This report was written for the general public and for mental health professionals in order to draw attention to — and offer some scientific insight about — the mental health issues faced by LGBT populations.

It arose from a request from Paul R. McHugh, M.D., the former chief of psychiatry at Johns Hopkins Hospital and one of the leading psychiatrists in the world. Dr. McHugh requested that I review a monograph he and colleagues had drafted on subjects related to sexual orientation and identity; my original assignment was to guarantee the accuracy of statistical inferences and to review additional sources. In the months that followed, I closely read over five hundred scientific articles on these topics and perused hundreds more. I was alarmed to learn that the LGBT community bears a disproportionate rate of mental health problems compared to the population as a whole.

As my interest grew, I explored research across a variety of scientific fields, including epidemiology, genetics, endocrinology, psychiatry, neuroscience, embryology, and pediatrics. I also reviewed many of the academic empirical studies done in the social sciences including psychology, sociology, political science, economics, and gender studies.

I agreed to take over as lead author, rewriting, reorganizing, and expanding the text. I support every sentence in this report, without reservation and without prejudice regarding any political or philosophical debates. This report is about science and medicine, nothing more and nothing less.

Follow The New AtlantisReaders wondering about this report’s synthesis of research from so many different fields may wish to know a little about its lead author. I am a full-time academic involved in all aspects of teaching, research, and professional service. I am a biostatistician and epidemiologist who focuses on the design, analysis, and interpretation of experimental and observational data in public health and medicine, particularly when the data are complex in terms of underlying scientific issues. I am a research physician, having trained in medicine and psychiatry in the U.K. and received the British equivalent (M.B.) to the American M.D. I have never practiced medicine (including psychiatry) in the United States or abroad. I have testified in dozens of federal and state legal proceedings and regulatory hearings, in most cases reviewing scientific literature to clarify the issues under examination. I strongly support equality and oppose discrimination for the LGBT community, and I have testified on their behalf as a statistical expert.

I have been a full-time tenured professor for over four decades. I have held professorial appointments at eight universities, including Princeton, the University of Pennsylvania, Stanford, Arizona State University, Johns Hopkins University Bloomberg School of Public Health and School of Medicine, Ohio State, Virginia Tech, and the University of Michigan. I have also held research faculty appointments at several other institutions, including the Mayo Clinic.

My full-time and part-time appointments have been in twenty-three disciplines, including statistics, biostatistics, epidemiology, public health, social methodology, psychiatry, mathematics, sociology, political science, economics, and biomedical informatics. But my research interests have varied far less than my academic appointments: the focus of my career has been to learn how statistics and models are employed across disciplines, with the goal of improving the use of models and data analytics in assessing issues of interest in the policy, regulatory, or legal realms.

I have been published in many top-tier peer-reviewed journals (including The Annals of Statistics, Biometrics, and American Journal of Political Science) and have reviewed hundreds of manuscripts submitted for publication to many of the major medical, statistical, and epidemiological journals (including The New England Journal of Medicine, Journal of the American Statistical Association, and American Journal of Public Health).

I am currently a scholar in residence in the Department of Psychiatry at Johns Hopkins School of Medicine and a professor of statistics and biostatistics at Arizona State University. Up until July 1, 2016, I also held part-time faculty appointments at the Johns Hopkins Bloomberg School of Public Health and School of Medicine, and at the Mayo Clinic.

An undertaking as ambitious as this report would not be possible without the counsel and advice of many gifted scholars and editors. I am grateful for the generous help of Laura E. Harrington, M.D., M.S., a psychiatrist with extensive training in internal medicine and neuroimmunology, whose clinical practice focuses on women in life transition, including affirmative treatment and therapy for the LGBT community. She contributed to the entire report, particularly lending her expertise to the sections on endocrinology and brain research. I am indebted also to Bentley J. Hanish, B.S., a young geneticist who expects to graduate medical school in 2021 with an M.D./Ph.D. in psychiatric epidemiology. He contributed to the entire report, particularly to those sections that concern genetics.

I gratefully acknowledge the support of Johns Hopkins University Bloomberg School of Public Health and School of Medicine, Arizona State University, and the Mayo Clinic.

In the course of writing this report, I consulted a number of individuals who asked that I not thank them by name. Some feared an angry response from the more militant elements of the LGBT community; others feared an angry response from the more strident elements of religiously conservative communities. Most bothersome, however, is that some feared reprisals from their own universities for engaging such controversial topics, regardless of the report’s content — a sad statement about academic freedom.

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I dedicate my work on this report, first, to the LGBT community, which bears a disproportionate rate of mental health problems compared to the population as a whole. We must find ways to relieve their suffering.

I dedicate it also to scholars doing impartial research on topics of public controversy. May they never lose their way in political hurricanes.

And above all, I dedicate it to children struggling with their sexuality and gender. Children are a special case when addressing gender issues. In the course of their development, many children explore the idea of being of the opposite sex. Some children may have improved psychological well-being if they are encouraged and supported in their cross-gender identification, particularly if the identification is strong and persistent over time. But nearly all children ultimately identify with their biological sex. The notion that a two-year-old, having expressed thoughts or behaviors identified with the opposite sex, can be labeled for life as transgender has absolutely no support in science. Indeed, it is iniquitous to believe that all children who have gender-atypical thoughts or behavior at some point in their development, particularly before puberty, should be encouraged to become transgender.

As citizens, scholars, and clinicians concerned with the problems facing LGBT people, we should not be dogmatically committed to any particular views about the nature of sexuality or gender identity; rather, we should be guided first and foremost by the needs of struggling patients, and we should seek with open minds for ways to help them lead meaningful, dignified lives.

Lawrence S. Mayer, M.B., M.S., Ph.D.

Executive Summary 

Lawrence S. Mayer, Paul R. McHugh

This report presents a careful summary and an up-to-date explanation of research — from the biological, psychological, and social sciences — related to sexual orientation and gender identity. It is offered in the hope that such an exposition can contribute to our capacity as physicians, scientists, and citizens to address health issues faced by LGBT populations within our society.

Some key findings:

Part One: Sexual Orientation

● The understanding of sexual orientation as an innate, biologically fixed property of human beings — the idea that people are “born that way” — is not supported by scientific evidence.

● While there is evidence that biological factors such as genes and hormones are associated with sexual behaviors and attractions, there are no compelling causal biological explanations for human sexual orientation. While minor differences in the brain structures and brain activity between homosexual and heterosexual individuals have been identified by researchers, such neurobiological findings do not demonstrate whether these differences are innate or are the result of environmental and psychological factors.

● Longitudinal studies of adolescents suggest that sexual orientation may be quite fluid over the life course for some people, with one study estimating that as many as 80% of male adolescents who report same-sex attractions no longer do so as adults (although the extent to which this figure reflects actual changes in same-sex attractions and not just artifacts of the survey process has been contested by some researchers).

● Compared to heterosexuals, non-heterosexuals are about two to three times as likely to have experienced childhood sexual abuse.

Part Two: Sexuality, Mental Health Outcomes, and Social Stress

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● Compared to the general population, non-heterosexual subpopulations are at an elevated risk for a variety of adverse health and mental health outcomes.

● Members of the non-heterosexual population are estimated to have about 1.5 times higher risk of experiencing anxiety disorders than members of the heterosexual population, as well as roughly double the risk of depression, 1.5 times the risk of substance abuse, and nearly 2.5 times the risk of suicide.

● Members of the transgender population are also at higher risk of a variety of mental health problems compared to members of the non-transgender population. Especially alarmingly, the rate of lifetime suicide attempts across all ages of transgender individuals is estimated at 41%, compared to under 5% in the overall U.S. population.

● There is evidence, albeit limited, that social stressors such as discrimination and stigma contribute to the elevated risk of poor mental health outcomes for non-heterosexual and transgender populations. More high-quality longitudinal studies are necessary for the “social stress model” to be a useful tool for understanding public health concerns.

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Part Three: Gender Identity

● The hypothesis that gender identity is an innate, fixed property of human beings that is independent of biological sex — that a person might be “a man trapped in a woman’s body” or “a woman trapped in a man’s body” — is not supported by scientific evidence.

● According to a recent estimate, about 0.6% of U.S. adults identify as a gender that does not correspond to their biological sex.

● Studies comparing the brain structures of transgender and non-transgender individuals have demonstrated weak correlations between brain structure and cross-gender identification. These correlations do not provide any evidence for a neurobiological basis for cross-gender identification.

● Compared to the general population, adults who have undergone sex-reassignment surgery continue to have a higher risk of experiencing poor mental health outcomes. One study found that, compared to controls, sex-reassigned individuals were about 5 times more likely to attempt suicide and about 19 times more likely to die by suicide.

● Children are a special case when addressing transgender issues. Only a minority of children who experience cross-gender identification will continue to do so into adolescence or adulthood.

● There is little scientific evidence for the therapeutic value of interventions that delay puberty or modify the secondary sex characteristics of adolescents, although some children may have improved psychological well-being if they are encouraged and supported in their cross-gender identification. There is no evidence that all children who express gender-atypical thoughts or behavior should be encouraged to become transgender.