Neurohormonal Wars

In May 2011, a majority of the districts in my denomination (Presbyterian Church, U.S.A.) voted to remove from its constitution the requirement that church leaders “live either in fidelity within the covenant of marriage between a man and a woman, or chastity in singleness.” Individual congregations and presbyteries still have the freedom to adhere to that earlier standard. Indeed, the Session of my own church passed a resolution affirming it shortly after its adoption by the PC(USA) in1996. But the more recent vote now makes it possible for persons in same-sex relationships to be considered for ordination to the offices of elder, deacon, or minister in churches and presbyteries that are open to it. Score another point, it would seem, for the view that same-sex attraction is biologically fixed, so the desire to act on it should not be constrained by literalist readings of ancient texts. Coincidentally, this is more or less the message coming from adherents of what is called Brain Organization Theory (BOT). Its working assumption is that the tendencies of women and men—whether related to sexuality, “masculine” vs. “feminine” personalities, or skills like verbal, mathematical, and spatial ability—are strongly driven by hormonal forces, beginning during prenatal development. These forces are assumed to produce complementary sets of virtues and skills, resulting in mutual heterosexual attraction. And even when nature is not so obliging (as in the case of homosexuals), hormonal events—in this case aberrant ones—are again assumed to be responsible.[1]

Around the same time, The New York Times Magazine ran a largely positive article on the American Psychological Association’s 2007 Task Force on Appropriate Therapeutic Responses to Sexual Orientation.[2] That document was critical of religious conservatives who insist same-sex attraction is never anything more than a careless choice or a reversible habit. But it also made a clear (and long overdue) acknowledgement of the importance of religious identity. If strongly religious persons with same-sex attractions seek to resist such impulses, it said, the appropriate response includes “therapist acceptance, support, and understanding of the clients, and the facilitation of clients’ active coping, social support, and identity exploration, without imposing a specific sexual orientation identity outcome.” Indeed, the task force discouraged the use of essentialist-sounding terms like lesbian, gay, and bisexual. It noted that “for some, sexual orientation development is fluid and has an indefinite outcome,” affected by factors such as “age, gender, gender identity, race, ethnicity, culture, national origin, religion, disability, language, and socioeconomic status.” The report cautioned that “not all sexual minorities (i.e., those who experience significant erotic and romantic attractions to adult members of their own sex) adopt a lesbian, gay, or bisexual identity.” Instead, “some individuals choose to live their lives in accordance with personal or religious values.”[3]

This clearly reflects a more social-constructionist view of sexuality and (by extension) other gender-related traits, interests, and behaviors. Brain organization theorists lean toward biological essentialism. They assume that terms like sexual orientation, masculinity, and femininity refer to obvious and largely stable behavioral patterns, then try to find the biological events that supposedly cause them. Social constructionists problematize these terms, asking how masculinity, femininity, and sexual orientation are differently defined and reinforced (or punished) in various times and places. Each side in this version of the nature-nurture debate agrees that both forces are at work, but they differ greatly as to which is the stronger, and how the two work together.

The Times article largely endorsed the APA’s more social-constructionist conclusions. Its author interviewed one actively gay and very secular therapist in Texas who claimed to have learned the hard way that some conservative Christian gay men are not helped by coming out of the closet, nor by switching to a more liberal, gay-affirming church. Prior to 2007 he had endorsed APA ethical guidelines that said, in effect, “We’re supposed to support religious beliefs and support sexual orientation.” But, he added, “there was nothing I knew of that says what to do when they conflict.” In wake of the task force report, he now helps such men stay discreetly closeted, be prudent in their same-gender sexual contacts to avoid health and professional risks, and otherwise remain faithful members of their church. One such client, a young assistant pastor, “didn’t want to join another church, nor did he want to come out. For many therapists, the approach would have been to affirm his sexual orientation. But the man cared more about preaching than he did about having an open, intimate relationship with a man.”

This may sound like a recycling of the old Victorian double standard for people of the “respectable” classes—i.e., pretend to follow the rules and have secret sexual dalliances on the side. But the article’s author also interviewed evangelical therapists Warren Throckmorton and Mark Yarhouse, of Grove City College and Regent University respectively. They too work with conservative Christian (mainly male) clients who are dealing with same-sex attraction, but who want their sexual identity and behavior to be disciplined by their commitment to historic Christian norms. They are given support for pursuing a celibate lifestyle, and sometimes even marriage and parenthood, provided that the wife is fully informed and supportive of the project. (Full disclosure: Mark Yarhouse was an undergraduate psychology student of mine about twenty years ago.)

And in fact, the APA task force saw this approach—Throckmorton and Yarhouse call it “Sexual-identity Therapy”—as a viable option. Its chairwoman, Judith Glassgold, was quoted in the article as saying, “People might want to develop an identity that fits with what their religion proscribes. Or they might want to be celibate rather than identify as a gay person. Some people prioritize their religion over their sexuality, like priests and nuns. That’s an identity.” She added that while gay activist and religious therapists mostly agree that attraction and arousal cannot be turned off or on at will, “What we can work on is self-acceptance, identity integration, and reducing stigma.” As if to underscore this affirmation of identity fluidity, the Times magazine article was followed by another, in which a gay rights activist described a visit to an erstwhile friend and fellow activist who, in the wake of a health scare, found God, renounced his longtime homosexual identity, and ended up at a Bible college in Wyoming. The article’s author conceded that this might just not be a case of someone “denying his true (i.e., gay) identity.” His friend, he concluded, “might call me some day to say he was gay after all … but I doubt that will happen any time soon.”[4]

A Brief Sermon on Method

Debates about the fixity vs. fluidity of sexual orientation, gender identity, and gendered behaviors take a different form in the academy than in the pastor’s or therapist’s office, though the latter are clearly influenced by what they think are conclusions drawn in the former. The phrase “what they think” is important, because clear scientific conclusions are not easy to come by. To begin with, most people understand that the gold standard for clinical research—medical or psychological—is the double-blind experiment. Thus, when a new drug is being tested, participants with the relevant medical condition are first randomly assigned to drug or placebo (fake drug) conditions in order to control for any pre-existing individual differences. Then, as the experiment proceeds, in order to control for what are known as “expectancy effects,” neither those who take or evaluate the effects of drug vs. placebo know which participants are in which condition: this is the “double blind” piece. At the end of the trial, only if there is a statistically significant difference in improvement between the two groups can the new drug be considered for marketing.

Can we use this research design for tracing causality when we’re comparing not the effects of drug vs. placebo, but the effects of biology vs. environment on gendered behavior? Imagine designing a clinical trial to determine whether boys are hard-wired to be more aggressive than girls, or girls more nurturing than boys. First, we’d have to randomly assign babies to be one sex or another, apart from all the other chromosomal baggage they come with. This we can’t do: girls and boys come as genetic package deals, and once conceived their genetic and environmental legacies are so intertwined that the effects are inseparable. If you think that it’s pre- or post-natal hormones (like estrogen and testosterone) more than unmediated genes that create behavioral sex differences, then you’d need a double-blind design in which you systematically interfere (or not) with the hormonal development of randomly divided groups of children, then trace the behavioral results. Most people agree that it’s acceptable to do this with rodents or monkeys, but not with humans—though it bears remembering that the Nazis did similar human experiments under the sinister rubric of uncovering “truth in nature.”

The animal research does show a relationship between increased testosterone levels and later aggression, regardless of the animal’s sex or whether the hormone is administered pre- or post-natally. By contrast, males castrated either pre- or post-natally may exhibit the opposite pattern of less aggression, unless they receive injected testosterone to compensate. They may also exhibit sexual behaviors typical of females (and vice-versa for females, if they get too much testosterone). Bear in mind that we know little about how these effects would generalize from isolated, lab-raised animals to those in natural settings: rodents and primates are, after all, quite sociable species. And human babies, given their much longer period of post-natal development, are even more susceptible to social influence: their long-term survival literally depends on it. Moreover, the most distinctive biological feature of humans is the plasticity of their brains. The legacy of a large cerebral cortex puts us on a looser behavioral leash than other animals, with the result that, more than any other species, we are built for continual learning—for passing on what we have created culturally, not just what we are inclined to do genetically and hormonally. We are, it seems, hard-wired for behavioral flexibility.[5]

In the absence of direct hormonal manipulation, suppose we were to separate nature from nurture by randomly designating some boy and girl infants to be raised as the other sex after they’re born, to see just how much (or little) they remain stubbornly “masculine” or “feminine” despite the reversal in gender socialization. But, ethical considerations aside, this wouldn’t even begin to approximate a double blind experiment—in the sense of controlling for expectancy effects—because the cat would be out of the bag (so to speak) as soon as the babies’ caretakers began changing their diapers. All this is to say that when studying human gender traits, gender identity, or sexual orientation, essential conditions for inferring cause and effect—the manipulation of one factor (sex) and the control of others (social as well as biological)—cannot be met. It means that “all data on sex differences, no matter what research method is used, are correlational data,”[6] and as every introductory social science student learns, you cannot draw firm conclusions about causality from merely correlational data.

“Eunuchs Made So by Others”: Some Lessons from History

This methodological uncertainty makes for constant debates between adherents of gender essentialist and social-constructionist camps, as the books to be reviewed all attest. Readers might wonder why the list includes historian Mathew Kuefler’s study of eunuchs in the late Roman Empire, and Kathryn Ringrose’s corresponding one on eunuchs in Byzantium. Very simply, few brain organization theorists read history to find connections between their own research and past cultural practices, such as that of castrating a non-trivial percentage of males in the Greco-Roman and Byzantine eras. This was of course not a controlled experiment, but it was a practice that lasted several centuries in the Roman West, as well as the Byzantine East and beyond, with many surviving texts (including some biblical ones) commenting on it. Kuefler and Ringrose try to connect the biological and cultural dots, with a stronger emphasis on the latter. They also examine the reciprocal impact between male castration and church law and practice, appealing to sources like medical texts, sermons, hagiographies, historical narratives, law codes, biographies, and standards for church office holders.

In both Rome and Byzantium, the theories of Aristotle, Galen, and Hippocrates were the accepted basis for doing science and medicine. Obviously, these scholars did not know about genes or hormones as those terms are used today—in fact, Aristotle believed that only fathers contributed any “seed” to fetal development. But they and their descendents were often astute clinical observers, and though castration of males (by removal of the testes and sometimes even the penis) was technically illegal within the Roman Empire, it occurred nonetheless. It was even more common in the barbarian hinterlands, resulting in a steady export of eunuchs to metropolitan areas like Rome and Constantinople. Over time, it was noted that the results of castration varied, depending on when it occurred. If done after puberty, eunuchs might still be able to have erections and orgasms, even though they were unable to reproduce. If done before, the longer-term dearth of testosterone resulted in tall slender bodies, beardless faces, less-developed musculature, and little if any libido. Such pre-pubertal castrates were often considered beautiful as young men (they were at times equated with angels, and some women even pretended to be male eunuchs to enjoy a freedom of mobility normally denied to their own sex), but they also tended to age prematurely and die young.

Because gender relations among the élite were organized primarily around male honor codes, with the concomitant obligation to produce and rule over a legally recognized family, non-reproducing eunuchs were alternately demonized as less than male (yet not quite female) and lauded as “perfect servants”: unencumbered by family or geographic ties and unpredictable passions, and thus able to assume trustworthy roles as domestic administrators, courtiers, imperial officers, and mediators between the worlds of men and women—even between sacred and secular. Kuefler and Ringrose never question the physiological effects of male castration. But they are concerned to demonstrate that, just as for intact males and females, stereotypes about eunuchs’ “essential” traits—not to mention their deliberate training to express such traits—varied too much over time and place for anyone to draw facile conclusions about the “inevitable” effects of biology on personality and behavior. As just one example, in some versions of the Roman Mater Deum (Mother of the Gods) fertility cult, the founding myth included the castration and death of the goddess’ consort as a punishment for his infidelity, and his subsequent resurrection (but not genital restoration) after she belatedly forgave him. During the cult’s annual spring rites, some male acolytes castrated themselves in order to become special priests to the goddess. This included adopting women’s dress—which, according to one source, they acquired by throwing their severed genitals in front of Roman households, whose women were then expected to relinquish some of their clothing.

Needless to say, early Western church leaders did not see such practices as examples of “perfect servanthood”—especially when accompanied by temple prostitution on the part of the Mater Deum eunuchs, as well as females recruited to the cult as virgins. Church leaders were repelled by the practice of testicular mutilation, and mindful of Old Testament strictures against admitting such men to worship spaces. But then there were biblical texts like Isaiah 56, which welcomes both eunuchs and foreigners who profess allegiance to Israel’s God, and Acts 8, which records Philip’s baptism of someone who was both: a eunuch and a high official of the Ethiopian queen. And what were they to do with Matthew 19? There Jesus distinguishes among eunuchs who have been born so, those that have been made so by other people, and those who “have made themselves eunuchs for the sake of the kingdom of heaven”—followed by the weighty words: “He who is able to receive this, let him receive it.” Apparently there were enough men taking this literally in the early church (Origen was reported to be one) for it to merit deliberation at the Council of Nicaea, which ordered priests who had castrated themselves to be removed from office—though exceptions were made if castration had been done by barbarians, or for medical reasons. The aspiring “perfect servant” of Christ was admired if he renounced sexual pleasure as an intact man. But self-made eunuchs were seen as unfairly gaming the system, since most didn’t have to struggle as much to attain the celibate state required for high-level sanctity.

In Kuefler’s account, the Western church’s real coup was to declare Jesus’ words about self-made eunuchs to be metaphorical rather than literal, then to make the war against the flesh needed to attain priestly celibacy a substitute for the Roman honor code, which treated family, military, and political power as the marks of hegemonic masculinity. Of course, clerical life did require “unmanly” submission to God as a metaphorical bride of Christ. But after the Constantinian legalization of Christianity, and in the wake of the later barbarian invasions, such initial submission conferred a lot of power, especially on bishops. They wielded spiritual authority over emperors, who were mere laymen by comparison, as well as over priests and laity in their own territories. They participated in church-wide council decisions that affected people of all stations. They prospered financially from tithes and donations instead of imperial taxes. In the 5th century, the church took over many civic duties as the Roman Empire collapsed, with bishops often assuming the symbolic power previously accorded secular magistrates. As spiritualized “manly eunuchs,” Western churchmen successfully exploited the language of male castration even as they renounced its actual practice.

In the Byzantine East, the fortunes of eunuchs proceeded somewhat differently. From about ad 600 to 1100, they were well-compensated professionals in a wide range of roles. Among the élite, they were household guards, military officers, administrators, doctors, musicians, and guardians of women and children; among the lower classes they were entertainers, actors and prostitutes. In the church, pre-pubertal castrates eventually served alongside “whole” or “bearded” men as priests, bishops, and even patriarchs, and were lauded for their perfect celibacy rather than ostracized for taking a dubious shortcut to achieve it. However, eunuchs were more marginal in the early centuries of the Byzantine era, due to the reigning Aristotelian gender ideology. This envisaged a ladder of virtue with more passive and less-rational women and girls at the bottom, boys who had left the women’s quarters en route to manhood in the middle, and optimally active, reasoning, reproductive males at the top. Especially if castrated before puberty, eunuchs were seen as cases of arrested development: more manly than women or young boys, but by virtue of their feminine appearance and infertility not capable of top-tier masculinity. Thus, in a manner reflecting both virtue and guilt by association, writes Ringrose, when earlier Byzantine sources “wanted to speak well of eunuchs, they did so in terms of positive attributes traditionally ascribed to men. When they wanted to be critical of eunuchs they did so in terms of negative values traditionally ascribed to women.”

In light of such ambivalence, how did the Eastern church later come to accept and honor male eunuchs at all levels of office? Ringrose suggests it was largely traceable to a new reading of Daniel 1, which emerged between the 9th and 11th centuries. The account of Daniel and his companions’ exile from Jerusalem to Babylon notes that they were “youths without blemish, handsome and skilful in all wisdom, endowed with knowledge, understanding learning, and competent to serve in the king’s court.” Moreover, they were trained and presented to the Babylonian court by the king’s chief eunuch. Thus, various exegetes concluded, though the text doesn’t say so directly, Daniel himself must have been a eunuch. This revised portrait of a major biblical prophet permitted “a broadening of the criteria that signified sanctity in ways that made it possible for eunuchs to assimilate to the religious culture of the era.” Rather than following the spiritualized “manly eunuch” route of the Western church, eunuchs became a kind of revered “third sex,” functioning “in ways that closely paralleled the supposed role of angels: facilitating miracles, conveying messages between divine sources and mortal recipients, and escorting holy individuals …. [I]n the Byzantine mind, eunuchs, while not capable of some things that ordinary mortals could do, possessed a potential for holiness, asexuality, and access to spiritual realms that was not part of the makeup of ordinary mortals.”

“Eunuchs from Birth”: Some Contemporary Controversies

One way to approximate an experiment in otherwise constrained circumstances is to do a longitudinal study. In a sense that’s what Kuefler and Ringrose have reconstructed. The physiological effects of male castration remained predictably consistent throughout the centuries they studied. But in terms of their effects on behavior, hormones (or in this case, their absence) did not rage: at most, they insinuated. Otherwise, these authors point out, history would not have produced such varying expressions and stereotypes of “essential” eunuch traits at different times and places—from Roman temple prostitutes to Christian miracle-mediators, and many things in between.

Such a conclusion does not cut much ice with bot adherents, many of whom think they have better ways as scientists to settle the nature/nurture question, despite the methodological challenges (mentioned earlier) that inevitably plague their work. One of these ways is to study so-called intersex people, whose bodies are atypical not from deliberate human interference, but due to accidents of nature. The goal is to infer causal relationships between the abnormal physiology and anatomy of such persons and any gender-atypical behavior they may later demonstrate, and in the process shed light on the causes of behavioral differences between ordinary men and women. Both Roman and Byzantine writers recorded the existence of such “eunuchs from birth.” These included males with undescended testes and people with otherwise ambiguous genitals, often accompanied by adult infertility and atypical secondary sex markers. It is possible that Jesus was referring to such people when he spoke of “eunuchs who have been so from birth.” In both Roman and Byzantine writings, they were often grouped together (for good or ill) with males who had been deliberately castrated.

With the advent of modern techniques to identify typical and atypical patterns of sex chromosomes, genes, and hormones, scientists began to make more nuanced distinctions, many of which are described in Fixing Sex by Stanford biomedical ethicist Katrina Karkazis. In the mid-20th century, with the development of staining techniques to assess the cellular presence of X and Y chromosomes, attention was focused on persons who were shown to have an atypical number of either—for example, Turner’s syndrome women (who have only one rather than two X chromosomes), Kleinfelter’s syndrome men (who have one Y and two or more X chromosomes) and other variations—such as XYY males or XXX females. Infants born with these syndromes do not exhibit external genital ambiguity, and so for the most part have remained medically and socially invisible throughout history. But as chromosome checks have become more common in hospital delivery rooms, other developmental problems—both physical and cognitive—have turned out to be correlated with these chromosomal anomalies.

For example, many Turner’s women can’t produce enough estrogen for adequate breast development, and so may opt for estrogen replacement therapy. And both males and females with extra sex chromosomes may have cognitive-developmental impairments. A few decades ago, the popular press made much of the fact that XYY males were disproportionately found in prison populations—demonstrating, some thought, that the Y chromosome was the source of male aggression. But it turned out that most XYY men had been incarcerated for non-violent crimes such as theft, which suggests it was probably cognitive impairment—rather than an extra Y chromosome beefing up their violence potential—that landed them behind bars: they were less able to plans their crimes carefully, and hence more likely to get caught than normal XY males.

With the rise of endocrinology as a discipline, scientists turned their attention to people who were actually born with ambiguous genitals. They discovered that testes and ovaries produced not just sperm or eggs but also hormones (substances produced by one tissue, and conveyed via the bloodstream to another, to stimulate certain physiological processes). And they found that both males and females produce the full range of gonadal hormones, although in differing ratios throughout the life cycle. In the mid-20th century, scientists discovered there was a prenatal “domino effect,” from genes to gonads (and other internal reproductive structures), to hormone secretion, and eventually to external genital appearance. The XX pattern leads to ovaries, which produce estrogen but very little testosterone, resulting in external female appearance at birth. Substitute a Y for one of the X’s and you get testes, which start secreting a lot more testosterone around the sixth week, eventually producing a male genital appearance at birth. Then, after years of almost complete hormonal latency, it’s a pubertal resurgence of testosterone and estrogen, again in different ratios, that produces male or female secondary sex characteristics such as different body hair distribution and different bone, voice, and breast development.

But in rare instances one of the developmental dominoes gets knocked out of line. The most common (and most studied) type of intersex condition is known as congenital adrenal hyperplasia (CAH), in which a genetic XX fetus, after successfully developing ovaries, uterus, and fallopian tubes, starts overproducing testosterone, though in this case it’s from the adrenal glands. The extra testosterone partially or completely masculinizes the external genitals: at birth, the clitoris appears more or less penis-like, and the labia more or less like a medially fused, but empty, scrotum. (This is not as astonishing as you might think, since male and female reproductive structures develop from a common embryological origin.) The syndrome can also occur in male fetuses, though it does not affect their internal or external sexual anatomy. But in either case, because testosterone overproduction continues after birth, there may follow a dramatically early puberty accompanied by typical male secondary sex characteristics, unless hormone therapy—in this case cortisone to counteract the effects of the extra testosterone—is supplied. In addition, about two-thirds of CAH children suffer from life-threatening salt imbalances that require other forms of intervention.

Even today, about a quarter of CAH females are initially assigned as males at birth. Some CAH adults who were surgically refeminized as infants are quite angry that nobody waited until they were old enough to have a say in the matter. They argue that it is not ambiguous genitals that are the problem but society’s inability to accept persons in whom genetic, gonadal, hormonal, and anatomical sex—never mind gender identity, gender roles, and sexual orientation—don’t line up in neatly dichotomous columns. In fact, most CAH adults profess a female gender identity, and are no more likely to engage in homosexual activity than women in the general population—but to CAH anti-surgery lobbyists that is beside the point. Genital surgery on CAH infants addresses no disease risk, and arguably causes more physical and emotional trauma than living a life with ambiguous genitals.

Of course today’s anti-surgery activists can’t turn back the clock to experience what it might have been like to grow up that way. And it’s also the case that many CAH adults operated on as children seem to be content with the results. Many prefer to remain completely anonymous, or at most members of internet or face-to-face support groups. Unlike their activist sisters, they have no interest in picketing the professional meetings of pediatric specialists who won’t stop doing corrective surgery. And, Karkazis points out, it’s hard to know if they should stop, when no well-designed research has been done on the physical, psychological, and social outcomes of genital refeminization, and when a more powerful double-blind study (randomly assigning some CAH infants to have surgery and some not, then following their development) is ethically untenable. Even so, the anti-surgery argument is somewhat supported by case research showing that, contrary to stereotypes about inevitable stigmatization, people who remained genitally ambiguous before the age of plastic surgery grew up with few emotional problems, were content with whatever gender identity they’d been assigned, and sometimes were not even aware that they were unusual. But that was in the days when ignorance about genes and hormones, if not exactly blissful, at least presented people with fewer agonizing choices. Medical progress is indeed a two-edged sword.

In Fixing Sex, Karkazis reports on her interviews with people from many corners of the intersex debate. She does not deal with the questions, attitudes, or pastoral practices of current religious traditions, but neither does she use religion as a whipping boy. She is for the most part scrupulously fair, recognizing that many doctors are well intentioned, and convinced from their own clinical experience that they can anticipate the best outcomes for their patients, with or without surgery. But it’s no secret that some surgeons can become arrogant empire builders, especially if they trained in an era when physicians were mostly independent professionals running their own private practices. Younger doctors, by contrast, are increasingly located in complex research and professional networks, and may even be in salaried rather than fee-for-service arrangements. Especially if they are women, Karkazis found, these doctors are more inclined than their predecessors to dialogue with intersex activists, however “unscientific” the latter’s arguments may appear to older members of the medical establishment. She also notes that both pro- and anti-surgery camps exploit the power of anecdote when it serves their own interests, but dismiss it as “unscientific” when used by their opponents.

Younger physicians are also apt to agree that predicting endocrinological and surgical outcomes is less a science than a complex conversation, requiring a team approach that includes parents, patients’ advocates, independent researchers, and CAH persons themselves. A 2005 consensus statement by an international panel of doctors, with input from intersex activists, basically codified these (among other) conclusions. Though it has only the force of recommendation, not law, it may represent a step toward greater transparency and inclusiveness in dealing with intersex persons. In the end, Karkazis’ conclusion on the nature-nurture debate parallels that of Kuefler and Ringrose. Although sexual difference “is seemingly obvious and certainly real on many levels … in another sense it is a carefully crafted story about the social relations of a particular time and place, mapped onto available bodies.” Nature and culture are mutually influential.

—This essay is part 1 of a two-part article.

1. More academic defenses of BOT include Simon Baron-Cohen, The Essential Difference: Men, Women and the Extreme Male Brain (Basic Books, 2003); Doreen Kimura, Sex and Cognition (MIT Press, 1999); and Susan Pinker, The Sexual Paradox: Men, Women, and the Real Gender Gap (Scribner, 2008). Popular treatments include Louann Brizendine, The Female Brain (Morgan Road Books, 2006); Michael Gurian, What Could He Be Thinking? A Guide to the Mysteries of a Man’s Mind (Jossey Bass, 2004); and Leonard Sax, Why Gender Matters (Doubleday, 2005).

2. Mimi Swartz, “Living the Good Lie: Should Therapists Help God-Fearing Gay People Stay in the Closet?” The New York Times Magazine, June 19, 2011, pp. 30-35, 54 & 57.

3. apa.org/pi/lgbt/resources/therapeutic-response.pdf

4. Benoit Denizet-Lewis, “Going Straight,” The New York Times Magazine, June 19, 2011, pp. 35-39, 46.

5. Evolutionary psychologists are famous for insisting that, due to the survival demands of our hunter-gatherer ancestors’ environment, human behaviors are on a much tighter genetic leash that we might fondly imagine. An assessment of this position is beyond the scope of this essay, but a balanced review and critique of it can be found in Robert C. Richardson, Evolutionary Psychology as Maladapted Psychology (MIT Press, 2007).

6. Hilary M. Lips, Sex and Gender: An Introduction, 5th ed. (McGraw Hill, 2005), p. 109.