Sexuality

Sex and sexual identity are not the same thing.

• Sex is defined by the traits usually used to distinguish between males and females, and it is determined by a variety of factors, including genetic, fetal developmental, psychological, and other interactions. Sex refers especially to the physical and biologic traits that are physically evident at birth; thus, the typical language of sex assignment is "assigned male at birth (AMAB)" and "assigned female at birth (AFAB)". However, about 1 in 4500 neonates have ambiguous genitalia (ie, their external genital features do not conform to either typically male or typically female patterns) (2, 3, 4). In some of these neonates, the ambiguous genitalia make an initial assignment of sex difficult (5). Sex is a complex concept; for a detailed review see Lehmiller, The Psychology of Human Sexuality, Third Edition, Wiley-Blackwell, New York, 2023.

• Sexual identity/sexual orientation is the pattern of emotional, romantic, and/or sexual attractions that people have toward others. It also refers to a person's sense of personal and social identity based on those attractions, related behaviors, and membership in a community of others with similar attractions and behaviors. There are many different sexual identities, such as heterosexual (attraction to the opposite sex), homosexual (attraction to the same sex), bisexual (attraction to both sexes), asexual (attraction to neither sex), and pansexual (sexual attraction to people irrespective of their gender identity or sex).

Gender identity is an internal sense of being male, female, or something else, which may or may not correspond to an individual's sex assigned at birth or sex characteristics. Gender identity does not necessarily describe an individual's romantic or sexual attractions. (See also Gender Incongruence and Gender Dysphoria.)

Helping adolescents put sexuality and sexual identity into a healthy context is extremely important.

Some adolescents struggle with the issue of sexual identity and may be afraid to reveal their sexual identity to friends or family members, particularly if they have a non-heterosexual identity. Adolescents with a non-heterosexual identity are 2 to 3 times more likely to have suicidal behavior and nonsuicidal, self-harming behaviors than their heterosexual peers (6, 7). Adolescents and their parents should be encouraged to speak openly regarding their attitudes toward sex and sexuality; parents' opinions remain an important determinant of adolescent behavior in spite of the ubiquitous influences of social media and internet sources of information on sexuality. Social media may form the basis for most information and misinformation on sexuality obtained by adolescents (8).

Children exposed to verbal and physical hostility, rejection, and cruelty may develop problems with sexual and emotional intimacy (9). For example, love and sexual arousal may become dissociated. As a result, emotional bonds may be formed with peers, but sexual relationships may occur only with those for whom there is no emotional intimacy, typically those who are devalued in some way (eg, sex workers, anonymous partners, people perceived to be of a lower socioeconomic class).

Societal attitudes about sex and sexuality, including masturbation, homosexuality, and extramarital sex differ in various societies and can change with time.

Health care professionals, when relevant, should take a sexual history as part of the medical history. Patients should be counseled about safer sex, contraception, and screened for intimate partner violence. Clinicians should discuss sexuality with their patients so that they can identify and address sexual issues, including sexual dysfunction (see Male Sexual Function and Dysfunction and Female Sexual Function and Dysfunction), gender dysphoria, and paraphilias.

Sexuality and sexual expression are often ignored in older adults (see Intimacy and Older Adults), including those who are institutionalized, even though sexual concerns are often important in this phase of life (21). Clinicians should be cognizant of the differences between identity-based and behavior-based sexual behaviors; assumptions cannot reliably be made between some people's expressed sexual identity and those with whom they choose to have sexual interactions (22). For example, men who identify as heterosexual may also have sexual encounters with other men, while not considering their behaviors homosexual (23). This may be critically important, because behaviors considered high risk for HIV and other sexually transmitted infections are not necessarily based on stated sexual identity or orientation.

Some health care professionals may not be confident in addressing sexual health issues (24). Health care professionals without the skill set to manage certain patients should make an appropriate referral.