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Sexual Desire and Fantasies in the LGBT+ Community: a Focus on Bisexuals, Transgender, and Other Shades of the Rainbow

Sexual Desire and Fantasies in the LGBT+ Community: a Focus on Bisexuals, Transgender, and Other... Purpose of Review The purpose of this review is to summarize the current knowledge on sexual desire expressions, sexual orientation, and identity in understudied groups inside the LGBT+ community. Recent Findings Sexual desire and related problems have unique expressions in LGBT+ people which influence their sexual health. Emerging sex-positive approaches might be powerful and prominent tools to provide support and education on behalf of safer sex practices and marginalized sexualities. The importance of deepening LGBT+ sexualities and relationships, not only in lesbian women and gay men but also in all the other shades of the rainbow (bisexual, transgender, asexual, fluid, and non-binary/ genderqueer identities), is strongly highlighted. Summary A lack of literature regarding sexual desire in LGBT+ people is reported. Results are controversial and research is still limited on this topic, with little information available about sexual and health needs of sexual minorities beyond gay and lesbian people. . . . . . Keywords LGBT+ Sexual desire Sexual minority Bisexuality Transgender Asexuality Introduction as the subjective psychological status to initiate and maintain human sexual behavior triggered by external and internal Sexual desire and its expressions are complex, multifaceted, stimuli [1]. Measures of sexual desire are usually indirect and difficult to define. In research, they are typically defined and focused on manifestations of drive (e.g., frequency of sexual intercourse or masturbation, sexual fantasies, arousal, self-reported level and intensity of sexual desire, sexual dis- This article is part of the Topical Collection on Urology, Gynecology, and tress, attempts or receptivity to have sex). Expressions of de- Endocrinology sire differ widely both among individuals and within the same person, ranging from momentary fluctuations to broad chang- * Filippo Maria Nimbi Filippo.nimbi@uniroma1.it es over life [2]. Most available studies have focused on the sexual desire and fantasies on heterosexual women and men [3]. Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy When it comes to expressions of sexual desire in the LGBT+ community, most studies focused primarily on lesbi- Department of Systems Medicine, University Tor Vergata, Rome, Italy an and gay sexual functioning as they attempted to identify differences and similarities with heterosexual people. In many Department of Psychological, Health and Territorial Sciences, University G. D’Annunzio of Chieti-Pescara, Chieti, Italy of these cases, the aim of the studies was to detect the deter- minants of sexual orientation rather than the idiosyncrasies of Department of General Psychology, University of Padua, Padua, Italy sexual expressions. Early studies were characterized by ste- reotypes and heteronormative beliefs, giving space for a more Texas A&M University Central Texas, 1001 Leadership Place, Killeen, TX 76549, USA realistic view of sexuality in recent years. However, scientific and clinical expertise in this field is still inadequate. For an in- Curr Sex Health Rep (2020) 12:162–169 163 depth discussion of sexual desire and fantasies in lesbian orientation (e.g., lesbian and bisexual women), and some au- women and gay men, readers are encouraged to refer to thors preferred to use collective terms based on sexual behav- Nimbi et al. [4]. ior rather than identity such as men who have sex with men Focusing on other groups under the LGBT+ umbrella, lim- (MSM) and women who have sex with women (WSW). Other ited research has investigated sexual desire in bisexual, trans- authors preferred to use terms such as “other sexual orienta- gender, asexual, fluid, and non-binary/genderqueer popula- tions,”“sexual minority women/men,” or “non-heterosexual tions. Members of these populations seem even more invisible orientation.” Due to these classification differences in the than gay and lesbian people among sexual minorities. The aim studies, comparing and discussing the evidence was quite of the present review was to discuss the current knowledge challenging and findings should be interpreted with caution. about sexual desire and its manifestations in these neglected groups (bisexual, transgender, asexual, fluid, and non-binary/ Bisexual Women and Men genderqueer people) belonging to the LGBT+ community with attention devoted to future research directions and some In the literature, many studies discussing sexual desire in les- clinical suggestions. bian women and gay men [4] have contemplated bisexual people within comprehensive categories such as MSM and WSW. Some of the conclusions drawn for lesbian and gay Methods people could be similar for bisexuals, but further studies in- vestigating the unique nature of sexual desire and erotic fan- The manuscripts for this review were collected based on the tasies in bisexual women and men are urgently needed. On results of a bibliographic research of relevant articles in one hand, joining homosexual and bisexual people in sam- Cochrane Library, Google Scholar, Web of Science, Scopus, pling may have helped researchers in recruiting more partici- and EBSCO. The search terms, including asterisks, were “sex- pants and in focusing on risky behaviors (e.g., studies on STIs ual desire,”“LGBT,”“Bisexual,”“Transgender,”“Asexual,” prevention and risk in MSM). On the other hand, it ascribed “Fluidity,”“Non-binary,”“Genderqueer,” and related terms that bisexuals, homosexuals, and other people who have (e.g., MSM, WSW, Trans, Queer, Fluid). Additional terms same-sex behavior are the same. This assumption might be included “sex* drive,”“sex* fantasies,”“sex* motivation,” incorrect and may express a form of invisibility of bisexual “sex* arousal,” and “sex* interest.” The results were reviewed people in research. Thus, it is important to highlight some following the aims of the current work. Experimental studies peculiarities emerging from the bisexual population in future focusing on different expressions of sexual desire and studies. biopsychosocial factors associated were selected. Books, sys- Bisexual women and men commonly face specific preju- tematic reviews, and meta-analyses describing models, guide- dices from both heterosexual and homosexual people. lines, gold standards, treatment algorithms, and critical issues Bisexuals are frequently considered as confused regarding were also considered for a better characterization of the topic. their sexuality (e.g., considered as homosexual people who Excluded studies were unrelated to the scope of this review have not yet admitted their sexual orientation, to themselves (e.g., focusing only on heterosexual desire only). Article ref- or to others), sexually promiscuous, open to new experiences, erences were reviewed to find additional manuscripts. All ar- unreliable romantic partners, and less inclined to maintain ticles selected were published in English and accessible in full monogamous long-term relationships [5, 6]. Interestingly, an text. When articles were not directly available, authors were online study with lesbian and gay participants found that bi- solicited by email. A total of 61 articles and other sources were sexual women and men were both perceived as being more included in the present review, indicating an emergent body of sexually attracted to men than women. Lesbian women report- research on LGBT+ sexuality in recent years. ed more negative attitudes towards bisexual women than, re- spectively, gay men towards bisexual men [7●]. The academic literature lacks evidence on sexual desire and Results arousal in bisexual women and men. Some studies reported that bisexual women usually showed higher levels of sexual The current review discusses the selected literature in para- desire compared with heterosexual and lesbian women graphs representing some groups of the LGBT+ community. [8–11]. In some cases, the higher level of interest has been For simplicity, we opted for describing 5 categories which are interpreted as expression of a problematic sexuality or para- poorly represented elsewhere: bisexual, transgender, asexual, philia, reinforcing the negative role of stereotypes of sexually fluid, and non-binary/genderqueer identities. This bisexuality. distinction may be, at times, too categorical and may Some studies suggested that response patterns to erotic underrepresent self-determination and flexibility in sexual be- stimuli in bisexual women may be different from other wom- en [9]. For example, bisexual women looked equally long at havior. Many studies did not differentiate between sexual 164 Curr Sex Health Rep (2020) 12:162–169 pictures of women and men, rating them similarly, while les- mental health, and sexual functioning. Historically, the major- bian and heterosexual women paid more attention to women ity of empirical studies about transgender people described and men, respectively (in line with their sexual orientation). cases of patients undergoing the “sex reassignment surgery,” Bisexual women reported highly stable desire over time. focusing on physiological and psychiatric outcomes in a clin- Moreover, bisexuals reported higher sexual desire and arousal ical perspective [21]. Thus, they were first pathologized and for women than heterosexuals and lesbians, while lesbians then recognized as natural expression of gender identity reported lower sexual arousal and desire with men than the thanks to the struggle of many activists and clinicians. Also, other groups [12, 13]. in sexology, research focused primarily on pharmacotherapy, Similar studies on bisexual men have focused on genital surgical treatments, and mental health of this heterogeneous and self-reported sexual arousal to sexual stimuli. Rieger et al. population. Few studies have attempted to understand trans- [14] found that bisexual men do not seem to have strong gender people’s sexual needs nor their desire to achieve a genital arousal to both male and female stimuli. More specif- more satisfying sexual experience [22]. Having a healthy ically, most bisexual men appeared primarily genitally and pleasurable sexual life can be challenging for transgender aroused by male stimuli, although some by female stimuli. individuals. Understanding the personal sexual expectations In contrast, they reported a subjective sexual arousal fitting and values within the trans population is central to determine with a bisexual pattern (towards both men and women). More the kind of sexual health care they may require, which may recent studies have demonstrated bisexual patterns of both vary widely for each individual. subjective and genital arousal in bisexual men [15, 16]. Studies on sexual desire in transsexual people have focused Bisexual men and women showed significantly more fan- primary on the effects of hormonal treatments (HT) and gen- tasies about having more than one sexual partner than hetero- der affirmative surgery (GAS) [23●]. HT directly affects tes- sexual and homosexual men and women, respectively [17]. tosterone levels, which are connected to sexual drive expres- Regarding relationships, bisexual people usually engage in sion. Trans women (MtF) who receive cross-sex hormone negotiations and discussion about their sexual fantasies with treatment usually experience a decrease in testosterone, their partners. A longitudinal study on bisexual women and whereas trans men (FtM) generally face an increase in testos- their partners [18●●] showed that the majority of couples terone levels. GAS may have less direct effects on sexual lived in long-term monogamous relationships, whereas a safe drive, whereas it seems to be more linked to general body space was devoted to discuss and define boundaries of their satisfaction, personal sexual identity recognition, and sexual relationships. The fact that one partner may have sexual desire pleasure [24]. A recentonlinesurvey[23●]revealed that the and fantasies for both genders may give the couple the possi- most frequent sexual problems experienced by trans women bility to talk more deeply about sexuality, to share their needs, and men in HT were desire and orgasm difficulties. Compared and to work more properly towards emotional and sexual with trans people (both men and women) under HT only, trans intimacy. people after GAS seemed to report low sexual desire, aver- Fetish and kinky fantasies and behaviors seem to be dif- sion, and arousal difficulties less often. A large Dutch study fused and have a prominent position in some bisexual, pan- [24] considered 325 MtF and 251 FtM divided in 3 groups: no sexual, and queer identities expressions [19●]. Kinky activi- desire for treatment (NTD), wanting a treatment (UTD), and ties and BDSM (a variety of behaviors involving bondage, treatment fulfilled (FTD). For MtF, no difference was found discipline, dominance, submission, sadomasochism, and other regarding partnered sexual activity frequency among the 3 practices) could be good opportunities for exploring gender groups, while masturbation was higher in NTD than the other identity and sexual orientation. The BDSM community has two groups. Regarding FtM, the frequency of masturbation been historically respectful of diversities and expressions and partnered sexual activity in UTD and FTD groups was [20]. Moreover, being inside a community can be an impor- higher than NTD. The authors underscored that UTD and tant supportive factor to contrast minority stress consequences FTD were taking HT, which may explain the desire variation such as shame, isolation, grief, and loss. This raises some between groups. important considerations for support and therapy. Kink- In general, we should be very careful in attributing power- aware and sex-positive clinicians might have a uniquely suited ful changes in sexuality to HT. The effect of testosterone approach and set of skills to work with bisexual, pansexual, treatments on sexual desire has been overestimated in recent and queer people [19●]. years [2, 3]. Currently, there is no evidence to confirm a direct positive association between testosterone levels and sexual Transgender Women and Men desire in FtM [25]. These findings are in line with other stud- ies highlighting lower levels of sexual desire reported by MtF During the years, transgender women and men have attracted and higher levels reported by FtM after gender-confirming many researchers as their condition questioned the existing interventions [26–29]. However, sexual desire variation after GAS is not always perceived as distressful for trans people as knowledge and definitions regarding sexuality, identity, Curr Sex Health Rep (2020) 12:162–169 165 many reported it as a “desired” effect, perceiving it as the indifference in this population [34–36]. A recent study [38●●] “typical” expression of their gender identity and role [28, highlighted that many asexual individuals reported sexual ac- 30]. Conversely, it should be noted that the will to adhere to tivities before realizing their asexual orientation. Interestingly, stereotypic gender roles of the identified gender may also all participants have experienced relationships, connection, influence the expression of sexual desire and behavior in and romance in unique and creative ways. Another study transgender people. For example, some FtM may report [36] showed that some asexual people enjoyed arousal and higher desire levels to show more masculine and virile atti- orgasms in different ways than other sexual orientations. tudes and behavior [31, 32]. Asexual individuals are more likely to report never having To better understand this controversial topic, other had a sexual fantasy than other men and women. Usually, biopsychosocial factors should be considered. Body dyspho- asexual individuals’ fantasies do not involve other people or, ria, sexual satisfaction, fear of fetishization, depression, anxi- when involved, have a peripheral role or are faceless [39–41]. ety, and other mental health issues are relevant dimensions Some asexual individuals reported only objects, situations, or that should be taken into account in transgender people’ssex- masturbation elicit desire and pleasure for them [41]. ual life [22, 28]. Furthermore, internalized transphobia could It may seem paradoxical, but many asexual people create have a negative role on sexual desire and satisfaction as significant relationships through BDSM, conventionally as- highlighted for homonegativity in lesbian and gay people sumed to involve sexual interactions. Asexual BDSM practi- [23●]. tioners seem to form non-sexual relationships based on affec- Regarding sexual fantasies, we did not find any available tion and domination rather than fulfillment of sexual desire. For study in the literature which focused on the transgender pop- example, these people adapt BDSM practice to generate trust, ulation. However, some clinical reports highlighted a differ- courage, insight, self-discipline, power, and attunement in their ence between pre- and post-surgery sexual fantasies in both relationships rather than sexual desire or pleasure [20, 41]. FtM and MtF. Pre-surgery erotic imagery may be more char- Asexual people may have desire and engage in sexual be- acterized by fantasies of oneself belonging to the opposite havior, but our current definitions of sexuality are too strict and biological sex (with focus on body parts), whereas the post- not comprehensive enough to describe their experiences. Lack surgery imagery seems more adherent to the fantasies of the of reliable tools, difficulties in recruiting sufficiently powered perceived gender (i.e., FtM are more in line with conventional samples, and reliance on web-based asexual communities are fantasies presented by cisgender men) [33]. the most common limitations of the available studies. Validated Diversity and variability within the transgender community questionnaires to identify asexuality are available [42], but in terms of identity, gender expression, sexual orientation, and when it comes to sexual health, no one yet knows what asexual lifestyle should also be recognized and celebrated in academic people need. Clinicians may be not prepared, aware, nor ready literature. Transgender people may benefit from sexual to fully understand and respect this population, and further ef- counseling at any stage of their transition and beyond [22], forts are needed to close the scientific gap. especially for those who experience distress in sexual desire or other sexual functions [27]. Clinicians should pay attention to Sexual Fluidity potential psychological and social barriers to their patients’ sexual health and be prepared to offer a sex-positive clinical Sexual fluidity could be defined as situation-dependent flexi- consultation, questioning their own prejudices and biases bility in sexual responsiveness, which makes it possible for about trans-sexualities. some people to experience attraction for either women or men regardless of their reported sexual orientation under certain Asexuals circumstances [43]. In the literature, women appear to be more fluid than men regarding their sexual attraction and orientation Since the 1990s, many people began to identify as “asexual” over the lifespan [44]. Data from a Swedish survey on almost through recognizing the absence of sexual attraction towards 2000 young participants [45] showed that women were twice individuals of any gender [34–36]. Asexuality has intrigued as likely as men to report fluid attraction. Factors associated researchers and clinicians as it challenges the idea of sexual with fluidity in both women and men were a maximal fluidity desire as a basic human instinct and need. Some researchers peak between 25 and 34 years old, not being religious, living have recognized asexuality as a heterogeneous entity that in urban contexts, and away from the family. Interestingly, meets the criteria for a sexual orientation [37], but there is fluid men reported higher education levels than men with no full agreement in literature yet on this point. more fixed sexual orientation and preferences. Contrary to stereotypes depicting asexual people as Being fluid about sexual attraction and orientation does not uninterested in sexual expressions or feelings, they do not mean that people are confused, perverted, or mentally unstable. necessarily abstain from sex. Literature has highlighted a var- Rather, it seems to have more to do with expanding sexual pref- iability of approaches to sexuality, ranging from revulsion to erences and a pattern of attractions over time [45, 46]. Farr et al. 166 Curr Sex Health Rep (2020) 12:162–169 [46] showed that lesbian and bisexual women had more stable sizable proportion of the population. About one-third of trans- same-sex attraction during their lives, while fluid women report- gender people primarily identified as non-binary [54]. ed more variable levels of attraction to men and women over Non-binary people present a variety of sexual orientations and time. Typically, the shifts are between adjacent categories refer- desire expressions, but research on this population is difficult and ring to the Kinsey scale (such as “Exclusively heterosexual” and limited [55]. Regarding the aim of the current review, we did not “Predominantly heterosexual, only incidentally homosexual”) find any source on sexual desire in non-binary/genderqueer pop- rather than broader changes (e.g., from “Exclusively homosexu- ulation. However, this blank page represents the possibility to al” to “Exclusively heterosexual”)[43]. open interesting and totally new lines of research. This opportu- Studies on arousal provided evidence that, while men dem- nity goes beyond the importance of understanding identities and onstrated genital arousal primarily to female or male sexual labels. It may represent the possibility to better understand how stimuli (based on their sexual orientation), women exhibit gender identity, desire, and sexual behavior interact to produce genital arousal to both male and female sexual stimuli regard- different sexual expressions [56]. less of their orientation [44, 47]. Dawson and Chivers [48] Queer identities are increasingly being recognized in west- reported the presence of a higher level of nonspecific gender ern societies by the legal, medical, and psychological systems pattern of arousal in androphilic women, both in solitary and in line with the emerging advocacy of the LGBT+ rights and dyadic desire rather than gynephilic women. health needs [54]. However, non-binary and genderqueer peo- A recent study on erotic imagery reported that fantasies about ple remain marginalized and at high risk of victimization and having homosexual activities were more frequent in women than minority stress, including within the LGBT+ community. men [49]: about 42.4% of women have fantasized about While not pathological in and of themselves, the experience watching two other women having sex, 35.7% about giving of being invisible and ostracized may affect their mental and cunnilingus, and 36.9% about having sex with another woman sexual health (high suicide risk, distress, high levels of depres- although only 19% of the respondents considered themselves as sion and anxiety). Some suggestions to mental health profes- bisexuals or lesbians. Interestingly, in the same study, also in sionals are present and valid [55], such as using gender-neutral men the percentages of people fantasizing about homosexual pronouns chosen by the person (e.g., “they/them/hers”)and activities significantly exceeded the percentages of gay or bisex- using gender-neutral terms that may prevent clients from feel- ual men: approximately 26.8% of men fantasized about giving ing misunderstood. Psychologists are strongly encouraged to fellatio and 20.6% about having sex with another man. challenge the dominant binary assumption about gender iden- In general, women seem to report less negative affect than tities, creating friendly environments that may include non- men in response to thoughts about homosexual sexual activity binary individuals and being supportive in the process of [50] and the higher level of fluidity in women could be due to self-affirmation and improvement of quality of life [54]. the fact that same-gender fantasies and behaviors could be more threatening to traditional male gender roles than to fe- male ones, thus impeding men from exploring or recognizing Conclusions themselves as fluid [51]. Other explanations were attributed to females’ higher erotic plasticity or being more open to change, LGBT+ people demonstrated a variety of sexual expressions while evolutionary psychology has proposed that fluidity may that are hard to categorize using the heteronormative sexual allow women in polygamous marriages to have sex with their standards that permeate the literature and clinical practice. cowives and reduce conflicts and tension [52]. Obviously, our This review represents a small drop in the ocean of sexual knowledge on fluidity is still extremely lacking. Clear defini- diversity. The more we explore this topic, the more we should tions and guidelines for sexual health are missing and clini- recognize that our theorical backgrounds are too rigid and cians may benefit from future studies focused on experiences, narrow to understand the kaleidoscopic nature of sexualities. negotiation, and needs of fluid people [53]. We urgently need to change our view on sexual health. It will be hard to consider distress as the main criteria for sexual problems while we cling to an antiquated view of “normal” Non-binary/Genderqueer Identities sexual behavior. Negative sexual beliefs and attitudes may represent barriers to access to sexual health care. Some people may identify as non-binary or genderqueer, indi- Recognizing them is part of clinical work and may allow cating a spectrum of gender identities that are not exclusively significant improvements in care and treatment [57]. masculine or feminine. This umbrella collects people identifying Addressing desire problems in LGBT+ people should include as having two or more genders, no gender, moving/fluctuating assessment of sexual practices, frequency of sexual activity, between genders, being a “third” gender, and more. couple discrepancies in desires levels, and erotic repertoires Epidemiological studies showed small percentages of non- [2, 3]. It is also important to explore how the couple commu- binary people but, in terms of raw numbers, they represented a nicates about sexual issues and improve said dialogue [58]. Curr Sex Health Rep (2020) 12:162–169 167 desire?”. J Sex Med. 2014;11(11):2709–19. https://doi.org/10. In conclusion, there is the need to recognize emerging sex- 1111/jsm.12683. positive approaches as powerful and prominent tools to pro- 2 Nimbi FM, Tripodi F, Rossi R, Navarro-Cremades F, Simonelli C. vide support and education on behalf of safer sex practices and Male sexual desire: an overview of biological, psychological, sexu- marginalized sexualities. Sex-positivity is a non-judgmental al, relational, and cultural factors influencing desire. Sexual medi- cine reviews. 2020;8(1):89–91. https://doi.org/10.1016/j.sxmr. philosophy that recognizes the differences in sexualities, be- 2018.12.002. yond heteronormative penetrative intercourse, and encounters 3 Nimbi FM, Tripodi F, Rossi R, Michetti PM, Simonelli C. Which the individual needs of each person [59]. It argues the need to psychosocial variables affect drive the most? Analysis of sexual emphasize the personal meaning of sexuality and its relation- desire in a group of Italian men. Int J Impot Res. 2019;31:410–23. https://doi.org/10.1038/s41443-018-0105-8. ship with health and well-being [60]. Overall, sex-positivity 4 Nimbi FM, Ciocca G, Limoncin E, Fontanesi L, Batuhan U, not only focuses on the absence of physical and emotional Flinchum M, Tambelli R, Jannini EA, Simonelli C. 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[56] Ciocca G, Zauri S, Limoncin E, Mollaioli D, D’Antuono L, Carosa Publisher’sNote Springer Nature remains neutral with regard to jurisdic- E, et al. Attachment style, sexual orientation, and biological sex in tional claims in published maps and institutional affiliations. their relationships with gender role. Sexual medicine. 2020;8(1): 76–83. https://doi.org/10.1016/j.esxm.2019.09.001. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Current Sexual Health Reports Springer Journals

Sexual Desire and Fantasies in the LGBT+ Community: a Focus on Bisexuals, Transgender, and Other Shades of the Rainbow

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Springer Journals
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Copyright © The Author(s) 2020
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1548-3584
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1548-3592
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10.1007/s11930-020-00262-8
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Abstract

Purpose of Review The purpose of this review is to summarize the current knowledge on sexual desire expressions, sexual orientation, and identity in understudied groups inside the LGBT+ community. Recent Findings Sexual desire and related problems have unique expressions in LGBT+ people which influence their sexual health. Emerging sex-positive approaches might be powerful and prominent tools to provide support and education on behalf of safer sex practices and marginalized sexualities. The importance of deepening LGBT+ sexualities and relationships, not only in lesbian women and gay men but also in all the other shades of the rainbow (bisexual, transgender, asexual, fluid, and non-binary/ genderqueer identities), is strongly highlighted. Summary A lack of literature regarding sexual desire in LGBT+ people is reported. Results are controversial and research is still limited on this topic, with little information available about sexual and health needs of sexual minorities beyond gay and lesbian people. . . . . . Keywords LGBT+ Sexual desire Sexual minority Bisexuality Transgender Asexuality Introduction as the subjective psychological status to initiate and maintain human sexual behavior triggered by external and internal Sexual desire and its expressions are complex, multifaceted, stimuli [1]. Measures of sexual desire are usually indirect and difficult to define. In research, they are typically defined and focused on manifestations of drive (e.g., frequency of sexual intercourse or masturbation, sexual fantasies, arousal, self-reported level and intensity of sexual desire, sexual dis- This article is part of the Topical Collection on Urology, Gynecology, and tress, attempts or receptivity to have sex). Expressions of de- Endocrinology sire differ widely both among individuals and within the same person, ranging from momentary fluctuations to broad chang- * Filippo Maria Nimbi Filippo.nimbi@uniroma1.it es over life [2]. Most available studies have focused on the sexual desire and fantasies on heterosexual women and men [3]. Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy When it comes to expressions of sexual desire in the LGBT+ community, most studies focused primarily on lesbi- Department of Systems Medicine, University Tor Vergata, Rome, Italy an and gay sexual functioning as they attempted to identify differences and similarities with heterosexual people. In many Department of Psychological, Health and Territorial Sciences, University G. D’Annunzio of Chieti-Pescara, Chieti, Italy of these cases, the aim of the studies was to detect the deter- minants of sexual orientation rather than the idiosyncrasies of Department of General Psychology, University of Padua, Padua, Italy sexual expressions. Early studies were characterized by ste- reotypes and heteronormative beliefs, giving space for a more Texas A&M University Central Texas, 1001 Leadership Place, Killeen, TX 76549, USA realistic view of sexuality in recent years. However, scientific and clinical expertise in this field is still inadequate. For an in- Curr Sex Health Rep (2020) 12:162–169 163 depth discussion of sexual desire and fantasies in lesbian orientation (e.g., lesbian and bisexual women), and some au- women and gay men, readers are encouraged to refer to thors preferred to use collective terms based on sexual behav- Nimbi et al. [4]. ior rather than identity such as men who have sex with men Focusing on other groups under the LGBT+ umbrella, lim- (MSM) and women who have sex with women (WSW). Other ited research has investigated sexual desire in bisexual, trans- authors preferred to use terms such as “other sexual orienta- gender, asexual, fluid, and non-binary/genderqueer popula- tions,”“sexual minority women/men,” or “non-heterosexual tions. Members of these populations seem even more invisible orientation.” Due to these classification differences in the than gay and lesbian people among sexual minorities. The aim studies, comparing and discussing the evidence was quite of the present review was to discuss the current knowledge challenging and findings should be interpreted with caution. about sexual desire and its manifestations in these neglected groups (bisexual, transgender, asexual, fluid, and non-binary/ Bisexual Women and Men genderqueer people) belonging to the LGBT+ community with attention devoted to future research directions and some In the literature, many studies discussing sexual desire in les- clinical suggestions. bian women and gay men [4] have contemplated bisexual people within comprehensive categories such as MSM and WSW. Some of the conclusions drawn for lesbian and gay Methods people could be similar for bisexuals, but further studies in- vestigating the unique nature of sexual desire and erotic fan- The manuscripts for this review were collected based on the tasies in bisexual women and men are urgently needed. On results of a bibliographic research of relevant articles in one hand, joining homosexual and bisexual people in sam- Cochrane Library, Google Scholar, Web of Science, Scopus, pling may have helped researchers in recruiting more partici- and EBSCO. The search terms, including asterisks, were “sex- pants and in focusing on risky behaviors (e.g., studies on STIs ual desire,”“LGBT,”“Bisexual,”“Transgender,”“Asexual,” prevention and risk in MSM). On the other hand, it ascribed “Fluidity,”“Non-binary,”“Genderqueer,” and related terms that bisexuals, homosexuals, and other people who have (e.g., MSM, WSW, Trans, Queer, Fluid). Additional terms same-sex behavior are the same. This assumption might be included “sex* drive,”“sex* fantasies,”“sex* motivation,” incorrect and may express a form of invisibility of bisexual “sex* arousal,” and “sex* interest.” The results were reviewed people in research. Thus, it is important to highlight some following the aims of the current work. Experimental studies peculiarities emerging from the bisexual population in future focusing on different expressions of sexual desire and studies. biopsychosocial factors associated were selected. Books, sys- Bisexual women and men commonly face specific preju- tematic reviews, and meta-analyses describing models, guide- dices from both heterosexual and homosexual people. lines, gold standards, treatment algorithms, and critical issues Bisexuals are frequently considered as confused regarding were also considered for a better characterization of the topic. their sexuality (e.g., considered as homosexual people who Excluded studies were unrelated to the scope of this review have not yet admitted their sexual orientation, to themselves (e.g., focusing only on heterosexual desire only). Article ref- or to others), sexually promiscuous, open to new experiences, erences were reviewed to find additional manuscripts. All ar- unreliable romantic partners, and less inclined to maintain ticles selected were published in English and accessible in full monogamous long-term relationships [5, 6]. Interestingly, an text. When articles were not directly available, authors were online study with lesbian and gay participants found that bi- solicited by email. A total of 61 articles and other sources were sexual women and men were both perceived as being more included in the present review, indicating an emergent body of sexually attracted to men than women. Lesbian women report- research on LGBT+ sexuality in recent years. ed more negative attitudes towards bisexual women than, re- spectively, gay men towards bisexual men [7●]. The academic literature lacks evidence on sexual desire and Results arousal in bisexual women and men. Some studies reported that bisexual women usually showed higher levels of sexual The current review discusses the selected literature in para- desire compared with heterosexual and lesbian women graphs representing some groups of the LGBT+ community. [8–11]. In some cases, the higher level of interest has been For simplicity, we opted for describing 5 categories which are interpreted as expression of a problematic sexuality or para- poorly represented elsewhere: bisexual, transgender, asexual, philia, reinforcing the negative role of stereotypes of sexually fluid, and non-binary/genderqueer identities. This bisexuality. distinction may be, at times, too categorical and may Some studies suggested that response patterns to erotic underrepresent self-determination and flexibility in sexual be- stimuli in bisexual women may be different from other wom- en [9]. For example, bisexual women looked equally long at havior. Many studies did not differentiate between sexual 164 Curr Sex Health Rep (2020) 12:162–169 pictures of women and men, rating them similarly, while les- mental health, and sexual functioning. Historically, the major- bian and heterosexual women paid more attention to women ity of empirical studies about transgender people described and men, respectively (in line with their sexual orientation). cases of patients undergoing the “sex reassignment surgery,” Bisexual women reported highly stable desire over time. focusing on physiological and psychiatric outcomes in a clin- Moreover, bisexuals reported higher sexual desire and arousal ical perspective [21]. Thus, they were first pathologized and for women than heterosexuals and lesbians, while lesbians then recognized as natural expression of gender identity reported lower sexual arousal and desire with men than the thanks to the struggle of many activists and clinicians. Also, other groups [12, 13]. in sexology, research focused primarily on pharmacotherapy, Similar studies on bisexual men have focused on genital surgical treatments, and mental health of this heterogeneous and self-reported sexual arousal to sexual stimuli. Rieger et al. population. Few studies have attempted to understand trans- [14] found that bisexual men do not seem to have strong gender people’s sexual needs nor their desire to achieve a genital arousal to both male and female stimuli. More specif- more satisfying sexual experience [22]. Having a healthy ically, most bisexual men appeared primarily genitally and pleasurable sexual life can be challenging for transgender aroused by male stimuli, although some by female stimuli. individuals. Understanding the personal sexual expectations In contrast, they reported a subjective sexual arousal fitting and values within the trans population is central to determine with a bisexual pattern (towards both men and women). More the kind of sexual health care they may require, which may recent studies have demonstrated bisexual patterns of both vary widely for each individual. subjective and genital arousal in bisexual men [15, 16]. Studies on sexual desire in transsexual people have focused Bisexual men and women showed significantly more fan- primary on the effects of hormonal treatments (HT) and gen- tasies about having more than one sexual partner than hetero- der affirmative surgery (GAS) [23●]. HT directly affects tes- sexual and homosexual men and women, respectively [17]. tosterone levels, which are connected to sexual drive expres- Regarding relationships, bisexual people usually engage in sion. Trans women (MtF) who receive cross-sex hormone negotiations and discussion about their sexual fantasies with treatment usually experience a decrease in testosterone, their partners. A longitudinal study on bisexual women and whereas trans men (FtM) generally face an increase in testos- their partners [18●●] showed that the majority of couples terone levels. GAS may have less direct effects on sexual lived in long-term monogamous relationships, whereas a safe drive, whereas it seems to be more linked to general body space was devoted to discuss and define boundaries of their satisfaction, personal sexual identity recognition, and sexual relationships. The fact that one partner may have sexual desire pleasure [24]. A recentonlinesurvey[23●]revealed that the and fantasies for both genders may give the couple the possi- most frequent sexual problems experienced by trans women bility to talk more deeply about sexuality, to share their needs, and men in HT were desire and orgasm difficulties. Compared and to work more properly towards emotional and sexual with trans people (both men and women) under HT only, trans intimacy. people after GAS seemed to report low sexual desire, aver- Fetish and kinky fantasies and behaviors seem to be dif- sion, and arousal difficulties less often. A large Dutch study fused and have a prominent position in some bisexual, pan- [24] considered 325 MtF and 251 FtM divided in 3 groups: no sexual, and queer identities expressions [19●]. Kinky activi- desire for treatment (NTD), wanting a treatment (UTD), and ties and BDSM (a variety of behaviors involving bondage, treatment fulfilled (FTD). For MtF, no difference was found discipline, dominance, submission, sadomasochism, and other regarding partnered sexual activity frequency among the 3 practices) could be good opportunities for exploring gender groups, while masturbation was higher in NTD than the other identity and sexual orientation. The BDSM community has two groups. Regarding FtM, the frequency of masturbation been historically respectful of diversities and expressions and partnered sexual activity in UTD and FTD groups was [20]. Moreover, being inside a community can be an impor- higher than NTD. The authors underscored that UTD and tant supportive factor to contrast minority stress consequences FTD were taking HT, which may explain the desire variation such as shame, isolation, grief, and loss. This raises some between groups. important considerations for support and therapy. Kink- In general, we should be very careful in attributing power- aware and sex-positive clinicians might have a uniquely suited ful changes in sexuality to HT. The effect of testosterone approach and set of skills to work with bisexual, pansexual, treatments on sexual desire has been overestimated in recent and queer people [19●]. years [2, 3]. Currently, there is no evidence to confirm a direct positive association between testosterone levels and sexual Transgender Women and Men desire in FtM [25]. These findings are in line with other stud- ies highlighting lower levels of sexual desire reported by MtF During the years, transgender women and men have attracted and higher levels reported by FtM after gender-confirming many researchers as their condition questioned the existing interventions [26–29]. However, sexual desire variation after GAS is not always perceived as distressful for trans people as knowledge and definitions regarding sexuality, identity, Curr Sex Health Rep (2020) 12:162–169 165 many reported it as a “desired” effect, perceiving it as the indifference in this population [34–36]. A recent study [38●●] “typical” expression of their gender identity and role [28, highlighted that many asexual individuals reported sexual ac- 30]. Conversely, it should be noted that the will to adhere to tivities before realizing their asexual orientation. Interestingly, stereotypic gender roles of the identified gender may also all participants have experienced relationships, connection, influence the expression of sexual desire and behavior in and romance in unique and creative ways. Another study transgender people. For example, some FtM may report [36] showed that some asexual people enjoyed arousal and higher desire levels to show more masculine and virile atti- orgasms in different ways than other sexual orientations. tudes and behavior [31, 32]. Asexual individuals are more likely to report never having To better understand this controversial topic, other had a sexual fantasy than other men and women. Usually, biopsychosocial factors should be considered. Body dyspho- asexual individuals’ fantasies do not involve other people or, ria, sexual satisfaction, fear of fetishization, depression, anxi- when involved, have a peripheral role or are faceless [39–41]. ety, and other mental health issues are relevant dimensions Some asexual individuals reported only objects, situations, or that should be taken into account in transgender people’ssex- masturbation elicit desire and pleasure for them [41]. ual life [22, 28]. Furthermore, internalized transphobia could It may seem paradoxical, but many asexual people create have a negative role on sexual desire and satisfaction as significant relationships through BDSM, conventionally as- highlighted for homonegativity in lesbian and gay people sumed to involve sexual interactions. Asexual BDSM practi- [23●]. tioners seem to form non-sexual relationships based on affec- Regarding sexual fantasies, we did not find any available tion and domination rather than fulfillment of sexual desire. For study in the literature which focused on the transgender pop- example, these people adapt BDSM practice to generate trust, ulation. However, some clinical reports highlighted a differ- courage, insight, self-discipline, power, and attunement in their ence between pre- and post-surgery sexual fantasies in both relationships rather than sexual desire or pleasure [20, 41]. FtM and MtF. Pre-surgery erotic imagery may be more char- Asexual people may have desire and engage in sexual be- acterized by fantasies of oneself belonging to the opposite havior, but our current definitions of sexuality are too strict and biological sex (with focus on body parts), whereas the post- not comprehensive enough to describe their experiences. Lack surgery imagery seems more adherent to the fantasies of the of reliable tools, difficulties in recruiting sufficiently powered perceived gender (i.e., FtM are more in line with conventional samples, and reliance on web-based asexual communities are fantasies presented by cisgender men) [33]. the most common limitations of the available studies. Validated Diversity and variability within the transgender community questionnaires to identify asexuality are available [42], but in terms of identity, gender expression, sexual orientation, and when it comes to sexual health, no one yet knows what asexual lifestyle should also be recognized and celebrated in academic people need. Clinicians may be not prepared, aware, nor ready literature. Transgender people may benefit from sexual to fully understand and respect this population, and further ef- counseling at any stage of their transition and beyond [22], forts are needed to close the scientific gap. especially for those who experience distress in sexual desire or other sexual functions [27]. Clinicians should pay attention to Sexual Fluidity potential psychological and social barriers to their patients’ sexual health and be prepared to offer a sex-positive clinical Sexual fluidity could be defined as situation-dependent flexi- consultation, questioning their own prejudices and biases bility in sexual responsiveness, which makes it possible for about trans-sexualities. some people to experience attraction for either women or men regardless of their reported sexual orientation under certain Asexuals circumstances [43]. In the literature, women appear to be more fluid than men regarding their sexual attraction and orientation Since the 1990s, many people began to identify as “asexual” over the lifespan [44]. Data from a Swedish survey on almost through recognizing the absence of sexual attraction towards 2000 young participants [45] showed that women were twice individuals of any gender [34–36]. Asexuality has intrigued as likely as men to report fluid attraction. Factors associated researchers and clinicians as it challenges the idea of sexual with fluidity in both women and men were a maximal fluidity desire as a basic human instinct and need. Some researchers peak between 25 and 34 years old, not being religious, living have recognized asexuality as a heterogeneous entity that in urban contexts, and away from the family. Interestingly, meets the criteria for a sexual orientation [37], but there is fluid men reported higher education levels than men with no full agreement in literature yet on this point. more fixed sexual orientation and preferences. Contrary to stereotypes depicting asexual people as Being fluid about sexual attraction and orientation does not uninterested in sexual expressions or feelings, they do not mean that people are confused, perverted, or mentally unstable. necessarily abstain from sex. Literature has highlighted a var- Rather, it seems to have more to do with expanding sexual pref- iability of approaches to sexuality, ranging from revulsion to erences and a pattern of attractions over time [45, 46]. Farr et al. 166 Curr Sex Health Rep (2020) 12:162–169 [46] showed that lesbian and bisexual women had more stable sizable proportion of the population. About one-third of trans- same-sex attraction during their lives, while fluid women report- gender people primarily identified as non-binary [54]. ed more variable levels of attraction to men and women over Non-binary people present a variety of sexual orientations and time. Typically, the shifts are between adjacent categories refer- desire expressions, but research on this population is difficult and ring to the Kinsey scale (such as “Exclusively heterosexual” and limited [55]. Regarding the aim of the current review, we did not “Predominantly heterosexual, only incidentally homosexual”) find any source on sexual desire in non-binary/genderqueer pop- rather than broader changes (e.g., from “Exclusively homosexu- ulation. However, this blank page represents the possibility to al” to “Exclusively heterosexual”)[43]. open interesting and totally new lines of research. This opportu- Studies on arousal provided evidence that, while men dem- nity goes beyond the importance of understanding identities and onstrated genital arousal primarily to female or male sexual labels. It may represent the possibility to better understand how stimuli (based on their sexual orientation), women exhibit gender identity, desire, and sexual behavior interact to produce genital arousal to both male and female sexual stimuli regard- different sexual expressions [56]. less of their orientation [44, 47]. Dawson and Chivers [48] Queer identities are increasingly being recognized in west- reported the presence of a higher level of nonspecific gender ern societies by the legal, medical, and psychological systems pattern of arousal in androphilic women, both in solitary and in line with the emerging advocacy of the LGBT+ rights and dyadic desire rather than gynephilic women. health needs [54]. However, non-binary and genderqueer peo- A recent study on erotic imagery reported that fantasies about ple remain marginalized and at high risk of victimization and having homosexual activities were more frequent in women than minority stress, including within the LGBT+ community. men [49]: about 42.4% of women have fantasized about While not pathological in and of themselves, the experience watching two other women having sex, 35.7% about giving of being invisible and ostracized may affect their mental and cunnilingus, and 36.9% about having sex with another woman sexual health (high suicide risk, distress, high levels of depres- although only 19% of the respondents considered themselves as sion and anxiety). Some suggestions to mental health profes- bisexuals or lesbians. Interestingly, in the same study, also in sionals are present and valid [55], such as using gender-neutral men the percentages of people fantasizing about homosexual pronouns chosen by the person (e.g., “they/them/hers”)and activities significantly exceeded the percentages of gay or bisex- using gender-neutral terms that may prevent clients from feel- ual men: approximately 26.8% of men fantasized about giving ing misunderstood. Psychologists are strongly encouraged to fellatio and 20.6% about having sex with another man. challenge the dominant binary assumption about gender iden- In general, women seem to report less negative affect than tities, creating friendly environments that may include non- men in response to thoughts about homosexual sexual activity binary individuals and being supportive in the process of [50] and the higher level of fluidity in women could be due to self-affirmation and improvement of quality of life [54]. the fact that same-gender fantasies and behaviors could be more threatening to traditional male gender roles than to fe- male ones, thus impeding men from exploring or recognizing Conclusions themselves as fluid [51]. Other explanations were attributed to females’ higher erotic plasticity or being more open to change, LGBT+ people demonstrated a variety of sexual expressions while evolutionary psychology has proposed that fluidity may that are hard to categorize using the heteronormative sexual allow women in polygamous marriages to have sex with their standards that permeate the literature and clinical practice. cowives and reduce conflicts and tension [52]. Obviously, our This review represents a small drop in the ocean of sexual knowledge on fluidity is still extremely lacking. Clear defini- diversity. The more we explore this topic, the more we should tions and guidelines for sexual health are missing and clini- recognize that our theorical backgrounds are too rigid and cians may benefit from future studies focused on experiences, narrow to understand the kaleidoscopic nature of sexualities. negotiation, and needs of fluid people [53]. We urgently need to change our view on sexual health. It will be hard to consider distress as the main criteria for sexual problems while we cling to an antiquated view of “normal” Non-binary/Genderqueer Identities sexual behavior. Negative sexual beliefs and attitudes may represent barriers to access to sexual health care. Some people may identify as non-binary or genderqueer, indi- Recognizing them is part of clinical work and may allow cating a spectrum of gender identities that are not exclusively significant improvements in care and treatment [57]. masculine or feminine. This umbrella collects people identifying Addressing desire problems in LGBT+ people should include as having two or more genders, no gender, moving/fluctuating assessment of sexual practices, frequency of sexual activity, between genders, being a “third” gender, and more. couple discrepancies in desires levels, and erotic repertoires Epidemiological studies showed small percentages of non- [2, 3]. It is also important to explore how the couple commu- binary people but, in terms of raw numbers, they represented a nicates about sexual issues and improve said dialogue [58]. Curr Sex Health Rep (2020) 12:162–169 167 desire?”. J Sex Med. 2014;11(11):2709–19. https://doi.org/10. In conclusion, there is the need to recognize emerging sex- 1111/jsm.12683. positive approaches as powerful and prominent tools to pro- 2 Nimbi FM, Tripodi F, Rossi R, Navarro-Cremades F, Simonelli C. vide support and education on behalf of safer sex practices and Male sexual desire: an overview of biological, psychological, sexu- marginalized sexualities. Sex-positivity is a non-judgmental al, relational, and cultural factors influencing desire. 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