requirements in Instructions for Authors. Female respondents were more likely to support sex and gender reporting policies than male respondents. While caution must be exercised in relation to the conclusions drawn, the survey results point to the paucity of sex- and gender-related policies concerning instructions for authors, guidelines for peer-reviewers and gender balance of both editorial boards and peer-reviewers.

Literature review

Our review identified policies developed and used by 62 journals, as well as 25 other sources of published materials in the form of journal articles, editorials, expert committee reports and conference proceedings.

The majority of sex and gender policies and guidelines fell into the Instructions for Authors category, covering a variety of scientific areas (e.g. “animal science,” “health – psychiatry”) and types of research (e.g. animal, human, cell or a combination of the three). In most cases, the instructions merely advise authors to report results for males and females separately, if appropriate.

Several journals [ 20 , 27 , 5 ] have used their editorial pages to announce the adoption of new policies or to promote the need for greater awareness of sex and gender issues. For example, the editors of Clinical Orthopaedic and Related Research published an editorial [ 5 ] recommending that researchers seeking publication in the journal use the following guidelines: (1) design studies that are sufficiently powered to answer research questions both for males and females if the health condition being studied occurs in all sexes and genders; (2) provide sex- and/or gender-specific data where relevant in all clinical, basic science and epidemiological studies; (3) analyse the influence (or association) of sex or gender on the results of the study, or indicate in the “ Methods ” section why such analyses were not performed, and consider this topic as a limitation to cover in the “ Discussion ” section and (4) if sex or gender analyses were performed post hoc, indicate that these analyses should be interpreted cautiously.

In a 2011 workshop “Sex-specific reporting of scientific research,” a broad cross section of stakeholders convened by the US Institute of Medicine identified key issues that journals and journal editors should address, such as requiring authors to report on the sex of study subjects, not only in studies with human participants but also in animal research and in studies with cells, tissues and other material from humans or animals.

Doull et al. [ 21 ] proposed that the methodologies of systematic reviews and of sex- and gender-based analysis be refined and synchronized to enhance the collection, synthesis and analysis of evidence for decision-making. Nowatski and Grant [ 23 ] provided a rationale for gender-based analysis (GBA), which is designed to identify the sources and consequences of inequalities between women and men and to develop strategies to address them. GBA focuses on gender differences in health and health care and appropriate policies.

SAGER guidelines

The policies, procedures and recommendations reviewed above were used as a basis for the SAGER guidelines, which are designed to promote systematic reporting of sex and gender in research. The guidelines provide researchers and authors with a tool to standardize sex and gender reporting in scientific publications, whenever appropriate. They are also aimed at editors to use as a practical instrument to evaluate a research manuscript and as a vehicle to raise awareness among authors and reviewers. Although reporting guidelines typically focus on how to report what was actually done in a study, we recognize that not all of the items included in the SAGER guidelines are feasible or applicable to a particular study. For this reason, SAGER encourages authors, editors and referees to consider if sex and gender are relevant to the topic of the study, and accordingly to follow the guidelines, whenever applicable. As a general principle, the SAGER guidelines recommend careful use of the words sex and gender in order to avoid confusing both terms. The use of common definitions will improve the ability to conduct meta-analyses of published and archived data. The term sex should be used as a classification of male or female based on biological distinction to the extent that this is possible to confirm. Authors should underline in the methods section whether sex of participants was defined based on self-report, or assigned following external or internal examination of body characteristics, or through genetic testing or other means. In studies of animals, the term sex should be used. In cell biological, molecular biological or biochemical experiments, the origin and sex chromosome constitutions of cells or tissue cultures should be stated. If unknown, the reasons should be stated. In other disciplines, such as the testing of devices or technology, authors should explain whether it will be applied or used by all genders and if it has been tested with a user’s gender in mind.

It is acknowledged that many studies will not have been “designed” to analyse sex and/or gender differences, but the panel felt these analyses are necessary to advance knowledge about sex and gender, especially in medical research.

Table  1 presents the SAGER guidelines. They apply to all research with humans, animals or any material originating from humans and animals (e.g. organs, cells, tissues), as well as other disciplines whose results will be applied to humans such as mechanics and engineering.

Title and abstract

If only one sex or gender is included in the study, the title and the abstract should specify the sex of animals or any cells, tissues and other material derived from these and the sex and gender of human participants. In applied sciences (technology, engineering, etc.), authors should indicate if the study model was based on one sex or the application was considered for the use of one specific sex. For studies (of a non-sex-specific issue) in which only one sex has been used, the article’s title should specify this fact by including “in males” or “in females” in the title and abstract. If cultures of primary cells, tissue, etc., were obtained from one sex, the sex should be indicated in the title [ 3 ].

Introduction

Authors should report, where relevant, previous studies that show presence or lack of sex or gender differences or similarities. If such studies are lacking, the authors should explain whether sex and/or gender may be an important variant and if differences may be expected.

Authors should report how sex and gender were taken into account in the design of the study, ensure adequate representation of males and females and justify reasons for the exclusion of males or females. Methodological choices about sex and gender in relation to study population and analytical approach should be reported and justified in the same way as other methodological choices.

In vivo and in vitro studies using primary cultures of cells, or cell lines from humans or animals, or ex vivo studies with tissues from humans or animals must state the sex of the subjects or source donors, except for immortalized cell lines, which are highly transformed [ 3 ]. In other cases, e.g. embryonic or early postnatal cultures, cell lines immortalized from a mixed culture or previously completed experiments for which sex was not documented, it is recommended that researchers determine the sex of cells or cell lines by chromosomal analysis and that the designations “mixed” or “unknown” should be used only when the sex cannot be determined through any methods.

Data should be reported disaggregated by sex, and an analysis of sex and gender differences and similarities should be described, where appropriate. Anatomical and physiological differences between men and women (height, weight, body mass, cell counts, hormonal cycles, etc.) as well as social and cultural variables (socio-economic status, education, etc.) should be taken into consideration in the presentation of data and/or analysis of the results. We recommend the use of the gendered innovations’ checklist for animals, tissues, cells and cultures [ 28 ]. If sex- and gender-based analyses have been performed, results should be reported regardless of the positive or negative outcome. In human studies, data on enrolment, participation, dropout, discontinuation and loss-to-follow up should be reported disaggregated by sex and gender (where appropriate), and the influence of sex and gender factors should be assessed a priori on the basis of their hypothesized role in the causation, course, treatment effectiveness, impact and outcome of health problems. Authors should refrain from conducting a post hoc gender-based analysis if the study design is insufficient to enable meaningful conclusions. In all cases, raw data should be published disaggregated by sex and gender for future pooling and meta-analysis.

In epidemiological studies, the impact of other exposures, such as socioeconomic variables, on health problems should be examined for all genders and should be analysed critically from a gender perspective.

We recognize that reporting guidelines focus on how to report what was actually done. However, not all of the items in the SAGER guidelines need to be done, as indicated by the words, “if appropriate.” The SAGER guidelines are intended to promote sex and gender equity in research; therefore, it encourages authors, editors and referees to consider if sex and gender are relevant to the topic of the study, and accordingly to follow the guidelines, whenever applicable.

The implications of sex and gender for the interpretation of study results should be elaborated, including the extent to which the findings can be generalized to all sexes and genders in a population. If no sex and gender-based analyses have been performed, authors should indicate the reasons for lack of such analyses when discussing the limitations of the study and discuss whether such analyses could have affected the results.

When interpreting research findings, past research should be examined for both methodological rigour and sex bias in procedure and interpretation. Authors should avoid confusing sex with gender and reducing complex or interactionist explanations to overly simple ones. Authors should consider all possible explanations for sex- and gender-related phenomena including social, cultural, biological and situational factors, recognizing that many sex-related behaviours might result from either cultural factors or biological factors. Covariation between biology and behaviour does not constitute evidence for physiological causation.

Appendix 2 provides a set of questions intended to raise awareness among authors. For many disciplines engaged in original scientific research, this list could serve as a basis for the preparation of a manuscript for submission.

The SAGER guidelines were developed over a 3-year period by a multidisciplinary group of academics, scientists and journal editors by means of literature reviews, expert feedback and public consultations at conferences. Authors, journal editors, publishers, reviewers and other members of the scientific community all have a role to play in addressing the neglect of the sex and gender dimension in scientific publishing.

The SAGER guidelines provide researchers and authors with a tool to standardize sex and gender reporting in scientific publications. They were designed to improve sex and gender reporting of scientific research, serve as a guide for authors and peer-reviewers, be flexible enough to accommodate a wide range of research areas and disciplines and improve the communication of research findings. Nevertheless, the guidelines do not make explicit recommendations regarding gender-diverse populations. We recognize that most studies will not be powered to detect differences in effects for gender-diverse populations such as transgender, especially in countries where such diversity is unknown. Yet authors need to consider the relevance of their research for gender-diverse populations.

Editors should make it clear that integration of sex and gender issues makes for more rigorous and ethical science. To the extent that mandates are difficult to implement, we recommend that journal editors endorse the SAGER guidelines and adapt them to the needs of their journals and their fields of science by including examples of good practice for each of the reporting items. At a minimum, journals publishing original research should request in their instructions to authors that all papers present data disaggregated by sex and gender and, where applicable, explain sex and gender differences or similarities adequately. Figure  1 provides a list of questions that could be used to guide the initial screening of submitted manuscripts. Editors should introduce specific questions in the checklist used to screen initial submissions, as an effort to systematize gender-conscious assessment of manuscripts among editorial staff. The following is an example of questions that can be introduced in peer-reviewers’ assessment forms:

SAGER flowchart guiding editors’ initial screening of submitted manuscripts

1. Are sex and gender relevant to the research in question?

2. Have authors adequately addressed sex and gender dimensions or justified absence of such analysis?

To be effective, the guidelines need to be endorsed by a broad cross section of the scientific community, including journal editors, publishers, editors’ societies, professional organizations, scientific advocacy groups, science journalists and other science communicators.

Editors should distribute the SAGER guidelines to their reviewers and encourage them to use them in the evaluation of manuscripts. They should ensure the manuscript assessment forms completed by peer-reviewers include specific questions regarding the importance and relevance of sex and gender.

Training the editorial staff on the importance of sex and gender-sensitive reporting should be conducted as part of regular training on ethical conduct and editorial practices.

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Acknowledgement

The SAGER guidelines are the result of collective effort by the EASE Gender Policy Committee (GPC) (please see EASE website for the list of committee members). The authors would particularly like to thank Joan Marsh, Ines Steffens and Paul Osborn for critically reading the manuscript and providing valuable comments on the various drafts of this paper. The authors would like to extend their gratitude to former EASE GPC members; Carina Sorensen, Joy Johnson, Meridith Sones, who made substantial contribution to the work of the committee and the process leading to the development of the SAGER guidelines. The EASE GPC would also like to thank the following individuals who offered expert advice during the consultation process: Enrico Alleva, Gustav Amberg, Magda Luz Atrián-Salazar, Vivienne Bachelet, Virginia Barbour, Janine Clayton, Sharon Bloom, Gillian Einstein, Helen Herman, Roderick Hunt, Astrid James, Ineke Klinge, Cameron Neylon, Elizabeth Pollitzer, Marta Rondon, and Londa Schiebinger.

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Shirin Heidari

Department of Community Medicine, University of Connecticut School of Medicine, Farmington, CT, 06030-6325, USA

Thomas F. Babor

Istituto Superiore di Sanità, Rome, Italy

Paola De Castro

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Correspondence to Thomas F. Babor .

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Competing interests.

None of the authors have any financial competing interests. All authors are unpaid, voluntary members of the Gender Policy Committee of the European Association of Science Editors, a registered charity in the UK.

Authors’ contributions

SH had the idea for the SAGER guidelines and the article, wrote the sections of the article and organized the planning, conducting and reporting of the work described in the article. TFB drafted the article and served as the corresponding author. PDC and MC participated in the discussions leading to the production of the SAGER guidelines and continued to write and revise the sections of the article. ST participated in the discussions leading to the production of the SAGER guidelines and contributed to the written and revised sections of the article, including the table and references. All authors read and approved the final manuscript. SH and TFB are responsible for the overall content as guarantors.

Glossary of terms

Gender . Gender refers to the socially constructed roles, behaviours and identities of female, male and gender-diverse people [ 1 ]. It influences how people perceive themselves and each other, how they behave and interact and the distribution of power and resources in society. Gender is usually incorrectly conceptualized as a binary factor (female/male). In reality, there is a spectrum of gender identities and expressions defining how individuals identify themselves and express their gender.

Gender identity . A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses and psychological and social pressures. It is the internal experience of gender role. (Mesh term, introduced in 1991, revised in 1975).

Gender-based analysis . An analytical tool that systematically integrates a gender perspective into the development of policies, programmes and legislation, as well as planning and decision-making processes. It helps to identify and clarify the differences between women and men and boys and girls and demonstrates how these differences affect health status, access to, and interaction with, the health care system.

( http://www.hc-sc.gc.ca/hl-vs/pubs/women-femmes/gender-sexes-eng.php )

Gender-sensitive analysis . Analysis of statistics that goes beyond simply disaggregating data according to sex (e.g. a mere “sex-counting” is not sufficient). Gender-sensitive analysis should question the underlying gender relations which are reflected in the data.

( http://www.oecd.org/dac/gender-development/44896238.pdf )

Gender perspective . The gender perspective looks at the impact of gender on people’s opportunities, social roles and interactions. Successful implementation of the policy, programme and project goals of international and national organizations is directly affected by the impact of gender and, in turn, influences the process of social development. Gender is an integral component of every aspect of the economic, social, daily and private lives of individuals and societies and of the different roles ascribed by society to men and women.

( http://www.fao.org/docrep/003/x2919e/x2919e04.htm )

Sex. Sex refers to a set of biological attributes in humans and animals that are associated with physical and physiological features including chromosomes, gene expression, hormone function and reproductive/sexual anatomy [ 1 ]. Sex is usually categorized as female or male, although there is variation in the biological attributes that constitute sex and how those attributes are expressed.

Sex- and Gender-Based Analysis . An analytical approach that integrates a sex and gender perspective into the development of health research, policies and programmes, as well as health planning and decision-making processes. It helps to identify and clarify the differences between women and men and boys and girls and demonstrates how these differences affect health status, access to, and interaction with, the health care system.

( http://www.hc-sc.gc.ca/hl-vs/gender-genre/analys/index-eng.php )

Sex-disaggregated data . Data that are collected and presented separately on men and women. Gender Mainstreaming Implementation Framework—UNESCO, 2003.

Sexism . Prejudice or discrimination based on gender or behaviour or attitudes that foster stereotyped social roles based on gender. (MESH term, introduced in 2013).

Transgender Persons, Transexual persons, Transgenders . Persons having a sense of persistent identification with, and expression of, gender-coded behaviours not typically associated with one’s anatomical sex at birth and with or without a desire to undergo sex reassignment procedures (MeSH term 2016 (2013).

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Heidari, S., Babor, T.F., De Castro, P. et al. Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev 1 , 2 (2016). https://doi.org/10.1186/s41073-016-0007-6

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Researchers explain social media's role in rapidly shifting social norms on gender and sexuality

by Allison Arteaga Soergel, University of California - Santa Cruz

A new paper summarizing decades of research demonstrates how social media has supported an explosion of diversity in gender and sexuality in America during the 21st century, and also how these technologies have equally enabled a cultural backlash.

The paper's authors, UC Santa Cruz Psychology Department faculty members Phil Hammack and Adriana Manago, identified five main narratives about gender and sexuality that they believe emerged through social media as people have strived to be "authentic" on these platforms. The findings, along with resulting recommendations for psychology researchers and practitioners, were published in American Psychologist .

Since its inception, social media has essentially reversed the flow of information in American society, challenging traditional sources of authority and empowering individuals to create and share information for themselves, the paper says. The formats and customs of social media especially encourage self-expression and "authenticity," or sharing your inner experience. Online connectivity also removes geographic barriers to finding other like-minded individuals.

Together, these conditions set the stage perfectly for new cultural norms to emerge, the paper's authors argue. Manago, an associate professor of psychology who studies how communication technology shapes human development , explained that the team's theory runs directly counter to "social contagion theory."

"We've seen so much change so quickly in things like pronouns and sexual orientation that people have been hungry for an explanation, and as a result, social contagion theory is this very harmful idea that has become popular, despite not being backed by good evidence," she said.

"Social contagion theory argues that adolescents are going online and seeing that expressing yourself as having an LGBTQ+ identity is cool and popular, so they are conforming to a popular notion outside of themselves," Manago continued. "Our paper argues the opposite. The diversity that we're seeing now was always there, but the dominant cultural paradigms previously masked it. Now, new communications tools are bringing it to light by promoting and enabling authenticity."

New cultural narratives of gender and sexuality

Among the new cultural narratives that researchers say have emerged from online authenticity is the concept of gender as self-constructed, meaning that there can be a difference between sex assigned at birth and a person's gender identity or expression. For example, research shows that Tumblr blogs have helped transgender people navigate the gender affirmation process, and TikTok has become a central resource for youth who are questioning their own gender or sexuality to explore identities and connect with others.

Hammack, a psychology professor and expert on generational differences in gender and sexuality, emphasizes that people are using social media as a tool to better understand complexities around gender identity that they already feel within themselves.

"We have to remember that with social media, an algorithm responds to the person," he said. "So if you're starting to question your gender, you're going to look for related content, and then the algorithm affirms that, but you are still the active agent who is on social media liking things. That agency sometimes gets downplayed when we talk about the influence of social media."

Another narrative that has gained traction on social media is the idea that sexuality is plural, playful, flexible, and fluid. One aspect of this is the possibility for attraction to multiple genders. For example, research that used the Craigslist personals section to recruit participants has bolstered new understandings of bisexuality among men and has also shown that some people who identify as straight still seek same-sex contact. Meanwhile, Tumblr helped to popularize the pansexual identity. And new social networking websites for people with fetishes have increased acceptance of a wider variety of sexual practices.

Some modern online narratives also present sexuality and monogamy as cultural compulsions, rather than biological ones. For example, asexuality has become an accepted identity for those who feel little or no sexual attraction, with help from a website that challenged traditional pathologizing views. And new dating apps have been developed specifically to support forms of consensual nonmonogamy that are gaining public visibility.

Intersectionality has become a key part of many online narratives too, such as the #SayHerName campaign on Twitter, which sought to draw attention to state-sanctioned violence against Black cisgender and transgender women alike. New terminologies and forms of identity have also developed on Tumblr that increasingly recognize how gender and sexuality intersect with each other, and these concepts have spilled over onto platforms like Twitter, now called X, and TikTok.

But not all online narratives that seek to convey authenticity in gender and sexuality promote diversity. A transphobic, homophobic, and misogynistic backlash has also spread through social media technology, sometimes resulting in real-world violence. One example is how Reddit and TikTok have spread "incel" or "involuntary celibate" ideology that views both women's equality and sexual and gender diversity as threats to masculinity.

"These reactionary forces that are being destabilized from their dominant position in society are also using authenticity narratives about being a 'real man' to spread their views, and they're claiming that all of these other narratives are false," Manago explained. "So authenticity is a central concept in all of the narratives on gender and sexuality that we see emerge through these platforms, regardless of whether they're progressive or regressive."

Recommendations for psychologists

Based on their findings, the paper's authors offer several recommendations. Psychology researchers and practitioners should start by grounding their work in people's lived experiences, the paper says. That could include counselors making sure they stay up to date on new popular terminology around gender and sexuality and researchers asking more open-ended questions and offering write-in options for collecting information about gender and sexuality.

The team also recommends approaching emerging forms of identity with affirmation, rather than suspicion and focusing on the phenomena of sexual and gender diversity more so than individual identity labels, which inevitably always leave someone out. The paper advises that social change on these issues is fluid and nonlinear, and the current context is not necessarily one of "achievement" for rights and recognition, as evidenced by regressive authenticity narratives that have spread alongside progressive ones.

Hammack and Manago ultimately encourage psychologists to continue challenging normative thinking, both around sexuality and gender and around social media's role in identity formation. They say social media is neither a source of youth corruption nor a cure-all for advancing acceptance and equity. Instead, meaningful cultural change that starts on social media should result in new resources and support in our geographic communities.

"If community spaces and educational spaces don't keep pace with these changes, that can become dangerous, because young people will continue to turn to social media , and they may lose confidence in other sources of authority, like teachers and parents, who they see as being socially behind the times," Hammack said.

"As adults, the responsible thing is for us to acknowledge that we live in a time of great change in gender and sexuality and to find ways to integrate new perspectives into education, our communities, and our families, so that young people don't experience isolation and don't lose confidence in us."

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• DOI: 10.1093/APPLIN/AMI027
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Language, Gender, and Sexuality: Current Issues and New Directions

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Language, gender and sexuality, normalization of sexuality in gender procedures: an analysis of language and gender, the french language, gender, and the discursive construction of sexuality in morocco, language and sexuality in south korea: a case study.

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Discourses of victimhood and agency: A case study of a teenage Indian girl negotiating her identity in a gendered world

Gender, sex and sexuality in two open access communication journals published in portugal: a critical overview of current discursive practices, linguistic negotiations of sexual agency in sexuality education, a critical encyclopedia of heterosex, language, sexuality and education, strategies of legitimation in sex education texts, 51 references, language and sexuality : contesting meaning in theory and practice, sexist talk: gender categories, participants’ orientations and irony, queerly phrased : language, gender, and sexuality, language and sexuality, gender articulated: language and the socially constructed self, gender trouble: feminism and the subversion of identity.

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The Management of Heterosexist Talk: Conversational Resources and Prejudiced Claims

Gender, heteroglossia and power: a sociolinguistic study of youth culture, jockeying for position: the construction of masculine identities, “why be normal”: language and identity practices in a community of nerd girls, related papers.

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• 28 May 2024

Heed lessons from past studies involving transgender people: first, do no harm

• Mathilde Kennis 0 ,
• Robin Staicu 1 ,
• Marieke Dewitte 2 ,
• Guy T’Sjoen 3 ,
• Alexander T. Sack 4 &
• Felix Duecker 5

Mathilde Kennis is a researcher in cognitive neuroscience and clinical psychological science at Maastricht University, the Netherlands.

You can also search for this author in PubMed   Google Scholar

Robin Staicu is a neuroscientist and specialist in diversity, equity and inclusion at Maastricht University, the Netherlands.

Marieke Dewitte is a sexologist and assistant professor in clinical psychological science at Maastricht University, the Netherlands.

Guy T’Sjoen is a clinical endocrinologist and professor in endocrinology at Ghent University Hospital, Belgium, the medical coordinator of the Centre for Sexology and Gender at Ghent University Hospital, and one of the founders of the European Professional Association for Transgender Health.

Alexander T. Sack is a professor in cognitive neuroscience at Maastricht University, the Netherlands.

Felix Duecker is an assistant professor in cognitive neuroscience at Maastricht University, the Netherlands.

You have full access to this article via your institution.

Over the past few decades, neuroscientists, endocrinologists, geneticists and social scientists have conducted numerous studies involving transgender people, meaning those whose gender identity does not conform to that typically associated with the sex to which they were assigned at birth. Justifications for doing such research have shifted over the years and, today, investigators are increasingly focused on assessments of transgender people’s mental health or the impact of hormone therapies.

But such work raises challenges. Despite researchers’ best intentions, these studies can perpetuate stigmas and make it even harder for transgender people to access appropriate medical care.

Here we focus on neuroscientific approaches to the study of transgender identity to explore how investigators might navigate these concerns.

Brain scanning

In 1995, neuroscientists at the Netherlands Institute for Brain Research in Amsterdam published findings from a post-mortem study, which included six transgender individuals 1 . They found that the volume of part of the brain’s hypothalamus — called the bed nucleus of the stria terminalis, which tends to be larger in men than in women — corresponded to the gender identity of the transgender individuals, not to their sex assigned at birth. Although the data were only correlative, the researchers suggested that people identify as transgender because of changes in the brain that happen before birth — in other words, that someone can be born with a male-typical body and brain characteristics more typical of a female brain, and vice versa.

Sex and gender in science

Since it was published, the paper has been cited more than 1,000 times, and at least a dozen researchers have probed this theory and related ones using tools such as structural and functional magnetic resonance imaging (MRI).

Although the results of these analyses have been inconsistent, several ideas have nonetheless arisen about a neurobiological basis for gender dysphoria — the distress associated with a person’s gender identity not aligning with the sex they were assigned at birth. These include the ‘own-body perception’ theory 2 , which proposes that a reduced structural and functional connectivity between certain brain networks is responsible. (Previous work has associated these networks with brain regions thought to be involved in people’s ability to link their own body to their sense of self 3 .)

As analytical tools and methods advance, brain research is becoming more sophisticated. The number of neuroscientific studies that include transgender participants has increased considerably since 1991 (see ‘On the rise’).

Some neuroscientists are using functional MRI to study the effects of hormone therapy on brain structure 4 and to examine cognitive processes such as face perception 5 . Others are applying machine-learning techniques to establish whether features in brain scans of cis- and transgender people correlate with their gender identity 6 . Researchers are also trying to assess whether particular features identified in brain scans make it more likely that transgender individuals will benefit from gender-affirming hormone therapy 7 . And some are conducting ‘mega-analyses’ — pooling the brain scans of hundreds of participants — to identify brain characteristics that are specific to transgender people 8 .

Help or harm?

One concern arising from such studies is that neuroscientific findings related to transgender identity could make it even harder for some people to access medical treatment that could help them.

In countries or regions where gender-affirming medical treatment is available, individuals often need a diagnosis of ‘gender dysphoria’ or ‘gender incongruence’ to be eligible for hormone therapy or gender-affirming surgery, and to be reimbursed for such treatments. Results from brain scans could be included in the suite of measurements used to assess whether someone is experiencing gender dysphoria or incongruence.

Those in favour of such requirements argue that it is necessary to prevent people taking irreversible steps that they might regret. Hormonal therapy can have adverse effects on fertility, for instance 9 . However, many transgender people argue that whether someone can receive gender-affirming hormone therapy or other treatment shouldn’t depend on a health-care practitioner deciding that they experience ‘enough’ gender dysphoria to be eligible 10 . The current approach, combined with a shortage of specialists qualified to make such diagnoses, has been linked to long waiting lists. In the Netherlands, waiting times can be more than two years .

A second possibility is that neuroscientific findings related to transgender identity will fuel transphobic narratives 11 .

Take the debate on social media and other platforms about gendered public spaces in countries such as the United States , the United Kingdom and Brazil 12 . Some people argue that allowing transgender women to access infrastructure, such as public toilets or women’s prisons, threatens the safety of “real women” . Neuroscientific research is sometimes misused to bolster flawed claims about what ‘real’ means.

Moreover, such studies could exacerbate tensions between scientific and transgender communities.

Scientists are aiming to identify brain characteristics that are specific to transgender people. Credit: Alain Jocard/AFP/Getty

Although cis- and transgender researchers have taken steps to improve people’s understanding, there is a history of tension between the scientific and transgender communities 13 . In the late 1980s, for instance, a sexologist argued that trans women who are mainly attracted to women experience sexual arousal from their own expression of femininity. He described their feelings of gender dysphoria as resulting from paraphilia — a sexual interest in objects, situations or individuals that are atypical 14 . This theory has not held up under broader scientific scrutiny 15 , but it has become notorious in the transgender community and, from our discussions with transgender people and discussions by other groups 16 , it is clear that such studies have reduced transgender people’s trust in science.

How four transgender researchers are improving the health of their communities

In 2021, for example, a neuroimaging study with transgender participants was suspended in the United States after backlash from the transgender community. The study would have involved showing participants images of themselves wearing tight clothes, with the intention of triggering gender dysphoria — an experience that is associated with depression, anxiety, social isolation and an increased risk of suicide. The study’s researchers had acquired ethical approval from their research institute and obtained informed consent from the participants. Yet they had failed to anticipate how the transgender community would perceive their experimental procedure.

In 2022, to learn more about how transgender people view current neuroscientific approaches to the study of transgender identity, we conducted focus-group interviews that lasted for three hours with eight transgender participants — all of whom had differing levels of knowledge about the topic.

The group expressed concern that studies that look for a neurological basis to transgender identities could have a pathologizing effect. “I think questions of aetiology are just inherently wrong,” one participant said. “We don’t ask ‘Why is someone’s favourite colour blue?’. These are questions that come from wanting to pathologize.” Participants also agreed that a biological-determinist approach does not do justice to the complex and layered experience of identifying as transgender.

Decades of work aimed at establishing how science can benefit minority groups 17 suggest that neuroscientists and other scholars could take several steps to ensure they help rather than harm transgender, non-binary and intersex individuals and other people who don’t conform to narrow definitions around sex and gender. Indeed, the four actions that we lay out here are broadly applicable to any studies involving marginalized groups.

Establish an advisory board. Researchers who work with transgender participants should collaborate with an advisory board that ideally consists of transgender people and members of other groups with relevant perspectives, including those who have some understanding of the science in question. Funding agencies should support such initiatives, to help prevent further distrust being sown because of how studies are designed.

Set up multidisciplinary teams. Researchers trained in neuroscience will view phenomena such as transgender identity through a different lens from, say, those trained in psychology. To prevent the outcomes of neuroscientific and other studies being described and published in an overly deterministic and simplistic way 18 , research teams should include social scientists. Ideally, such collaborations would also include transgender researchers or others with diverse gender identities, because their input would help to prevent a cis-normative bias in study design and in the interpretation of results. Indeed, our own group has benefited from this diversity (one of us is transgender).

Prioritize research that is likely to improve people’s lives. Neuroscientists and others engaged in research involving transgender participants, non-binary people or individuals with diverse gender identities should prioritize research questions that are likely to enhance the health of these groups. Although the applications of basic research can be hard to predict, investigations into the neurobiological impacts of hormone treatment on the brain, for instance, could be more directly informative to health-care practitioners and transgender individuals than might investigations into the underlying bases of transgender identity.

Rethink how ethical approval is obtained. Ethical boards at universities typically consist of scientists with diverse backgrounds. But it is unrealistic to expect them to be educated on the sensitivities of every minority group, whether in relation to gender, religion, ethnicity or anything else. One way to address this problem is for ethical boards to require researchers to state what feedback and other information they have gathered through community engagement. A university’s ethical review committee could then evaluate whether the researchers have done enough to understand and address people’s concerns and sensitivities.

Our aim is not to halt scientific enquiry. But when it comes to transgender identity, knowledge cannot be pursued in isolation from the many societal factors that shape how that knowledge is received and acted on.

Nature 629 , 998-1000 (2024)

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Lucinda Platt

May 29th, 2024, sex and gender: a contemporary reader – review.

0 comments | 8 shares

Estimated reading time: 7 minutes

In Sex and Gender , editors Alice Sullivan and Selina Todd marshal a range of academics in different fields – from neuroscience to sociology – to explore the relationship between sex, gender and gender identity. Encompassing a broad range of topics and lenses, the volume presents illuminating research in this contested area, writes Lucinda Platt .

Sex and Gender: A Contemporary Reader. Alice Sullivan and Selina Todd (eds.). Routledge. 2023.

The authors all recognise that sex is a biological referent – ie, immutable and determined at conception – but they provide a range of ways for thinking about gender as a social category, with different emphases on patriarchy (eg, Jones), socialism (eg, Todd), and the role of the state. They share an emphasis on the importance of clarity around terms: the authors take care with their language, and their articulation of concepts, whether the conception of woman (Stock) or sex itself (Hilton and Wright), its measurement (Sullivan, Murray and Mackenzie), or how “inclusion” has been reformulated to encompass the exclusion of women’s concerns (Benjamin; Devine). Such clarity is especially important in a context where the commonly understood meaning of words relating to sex and gender has been undermined .

My first thought on reading this collection was the extent to which assumptions, which were only recently taken for granted as self-evident, now have to be spelled out.

My first thought on reading this collection was the extent to which assumptions, which were only recently taken for granted as self-evident, now have to be spelled out. For example, that woman has a singular meaning, even if there is great heterogeneity among women themselves (Stock; Jones; Todd; Auchmuty and Freedman; Devine); that sex is both binary and immutable – and that humans are not clownfish (Hilton and Wright); that the commonplace use of “gender” to designate men and women (ie, sex) that was unproblematically understood as such, whether in nineteenth century novels, legal discussions or contemporary economic analysis, is now easily, or wilfully, misunderstood and typically needs to be caveated (Stock; Auchmuty and Freedman; Sullivan, Murray and Mackenzie); that that those with disorders or differences of sex development (DSD)s do not represent a ””third sex”, since disorders in development or “limit cases” do not alter the fact that there are two sexes among humans, as all mammals (Hilton and Wright; Stock; Sullivan; Devine). The volume helpfully evidences such points.

The contemporary regular conflation of the term “gender”  [… ]  has also raised questions about how “gender identity” can be understood without reference to (regressive) gender stereotypes.

The contemporary regular conflation of the term “gender” (as the social organisation of society around particular understandings of men’s and women’s roles and positions) with “gender identity”, which implies an identification with a “ gendered soul ” that may or may not reflect one’s sex, has clearly generated much confusion. It has also raised questions about how “gender identity” can be understood without reference to (regressive) gender stereotypes. The frequent insistence that any discussion of or teaching on “gender” (as social organisation or the cultural basis of inequality) must necessarily involve discussion – or endorsement – of “gender identity”, has impacted many teachers and educationalists (myself among them). For them, this book offers a useful resource that can help to clarify the scope of discussion of gender around the particular topics being addressed, whether biology, education or criminal justice.

Beyond this, the book provides original insights in its different chapters and highlights some recurrent themes across the diverse discussions. Being introduced to accounts from different disciplines, I learnt a lot about what we do and do not know. The chapter by Scott, for example, on sex and the brain argues that while there are clear physical differences (male brains are larger and women’s have proportionately more grey matter), the implications for behaviour have been more elusive. There is little evidence for distinctively female or male brains in terms of (culturally formed) expectations about differences in men’s and women’s abilities or behaviour. Scott also highlights how some key areas of well-attested differences in male and female behaviour (eg, aggression) have been neglected by cognitive neuroscientists, and comments on the ways in which disciplines find some questions harder to ask than others.

There is little evidence for distinctively female or male brains in terms of (culturally formed) expectations about differences in men’s and women’s abilities or behaviour.

Such absence of evidence and claims-making without a solid evidence base, with important consequences, is a theme that recurs across a number of chapters. Sullivan, Murray and Mackenzie highlight how the corruption of data collection on sex and the failure to collect good data on gender identity acts in opposition to the substantiation (or otherwise) of claims about gender (identity), potentially negatively impacting the rights and care of trans people (for example, if screening programmes relating to prostate or cervical cancer do not have information on natal sex). Littman discusses the poor evidence base on the dramatic increases among adolescent girls identifying as trans or non-binary; and Devine charts the neglect of evidence on the physical advantage retained by trans women in women’s sport. An apparently cavalier attitude to evidence is perhaps also what has facilitated the extensive “policy capture” that is charted in chapters on the law in the UK (Auchmuty and Freedman), the US (Burt) and education (Benjamin). Auchmuty and Freedman, for example, note that it came to the attention of grassroots organisations that Stonewall had been providing advice on single-sex spaces that was “legally incorrect”. A willingness to misrepresent the law (and the nature of evidence) flouts of course the sorts of norms on which we typically depend for a functioning society.

Disregard for evidence is perhaps most chillingly described in Bigg’s chapter on puberty blockers. While Biggs notes that children prescribed puberty blockers are a small proportion of all those identifying out of their natal sex, they are clearly particularly vulnerable. Biggs charts how at the time the initial (Dutch) protocols on puberty blockers were adopted, the only evidence derived from one patient. Subsequent evidence on outcomes of those treated was misrepresented (eg, a follow up from an original Dutch cohort, based its positive evaluation on only a subsample of those originally treated, and failed to mention that one had died due to post-operative complications related to puberty suppression); or was subject to lack of follow up for longer rather than limited short term outcomes (a point also made by Littman), or was suppressed. Biggs’ own analysis, after a concerted campaign for access, of a group identified for experimental investigation of outcomes from the UK Gender Identity Development Service found no positive effects of puberty blockers, contrary to claims on which roll-out of the treatment was based, a finding recently endorsed in the Cass Report . The argument that puberty blockers are “reversible” was, according to Biggs, a “rhetorical device” without evidence; and despite the limits to follow-up discussed, there is now some evidence for negative irreversible impacts of such treatment.

Despite the extensive coverage of the volume, there are two things I missed. First, while there is a cogently written introduction from Sullivan and Todd setting the scene, I would have appreciated a concluding chapter reflecting on the different perspectives and issues covered in the volume. While some seemed to see an unravelling of ill-informed claims about gender, others seemed to see their consolidation. Can a view be taken on this point? In addition, the ways that the chapters speak to each other (even if in terms of qualifying each other) might have been further drawn out.

Second, while I appreciated the measured and sensitive treatment of issues of “balance” and support of different rights eg, in sport (Devine) or US equality law (Burt), I would have welcomed further reflection on the reach and limits of an “inclusive” agenda (Benjamin), and the importance or not of spaces for women/girls to enjoy separateness or privacy, beyond the obvious cases such as sports (Devine) and prisons (Phoenix).

For those struggling to understand the disputes around the meanings of sex and gender or how to balance fairness and maintenance of the rights of different parties [  …  ] this book provides an invaluable and authoritative introduction to the issues.

For those struggling to understand the disputes around the meanings of sex and gender or how to balance fairness and maintenance of the rights of different parties, whether as someone involved in teaching or research, or as an interested lay reader, this book provides an invaluable and authoritative introduction to the issues.

Note: This review gives the views of the author, and not the position of the LSE Review of Books blog, nor of the London School of Economics and Political Science.

Image credit:   Darya Palchikova  on Shutterstock .

About the author

Lucinda Platt is Professor of Social Policy and Sociology in the Social Policy Department at the London School of Economics and Political Science. Her research focuses on social inequality and she is author of Understanding Inequalities, Stratification and Difference (Polity, 2nd Edition 2017).

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Less Marriage, Less Sex, Less Agreement

By Nicholas Kristof

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I wrote a column recently lamenting the decline in marriage rates, noting that a record half of American adults are now unmarried. As a long-married romantic myself, steeped in statistics suggesting that marriage correlates with happiness, I found that sad.

My readers, not so much.

Many women readers in particular dismissed heterosexual marriage as an outdated institution that pampers men while turning women into unpaid servants.

“Marriage is generally GREAT for men,” declared a woman reader from North Carolina whose comment on the column was the single most liked, with more than 2,000 people recommending it. Wives get stuck with the caregiving, she added, and “the sex that receives the care is gonna be happier than the sex that doesn’t receive the care.”

The second most recommended reader comment came from a woman who said that when she and her women friends get together, “We all say, ‘Never again.’ Men require a lot of care. They can be such babies.”

I think these skeptics make some valid points — we men do need to up our game! — even as I remain a staunch believer in marriage for both straight and gay couples. But put aside for a moment questions about marriage. The deluge of annoyance among some women readers intrigued me because while it’s anecdotal, it aligns with considerable survey evidence of a growing political, cultural and social divide between men and women throughout the industrialized world.

A poll across 20 countries by the Glocalities research group found “a growing divide between young men and young women” in political and social outlook, while The Economist examined polling across rich countries and likewise found that young women are becoming significantly more liberal as young men are becoming somewhat more conservative.

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5. Gender identity, sexual orientation and the 2024 election

Table of contents.

• Voters’ views about race and society, the impact of the legacy of slavery
• Most voters, but not all, view the nation’s diversity as a strength
• How should the country handle undocumented immigrants currently in the U.S.?
• Attitudes toward hearing other languages in public places
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• How does the U.S. compare with other countries?
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• How much of a priority should marriage and children be?
• Abortion, IVF access and birth control
• Views of gender identity
• Voters’ attitudes toward use of gender-neutral pronouns
• Societal impact of more social acceptance of lesbian, gay, bisexual people
• Religion and government policy
• How much influence should the Bible have on the nation’s laws, if any?
• Views on the federal government’s role in promoting Christian values
• Most voters say it is not necessary to believe in God to be moral
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Voters who support Joe Biden and Donald Trump have wide differences across a broad range of issues related to gender identity and sexual orientation.

Trump supporters overwhelmingly say a person’s gender is determined by the sex they were assigned at birth. A majority of Biden supporters, by a less one-sided margin, say someone can be a man or woman even if that is different from their sex at birth.

Biden’s supporters also are far more comfortable than Trump supporters with people using the pronouns “they” or “them” to describe themselves.

And two decades after the first same-sex marriages were legally performed in the U.S., Biden supporters are roughly five times as likely as Trump supporters to say legalizing same-sex marriage has been good for society.

Nearly two-thirds of registered voters (65%) say whether a person is a man or woman is determined by the sex assigned to them at birth. About a third (34%) say whether someone is a man or woman can be different from the sex at birth.

Nine-in-ten Trump supporters and about four-in-ten Biden supporters (39%) say sex at birth determines if someone is a man or a woman.

About six-in-ten Biden supporters (59%) say a person’s gender can be different from their sex at birth. Only about one-in-ten Trump supporters (9%) say this.

There are wider demographic differences in opinions about gender identity among Biden supporters than among Trump supporters.

Among Biden supporters

Nearly two-thirds of Black voters who support Biden (64%) say gender is determined by a person’s sex assigned at birth. That compares with 46% of Biden’s Hispanic supporters and smaller shares of his White (32%) and Asian supporters (27%).

Biden supporters without college degrees (47%) are more likely than those with college degrees or more education (30%) to say sex at birth determines someone’s gender.

Biden supporters under age 35 (29%) are less likely than older Biden supporters to say gender is determined by sex assigned at birth.

Among Trump supporters

Across demographic groups, wide majorities of Trump supporters say gender is determined by sex at birth.

However, there are some differences among these voters. Hispanic Trump supporters (79%) are less likely than White Trump supporters (92%) to say sex birth determines gender identity, and Trump supporters ages 18 to 34 (83%) are less likely to say this than older Trump supporters.

Changing views about gender identity

The share of voters who say that sex at birth determines whether someone is a man or a woman has increased since 2017, and this increase has occurred within both parties.

In 2017, 53% of voters said sex assigned at birth determines gender; 65% express this view today.

The share of Republican and Republican-leaning voters who say that sex at birth determines gender identity has grown from 79% in 2017 to 91% now.

In the same period, the share of Democratic and Democratic-leaning voters who say this has increased, from 30% to 39%.

Over half of voters (56%) say they are not comfortable with someone using the pronouns “they” or “them” to describe themselves, rather than “he” or “she.” Roughly four-in-ten (43%) are comfortable with the use of these pronouns.

Biden supporters are more than three times as likely as Trump supporters to say they are comfortable with the use of “they/them” pronouns (66% to 20%).

• Black voters who support Biden (55%) are less comfortable with the use of they/them pronouns than Biden’s White (69%), Hispanic (68%) and Asian (72%) backers.
• Hispanic Trump supporters (33%) are somewhat more likely than the former president’s White supporters (16%) to say they are comfortable.

Voters under 50 are more comfortable than those 50 and older with people using gender-neutral pronouns. There is an age gap on this question among both candidates’ supporters, but it is particularly stark among Biden voters: 79% of Biden’s supporters ages 18 to 49 say they are comfortable, compared with 56% of his supporters who are 50 and older.

Voters are divided over the societal effects of more people being comfortable with identifying as gay, lesbian or bisexual and same-sex marriages being legal in the U.S.

Roughly a third say each trend has been very or somewhat good for society, while about as many say the changes have been bad for society. The remainder say they have been neither good nor bad.

As with opinions about gender identity, there are sizable differences between Biden and Trump supporters.

About half of Biden supporters (51%) say more people being comfortable identifying as gay, lesbian or bisexual is good for society. And a majority of Biden supporters (57%) say legalization of same-sex marriage is good for society.

About half of Trump supporters say both changes are bad for society: 53% say this about increased comfort with people identifying as lesbian, gay or bisexual, and 51% say this about legalization of same-sex marriage.

There are age differences among both candidates’ supporters.

• Majorities of Biden supporters ages 18 to 49 view both trends positively: 63% say more people being comfortable identifying as lesbian, gay or bisexual is good for society, while 67% say the same of the legalization of same-sex marriage. About half or fewer of Biden supporters 50 and older share these views. (This group is more likely to instead say that these trends are neither good nor bad.)
• Older Trump supporters are more likely than his younger supporters to have a negative view of the impact of legalizing same-sex marriage (57% of those 50 and older say it is bad for society, compared with 41% of those younger than 50). There are no meaningful age differences in how Trump supporters assess the impact of more people being comfortable with identifying as lesbian, gay or bisexual.
• Black voters who support Biden are far less likely than Biden’s supporters in other racial and ethnic groups to say increased comfort with identifying as lesbian, gay or bisexual and legalized same-sex marriage are good for society. About a quarter of Black Biden supporters say these things are good, compared with about half or more among his White, Hispanic and Asian backers.

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Sex and gender: What is the difference?

People often use the terms “sex” and “gender” interchangeably, but this is incorrect. Sex refers to biological physical differences, while gender is how people identify.

“Sex” refers to the physical differences between people who are male, female, or intersex . A person typically has their sex assigned at birth based on physiological characteristics, including their genitalia and chromosome composition. This assigned sex is called a person’s “natal sex.”

Gender, on the other hand, involves how a person identifies. Unlike natal sex, gender is not made up of binary forms. Instead, gender is a broad spectrum. A person may identify at any point within this spectrum or outside of it entirely.

People may identify with genders that are different from their natal sex or with none at all. These identities may include transgender , nonbinary, or gender-neutral. There are many other ways in which a person may define their own gender.

Gender also exists as social constructs — as gender “roles” or “norms.” These are defined as the socially constructed roles, behaviors, and attributes that a society considers appropriate for men and women.

Sex assignment typically happens at birth based on anatomical and physiological markers.

Male and female genitalia, both internal and external, are different, and male and female bodies have distinct hormonal and chromosomal makeups. Doctors use these factors to assign natal sex.

At birth, female-assigned people have higher levels of estrogen and progesterone , and while assigned males have higher levels of testosterone . Assigned females typically have two copies of the X chromosome, and assigned males have one X and one Y chromosome.

Society often sees maleness and femaleness as a biological binary. However, there are issues with this distinction. For instance, the chromosomal markers are not always clear-cut. Some male babies are born with two or three X chromosomes, just as some female babies are born with a Y chromosome.

Also, some babies are born with atypical genitalia due to a difference in sex development. This type of difference was once called a “disorder of sex development,” but this term is problematic. In a 2015 survey , most respondents perceived the term negatively. A further review found that many people do not use it at all, and instead use “intersex.”

Being intersex can mean different things. For example, a person might have genitals or internal sex organs that fall outside of typical binary categories. Or, a person might have a different combination of chromosomes. Some people do not know that they are intersex until they reach puberty.

Biologists have started to discuss the idea that sex may be a spectrum. This is not a new concept but one that has taken time to come into the public consciousness. For example, the idea of sex as a spectrum was discussed in a 1993 article published by the New York Academy of Sciences.

In the United States, gender has historically been defined as a binary. Many other cultures have long recognized third genders or do not recognize a binary that matches the American understanding. In any case, the idea of gender as an either/or issue is incorrect.

Someone who identifies with the gender that they were assigned at birth is called “cisgender.” Someone who is not cisgender and does not identify within the gender binary — of man or woman, boy or girl — may identify as nonbinary, genderfluid, or genderqueer, among other identities.

A person whose gender identity is different from their natal sex might identify as transgender.

A 2016 review confirms that gender exists on a broad spectrum — in contrast to the genetic definitions of sex.

A person may fully or partially identify with existing gender roles. They may not identify with any gender roles at all. People who do not identify with existing gender binaries may identify as nonbinary. This umbrella term covers a range of identities, including genderfluid, bigender, and gender-neutral.

Gender and society

Gender is also a social construct. As the World Health Organization (WHO) explains:

“Gender refers to the socially constructed characteristics of women and men, such as norms, roles, and relationships of and between groups of women and men. It varies from society to society and can be changed.”

Gender roles in some societies are more rigid than in others. However, these are not always set in stone, and roles and stereotypes can shift over time. A 2018 meta-analysis of public opinion polls about gender stereotypes in the U.S. reflects this shift.

Gender and health

There are complex relationship between gender and both physical and mental health .

Health systems are not gender-neutral.

A WHO report highlights the ways that gender stereotypes and stigmas influence a person’s healthcare experience. Gender stereotypes can affect health coverage, pathways of care, and accountability and inclusivity within health systems throughout the world.

A review of first-hand case studies shows that by failing to address gender-based inequalities, health systems can reinforce prescriptive and exclusive gender binaries.

The researchers also emphasized that these inequalities in care can intersect with and amplify other social inequities.

The review concluded that health systems must be held accountable to address gender inequalities and restrictive gender norms.

Identity and expression

A person may identify and express their gender in different ways.

Gender identity is how a person feels internally, while their expression is how they present themselves to the outside world. For example, a person may identify as nonbinary but present as a man to the outside world.

GLAAD, formerly called the Gay and Lesbian Alliance Against Defamation, describes gender identity as “one’s internal, personal sense” of belonging at some point on or off of the gender spectrum. The organization adds:

“Most people have a gender identity of man or woman (or boy or girl). For some people, their gender identity does not fit neatly into one of those two choices.”

GLAAD describes gender expression as: “External manifestations of gender, expressed through one’s name, pronouns, clothing, haircut, behavior, voice, or body characteristics. Society identifies these cues as masculine and feminine, although what is considered masculine and feminine changes over time and varies by culture.”

LGBTQIA+ resources

To discover more evidence-based health information and resources for LGBTQIA+ individuals, visit our dedicated hub .

For centuries, many societies have enforced the notion that a person is either a man or woman based on their physical characteristics. This idea conflates sex and gender, which is incorrect. Sex and gender are not the same.

In general terms, sex refers to a person’s physical characteristics at birth, and gender encompasses a person’s identities, expressions, and societal roles.

A person may identify with a gender that is different from their natal sex or with no gender at all. The latter identity is often referred to as nonbinary, but this is an umbrella term that covers many identifications.

Last medically reviewed on May 11, 2021

• Men's Health
• Public Health
• Sexual Health / STDs
• Women's Health / Gynecology
• genderandsexualidentity

How we reviewed this article:

• Ainsworth, C. (2015). Sex redefined. https://www.nature.com/news/sex-redefined-1.16943#spectrum
• Eagly, A. H., et al. (2020). Gender stereotypes have changed: A cross-temporal meta-analysis of U.S. public opinion polls From 1946 to 2018. https://doi.apa.org/doiLanding?doi=10.1037%2Famp0000494
• Fausto-Sterling, A. (1993). The five sexes. https://www.fd.unl.pt/docentes_docs/ma/TPB_MA_5937.pdf
• Fleming, P. J., et al. (2015). Current trends in the study of gender norms and health behaviours. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461071/
• Gender and health. (n.d.). https://www.who.int/health-topics/gender#
• Hay, K., et al. (2019). Disrupting gender norms in health systems: Making the case for change. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233290/
• How many chromosomes do people have? (2021). https://medlineplus.gov/genetics/understanding/basics/howmanychromosomes/
• Lee, P. A., et al. (2016). Global disorders of sex development update since 2006: Perceptions, approach and care. https://www.karger.com/article/fulltext/442975/27603905
• Lin-Su, K., et al. (2015). Congenital adrenal hyperplasia patient perception of ‘disorders of sex development’ nomenclature. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4360949/
• Majumder, A., et al. (2020). An observational study of the quality of life among gender incongruent individuals from the Hijra community of India. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540832/
• Manandhar, M., et al. (2018). Gender, health, and the 2030 agenda for sustainable development. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154065/
• Richards, C., et al. (2016). Non-binary or genderqueer genders. https://core.ac.uk/reader/55894044?utm_source=linkout
• Transgender. (n.d.). https://www.glaad.org/reference/transgender
• What is intersex? (n.d.). https://www.plannedparenthood.org/learn/gender-identity/sex-gender-identity/whats-intersex

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