Clinical evidence in sexual orientations: definitions, neurobiological profiles, and psychological implications

Purpose: The aim of this research is to detect any clinical evidence in patients on the basis of their sexual orientation choice. The starting hypothesis, taking into account the neurobiological and endocrinological data of the last twenty years on the subject of sexual orientation, is to demonstrate an increase in psychopathological indexation in non-heterosexual patients, and then to detect among the possible psychological causal hypotheses which indicators are most present in the individual clinical history, in order to demonstrate that sexual orientation other than heterosexuality is an adaptation to a previous psychological trauma with a strong emotional and sexual impact. This research work aims to answer the following one question: “Are there any dysfunctional psychological factors that occur more frequently in any of the fi ve identifi ed groups?”. Methods: Clinical interview and administration of the PICI-1 and PSM-1. Results: In the male heterosexual group, the psychopathological values were 43.96%, with a greater presence of neurotic disorders, while in the female heterosexual group, the values were 57.27%, with the same majority found in the male group. In the male homosexual group, the psychopathological values were 66%, with a greater presence of neurotic disorders, while in the female homosexual group, the values were 76.97%, with the same majority found in the male group. In the male bisexual group the psychopathological values were 76.44%, with a greater presence of neurotic disorders, while in the female bisexual group the values were 70%, with the same majority as in the male group. In the groups related to the other sexual orientations (bi-curiosity, asexuality and pansexuality), none of the respondents ticked “None of the above”, thus endorsing the thesis that at least one of these factors could be a concomitant cause of the onset of non-heterosexual preference. With reference to the results obtained from the PSM-1, to the question “Are there dysfunctional psychological factors that occur more frequently?” the ticking of “None of the above” emerges in half of the respondents and tends to decrease to zero in the non-heterosexual orientations, confi rming the trend already underlined. Conclusions: The topic under consideration is very thorny, more for its socio-political implications than for its clinical ones. Here, in fact, is not at stake any judgment of merit or form, but the exact clinical placement in the cognitive and experiential framework. These considerations are completely detached and far from any form of judgment or condemnation ethical, moral, social and personal. On the subject of the pathologization of sexual orientations other than heterosexuality, between the two theses under discussion (confi rmation, on the one hand, or disconfi rmation, on the other), this research suggests the “median” position that on the one hand confi rms the non-pathological nature of sexual orientations other than heterosexuality in itself (since there is no scientifi c evidence to the contrary), but on the other confi rms the hypothesis that, on the basis of the person’s experience, psychopathological conditions can coexist that require psychotherapeutic intervention, regardless of the orientation in itself. In conclusion, therefore, signifi cant data emerge from this research in favor of the psychological etiological hypothesis (even if the writer adheres to the multi-causal hypothesis) according to which in sexual orientations other than heterosexuality there is a marked indexation of psychopathological and dysfunctional traits compared to the heterosexual group, with the presence of causal indicators identifi ed in PSM-1 in increasing numbers in the same non-heterosexual groups. These data would support the hypothesis that non-heterosexual orientations could actually be the adaptive consequence of a psychological trauma, with a strong emotional and sexual impact (including abuse, violence, neurobiological, hormonal, and somatic predispositions, affective-emotional dysregulation with reference fi gures, and socioenvironmental and family readjustments), in itself therefore not pathological but circumstances favoring negative and unfavorable dynamics, of social and environmental matrix, such as to favor or aggravate psychopathological conditions, including mood, depressive, obsessive, somatic, personality and suicidal disorders. Research Article Clinical evidence in sexual orientations: defi nitions, neurobiological profi les, and psychological implications


Introduction and background
In the last thirty years, neurosciences have been very interested in the study of the correlation between sexual orientation (intended as a form of emotional, sentimental and / or sexual attraction of a person to another person regardless of the biological sex of belonging or his sexual identity) and certain neurobiological and neurophysiological components, capable of demonstrating the existence or otherwise of the direct relationship. Sexual orientation, properly so called, is therefore a lasting model towards another subject. From the second half of the twentieth century, the fi rst idea of "homosexuality" was declassifi ed, moving from the psychopathological condition thinking was well oriented towards the opposite; in fact, homosexuality had hitherto been considered a "morbid obsession" (Charcot), a "sexual psychopathy" (von Krafft-Ebing), an "arrest of normal development" (S. Freud), a "narcissistic fi xation" (Ferenczi), a "neurotic escape" (Adler) or a "parapathic neurosis that originates from the confl ict between instinct and inhibition" (Stekel). However, this evolution has certainly led to an opening towards social rights but also to a fl uidity in sexual orientation, where the main problems emerge especially in the bisexual position [1]. The legal status of homosexual relationships varies enormously from one state to another and there still remain jurisdictions in which some homosexual behavior is considered a crime and punished with severe penalties (imprisonment), up to capital punishment (death); this still happens in many African and Middle Eastern countries. Sexual orientation is therefore commonly debated as a characteristic of the individual, as well as for biological sex, gender identity or age. However, this perspective is incomplete, since sexual orientation is always defi ned on the basis of relational terms and necessarily concerns relationships with other individuals. Sexual acts and romantic attractions are categorized as homosexual or heterosexual based on the biological sex of the individual involved in them, relative to the partners. Indeed, it is through performance -or the desire to lend -with another person that individuals express their heterosexuality, homosexuality or bisexuality. Thus, sexual orientation is fully connected to the intimate personal relationships that human beings form with others to meet their deepest sentimental needs for love, bond and intimacy.
In addition to sexual behavior, these constraints include not-sexual physical affections between partners, sharing goals and values, mutual support and constant commitment.
Consequently, sexual orientation is not merely a personal characteristic that can be defi ned in isolation. Likewise, one's sexual orientation defi nes the universe of people with whom a person is able to fi nd satisfying and fulfi lling relationships which, for many individuals, comprise an essential component of personal identity .
From a neurobiological point of view, robust evidence shows that between heterosexual and homosexual brains, there are signifi cant structural and functional differences in different areas (thalamus, hypothalamus, basal ganglia, amygdala, corpus callosum, frontal lobe, grey matter and cerebral cortex) ; more than interesting, the analyzes regarding these directly related aspects appear, contextualising: any differences between the "homosexual tendency" (determined perhaps by paraphilic or post-traumatic adaptive factors) and the precise and conscious decision to perceive one's balance in the "homosexual or bisexual condition" (therefore the de facto choice of orientation); any that allow to clearly distinguish comorbid conditions (such as anxiety disorders, eating disorders, depressive disorders, panic, obsessions, behavioral addictions and suicidal risk) from the choice homosexual or bisexual (and whether the latter is able to feed the comorbid conditions); the differences between highly adaptive and functional conditions from those that cause the patient to feel unwell and dysfunctional [98][99][100][101][102][103][104][105][106].
The direct and indirect implications on the confi rmation of the clinical hypothesis of the homosexual and / or bisexual condition would bring further complications, with reference to the management of the patients' treatments and therapies, while making important differences between highly adaptive patients and those who perceive their condition as dysfunctional with respect to the surrounding environment. The question to ask, in this theoretical hypothesis, is whether we must actually intervene clinically to correct the homosexual or bisexual condition and lead the patient towards a heterosexual orientation, or simply accompany him towards a better perception of his emotions, desires and needs strategically [107][108][109].

Research objectives and methods
Starting therefore from the psychological aetiological hypothesis, as stated in the introduction to this research work, that sexual orientations other than homosexuality could in reality be the consequence of an adaptation to particularly destabilising traumatic events in the emotional and family sphere of the person, the present research aims to identify the possible psychological causes capable of justifying a preference other than heterosexuality.
For the purposes of this research, other possible causes that are not directly linked to a psychological nature are therefore excluded.
In order to facilitate the research work, a specifi c questionnaire (Perrotta Individual Sexual Matrix Questionnaire, PSM-1) [110] has been selected, capable of providing anamnestic information and data on the emotional, emotional and family sphere, which will be submitted to the selected sample of the population together with the Perrotta Integrative Clinical Interview, PICI-1 (TA version) , taking into account the age, in order to facilitate the identifi cation of 2) Administration of the PICI-1 to each population group.
3) Data processing following administration.

Setting and participants
The requirements decided for the selection of the sample population are: 1) Age between 18 years and 75 years.
2) Italian nationality, with Italian ancestors in the last three generations.  All participants were guaranteed anonymity.

Results, limits and possible confl icts of interest
After the selection of the chosen population sample (fi rst stage), the PICI-1(TA) results were administered (second stage) and processed (third stage), obtaining the following results: Since the research is not fi nanced by anyone, it is free of confl icts of interest.

Are non-heterosexual sexual orientations to be considered pathological?
The current generally accepted clinical position on homosexuality and other orientations other than heterosexuality [1], since the 1970s, is to consider them not pathological but simply a normal variation of sexual behavior; in particular,   and the impact of the EMDR technique that is able to "move" the area of trauma to another area following psychological reworking. Certainly, the structural and functional differences found are interesting, but these studies deserve further study before being considered scientifi c evidence of the morbidity of homosexuality.
Having said this, the writer, in relation to the data obtained from the present study, illustrates the theoretical hypothesis that he defi nes as "median" with respect to the two poles

Conclusions
Processing the data obtained from the selected population sample, the following results emerge:  b) In the homosexual group the same discourse made in point 1 is valid, with some variations: also point 1 (sexual abuse or physical violence in childhood and/or preadolescence) and 3 (dysfunctional caring on the part of the caregiver during the attachment period, 0-6 years) come into play in a signifi cant way, and the presence of the marking "None of the above" is clearly inferior (8.16% in male and 7.16% in female). This profi le would lead one to think that in the homosexual group the greater presence of the dysfunctional indicators would confi rm the aetiological hypothesis of a psychological nature.
c) In the bisexual group, the discourse addressed in point 2 is even more marked: all the indicators come into play except "None of the above" which is never marked, both in the male and in the female group. This profi le would strengthen the conclusive hypothesis stated in point 2. the sacrosanct civil rights struggles of the last decades are welcome, to recognize equal conditions and not discriminate against any person regarding their sexual choice. Here, therefore, at stake, there is no condemnation of a category but simply the stance of a strictly clinical evaluation, also in light of the neurobiological results of recent years. Research on the relationship between neuroscience and sexual orientation is still in its infancy, despite the numerous progress made and the fi nding of substantial elements capable of supposing that the neuroanatomophysiology of a not-heterosexual subject is different from a heterosexual subject. However, to date, studies have not yet clarifi ed whether it is these differences that cause different sexual orientation or whether orientation (learned through social conditioning or genetic predisposition) shapes the anatomy and physiology of the brain by inducing the changes. It is logical and consequential to think, however, that the fi rst solution is the most acceptable and therefore some anatomical-physiological alterations cause the subject to perceive his orientation as "not-heterosexual". On this hypothesis, still to be verifi ed, the suspicion remains that the decision to "reroute" homosexuality and bisexualitymaking them become normal and sexual orientations, such as heterosexuality -can be considered forced (based on more social and political pressures, which are strictly clinical), in the light of the various neurobiological fi ndings that have emerged in research over the past thirty years. Excluding the social and legal implications, thus suspending any moral and ethical judgment on the various positions of sexual orientation, the need to better contextualise the clinical profi les relating to the topic under examination appears interesting [1].
On the subject of the pathologization of sexual orientations other than heterosexuality, between the two theses under discussion (confi rmation, on the one hand, or disconfi rmation, on the other), this research suggests the "median" position that on the one hand confi rms the non-pathological nature of sexual orientations other than heterosexuality per se (since there is no scientifi c evidence to the contrary), but on the other confi rms the hypothesis that, on the basis of the person's experience, psychopathological conditions may coexist that require psychotherapeutic intervention.