Gender and sexual orientation of undergraduate medical students in India: A cross-sectional study

ABSTRACT

Background:

Although the potential for alternate conceptions of gender roles and sexual orientations are diverse, it is by-and-large not well tolerated. This study explores the self-reported gender-roles and sexual orientations of Indian undergraduate medical students.

Aim:

To study self-reported gender role and sexual orientation of undergraduate medical students in India.

Method:

One hundred twenty volunteers were included in the study consisting of 60 males and 60 females. A questionnaire comprising of a sociodemographic proforma, Bem Sex-Role Inventory (BSRI), and Epstein Sexual Orientation Inventory (ESOI) were given to each participant. The scales were scored, tabulated, and statistically analyzed.

Results:

The BSRI revealed that femininity was predominant in both female and male participants, at 68.33% and 55%, respectively. The ESOI revealed that females had significantly higher opposite-sex attraction than males. Though males had higher same-sex attraction than females, the difference was not statistically significant. Females also had a significantly higher sexual orientation range and a mean sexual orientation. Sexual drive was significantly higher in males. Significantly more females supported homosexuality and bisexuality as compared to males.

Conclusion:

This study helps establish that gender roles can be non-conforming. It helps ascertain that while heterosexual orientation predominates, alternate sexual orientations also exist. It paves the way for future studies and explorations to alleviate public misconceptions.

Man/woman, male/female, his/her: identification and addressal in these binary terms comprise a crucial role in the societal perception of an individual. It isn’t unusual to begin the description of an individual with their gender, both in formal and informal contexts. Studies of eminence, demographic data, census—all take into account gender, usually in the binary form of male/female. It is indisputable that gender is a fundamental constituent of the structure and order of human life in society. Studying gender became a critical trend in the twentieth century, and its importance has not dwindled since. The study of sociology regards gender to be the sacrosanct foundation of their discipline.[1]

The stereotypy in defining gender as a binary concept is rigid and narrow and takes much root from the predetermined roles passed on from historical times. It allows little scope for alternate expressions in not just identification but also personal preferences. There are people who do not conform to the standard and accepted binaries in various ways, of which profession, dressing, communication, sexual attraction are a few. Lack of societal acceptance of lesbian, gay, bisexual, transgender (LGBT) people reflect in the overall well-being of these individuals. Besides being more prone to mental health issues of anxiety, depression, suicide, substance abuse, and HIV infections, they also find themselves more vulnerable and at-risk when dealing with medical and surgical illnesses—which affect the general population as well—due to reluctance in their health-seeking attitudes from fear of discrimination and rejection.[2]

Adherence to the personality characteristics for each sex as a compulsion has not only been passed down from generations in the past, but also finds encouragement in various religious scriptures. Devout individuals are more disapproving of homosexual, bisexual, or gender non-conforming attitudes.[3] Societies encourage sex-type behavior and any deviance is not readily accepted.[1,2] Masculinity from women and femininity from men are ideas that have long been frowned upon, particularly from the older sects of society.[4] The LGBT community, particularly the men, have also to live with the blame of being responsible for the spread of HIV/AIDS and various other sexually transmitted diseases. In view of the absence of Indian studies in this area, the present study was undertaken with the aim to study self-reported gender roles and sexual orientations of undergraduate medical students in India.

METHOD

This cross-sectional, analytical study was conducted in a medical college attached to a tertiary care hospital in a rural area of Maharashtra. The study obtained approval from the institutional ethical and scientific committees. The aim and objectives of the study were explained to each participant. All participants gave written and informed consent.

Sample

The study sample consisted of 120 undergraduate medical students selected via purposive sampling from all years of MBBS, among whom 60 were male and 60 female. All subjects were willing to participate in the study and were not diagnosed with intellectual disability, substance use disorders, psychotic disorders, mood disorders, anxiety disorders, central nervous system disorders, or any critical illness.

Tools

Sociodemographic data sheet

The sociodemographic and biographical data were recorded on a specially designed pro forma. Psychosocial stressors and addictions were assessed in a brief interview. Socioeconomic status was determined according to the Modified Kuppuswamy Socioeconomic Scale, 2021.[5]

Additionally, they were asked a few questions about attitude to sexuality.

Bem Sex-Role Inventory (BSRI)

The Bem Sex-Role Inventory (BSRI) is a widely used tool that serves as a psychological measure to assess an individual’s gender role orientation. The classifications offered by the BSRI are as follows: masculine, feminine, androgyny, undifferentiated. It was created by American psychologist Sandra L. Bem in 1974 with the intention to ascertain the influence of societal and cultural perceptions of masculinity and femininity over an individual’s description of the self. The inventory comprises of 60 personality characteristics which are self-rated by the respondent on a 7-point Likert scale ranging from 1 to 7, in which 1 is “never or almost never true”, 2 is “usually not true”, 3 is “sometimes but infrequently true”, 4 is “occasionally true”, 5 is “often true”, 6 is “usually true,” and 7 is “always or almost always true”. There are 20 characteristics assigned to each femininity and masculinity, and 20 are neutral characteristics with respect to gender. The feminine and masculine characteristics were desirable for the opposite sexes, and the neutral characteristics were indicative of an individual’s social desirability.[6] Scoring only takes into account the scores of the masculine and feminine characteristics, using which the final BSRI is calculated by subtracting the masculinity score from the femininity score. A larger positive value insinuates predominance of femininity and a larger negative value implies predominant masculinity. A score nearing zero indicates an androgynous response.[7] Cronbach’s alpha for masculinity was 0.86 and for femininity was 0.82. The BSRI also has high test-retest reliability.[7,8]

Epstein’s Sexual Orientation Inventory (ESOI)

Epstein’s Sexual Orientation Inventory (ESOI) is based on the study performed by Alfred Kinsey which proposed that sexuality lies on a continuum and cannot be classified into the prevalent three categories of heterosexuality, homosexuality, and bisexuality.[9] He proceeded to call it the sexual orientation continuum (SOC).[10] Kinsey graded sexual orientation on a scale spanning across seven points: 0, 1, 2, 3, 4, 5, 6. A zero denoted complete and exclusive heterosexuality, whereas a 6 indicated complete and exclusive homosexuality, and the gradations in between indicated varying degrees of homosexuality and heterosexuality. The score 3 was indicative of equal degrees of both heterosexuality and homosexuality.[11] In 2012, Epstein et al.[10] demonstrated individual measures of same-sex (SS) and opposite-sex (OS) sexual inclinations as distinguished points on the SOC by evaluating an 18-item questionnaire. Nine items were allotted for inclinations toward SS and OS, each.[11] A scale was used for representation of SOC, with 0 signifying heterosexuality and 13 signifying homosexuality. The first 9 items were used to score SS inclinations on a range of 0–13. The second 9 items were used to score OS inclinations on a range of 0–13, and the score was then reversed to exist on a range of 13–0 for the sake of convenience. The scores were then placed on their respective positions on the SOC. Sexual orientation range (SOR) was the numerical difference between the two values, as was also visible on the plotted scale. It became the measure of flexibility of an individual in choosing their sexual orientation. The numerical average of the above two values was computed and designated as mean sexual orientation (MSO).[11] Cronbach’s alpha for the inventory was 0.88, suggesting high internal consistency. The ESOI was also demonstrated to have considerable validity.[11] The mid-point between an individual’s SS and OS was marked as the MSO for that individual, and the interval between the two points was termed as SOR for that individual. SOR is regarded as a valid measure for the assessment of the construct of SOC.[10]

Methodology

The selected participants were explained the aim and objectives of the study, and written informed consent was obtained. Then the student was interviewed and the sociodemographic pro forma was filled. Thereafter, the BSRI and ESOI were applied individually to the participants. The anonymity of the data provided was guaranteed to the participants. They took around 20 minutes to complete the questionnaire. All participants completed the survey. The collected data was assimilated in a Microsoft Excel sheet. Statistical analysis of the data was carried out using descriptive and inferential statistics.

RESULTS

The mean age of the female participants was 20.38 ± 1.11 years and that of the male participants was 21.80 ± 1.61 years. The difference was not statistically significant. Similarly, the two groups did not differ in domicile and socioeconomic status. All the subjects were unmarried Table 1 shows the comparison between the female and male participants on the basis of sociodemographic variables. The prevalence of regular consumption of alcohol was significantly higher in males. There was no significant difference between the two groups regarding marijuana, tobacco, and cigarette-smoking. No significant difference was observed between the two groups with regard to history of physical and sexual abuse and stressful events in the past six months of their lives. Male participants were significantly taller and heavier than the female participants.

Table 1.

Sociodemographic and clinical characteristics of participants

Characteristics	Female (n=60)	Male (n=60)	T test/Chi-squared test	P
Age
Mean (in years)	20.38±1.11	21.80±1.61	1.650	0.102 NS
Domicile
Urban	57	54	1.08	0.298 NS
Rural	3	6
Religion
Hindu	57	54	Fisher’s exact test	0.008 S
Muslim	0	4
Others	3	0
Sikh	0	2
Socioeconomic status
I	54	52	0.323	0.569
II	6	8
Alcohol
Regularly	2	11	6.99	0.008 S
Smoking
Daily	0	12	Fisher’s exact test	0.0003S
Cannabis
Daily	0	1	Fisher’s exact test	1 NS
History of
Physical abuse	0	4	Fisher’s exact test	0.118 NS
Sexual abuse	2	3	Fisher’s exact test	1 NS
Stress	10	8	0.2614	0.609 NS
Height
m	1.61±0.10	1.68±0.10	−3.072	0.003 S
Weight
kg	58.73±11.03	72.02±16.07	−5.281	0.000 S
Basal metabolic rate
kg/m2	22.48±3.90	24.83±4.04	−3.240	0.002 S

The BSRI revealed female participants to have a mean masculinity score of 62.54% ± 13.00%, a mean femininity score of 69.00% ± 9.11%, and a mean androgynous score of 64.07% ± 8.23%. Male participants had a mean masculinity score of 59.16% ± 16.68%, a mean femininity score of 59.66% ± 15.32%, and a mean androgynous score of 57.53% ± 15.27%. There was no significant difference in the prevalence of predominantly feminine and masculine characteristics in the two groups [Table 2].

Table 2.

Interpretation of final BSRI scores

Interpretation of Final BSRI	Female	Male	Chi-squared Test	P
Number of participants with predominant femininity	41	33	2.26	0.133 NS
Number of participants with predominant masculinity	19	27

Analysis of the ESOI revealed that the female participants had a mean SS attraction of 0.67 ± 1.36 and a mean OS attraction of 6 ± 2.84. The mean SOR for them was 6.48 ± 3.27, and their MSO was 3.85 with a standard deviation of 1.36. The mean SS attraction for the male participants was 1.25 ± 2.41 and the mean OS attraction for them was 5.5 ± 2.55. The mean SOR for the males was 4.51 ± 2.87. Their MSO was 3.38 with a standard deviation of 1.88. The mean sex drive for the male participants was 5.15 ± 1.88 and for the female participants was 4.11 ± 2.25. Tabulation of the ESOI has been disclosed in Table 3 and Figure 1.

Table 3.

Epstein’s Sexual Orientation Inventory scores of male and female medical students

ESOI subscales	Mean	SD	Min.	Max.	MWU	P
MSO
Male	3.38	1.88	1	11	1273	0.005
Female	3.85	1.36	1	6.5
SOR
Male	4.51	2.87	1	13	1069.5	0.000
Female	6.48	3.27	1	13
SD
Male	5.15	1.88	0	8	1303.5	0.009
Female	4.11	2.25	0.5	8.5
SSA
Male	1.25	2.41	0	10	1748	0.738
Female	0.68	1.36	0	6
OSA
Male	5.50	2.55	2	13	1096	0.000
Female	7.01	2.83	4	13

SD: Standard deviation; MWU: Mann–Whitney U Test; MSO: Mean sexual orientation; SOR: Sexual orientation range; SD: Sexual drive; SSA: Same-sex attraction; OSA: Opposite-sex attraction

Figure 1.

Epstein’s Sexual Orientation Inventory scores of male and female medical students. MSO: Mean sexual orientation; SOR: Sexual orientation range; SD: Sexual drive; SSA: Same-sex attraction; OSA: Opposite-sex attraction

The study revealed that significantly more females supported homosexuality and bisexuality compared to males. A higher number of female participants compared to male participants in the study reported to not have any encumbrance in embracing a friend of homosexual or bisexual orientation, did not indulge in shaming or mocking homosexuals or bisexuals, were aware of the prevalent stigma around them, and were ready to disclose their own deviant sexual orientations, if it were so; however, these findings were not significant. More number of male participants were allowed privy to the deviant sexual orientation of others, despite a higher number also believing that an individual’s characteristics should be congruent to their secondary sex characters: these comparisons weren’t significant either Table 4 provides insight into the questions asked for assessment of openness to deviant sexual orientations, and interpretation of the information.

Table 4.

Interpretation of data to assess openness to deviant sexual orientations

Question	Gender	Yes	No	Chi-squared Test	P
Would you mind being friends with a homosexual?	Male	11	49	1.71	0.191 NS
	Female	6	54
Would you mind being friends with a bisexual?	Male	10	50	0.261	0.609 NS
	Female	8	52
Do you support homosexuality?	Male	33	27	18.432	0.000018 S
	Female	54	6
Do you support bisexuality?	Male	38	22	11.925	0.00055 S
	Female	54	6
Have you ever made fun of any homosexual individual?	Male	12	48	1.563	0.211 NS
	Female	7	53
Have you ever made fun of any bisexual individual?	Male	8	52	1.481	0.223 NS
	Female	4	56
Has anybody ever confided in you their deviant sexual orientation?	Male	15	45	0.785	0.375 NS
	Female	11	49
Do you know of anyone who faces mockery from his/her peers for not adhering to his/her gender role?	Male	16	44	0	1
	Female	16	44		NS
Do you think characteristics of male and female should be strictly present in individuals based on their biology?	Male	17	43	1.367	0.286 NS
	Female	12	48
Would you prefer coming out of the closet if, hypothetically, you discover that you have a deviant sexual orientation?	Male	32	28	2.833	0.923 NS
	Female	41	19

S: Significant; NS: Non-significant

DISCUSSION

While 41 (68.33%) female participants had predominance of feminine characteristics, 19 (31.67%) were predominantly masculine. There have been studies that have explored the defiance of pre-structured gender norms, where some women have self reported themselves to be more masculine than men. The results were seen to be in concordance with earlier studies conducted in this domain.[12,13] Most past studies have had women self-reporting themselves to have higher feminine characteristics than masculine characteristics.[12,13] Across cultures, there exists a set of predetermined expectations towards men and women which make them acceptable and even desirable in a societal setting. For men, the expectations are aggressiveness, dominance, independence, confidence, rivalry, and rationality. On the other hand, women are expected to be the polar opposite: docile, tactful, loyal, adjustable and dependable.[12] A higher subjective femininity score by females indicates that gender stereotyping may have a role in modeling how individuals wish to be perceived, as femininity in women is a widely endured concept, and these women are deemed traditionally “attractive”.[14] However, a deviance from these archetypal notions has been long doing the rounds. Women have entered the working and entrepreneurial spaces in full force and are as rivetted and focused in their work as men are. Thriving in workspaces demands development of traits which may deem one “masculine”. Newer paradigms of cultural appropriacy have blurred the lines between masculinity and femininity, after having garnered strength from the feminist revolutions beginning in the 1960s, which have nothing to do with their sexual orientations.[12,13,15]

Male participants had a mean masculinity score of 59.16% ± 16.68%, a mean femininity score of 59.66% ± 15.32%, and a mean androgynous score of 57.53% ± 15.27%. Thirty-three male participants (55%) were seen to have a predominance of feminine characteristics and 27 (45%) had predominant masculinity. This result too finds concordance with various studies conducted in the past where higher feminine characteristics were self-reported by men.[12] The aforementioned paradigmatic shifts also granted men with the freedom of self-expression and non-adherence to cultural gender roles. Moreover, workspaces required traits of affability, tactfulness, and dependability as well, over and above ambitiousness and drive. To survive and excel in such environments, men had to either inculcate or harness what were traditionally considered as “feminine” traits. Masculine traits bear semblance to type A personality traits, which in itself holds close associations to self destructive behaviors as well as symptoms of anxiety, low self-esteem, somatic complaints, and cardiovascular diseases. Preservation of mental and physical health have also pushed men to expand the scope of masculinity.[16] Perceptual changes of gender-based personality traits are looking outwards from the predetermined traditional notions for both men and women.[12] There exists evidence suggesting that femininity reported by men was likely to be associated with better mental health and functioning in men.[17]

MSO of females was significantly higher than males which is in agreement with earlier studies.[9,10,11] SOR of females was significantly higher than males which is in agreement with earlier studies.[9,10,11,18,19] OS attraction of females was significantly higher than males.[18,20] Studies observed that female genitalia in humans showed responsiveness to a wide variety of sexual stimuli irrespective of the sexual preference of the subject, whereas men showed genital responsiveness specific to their preferences. Women lean more on emotional connection over physical connection to form and facilitate bonds and give value to the concept of “emotional partners” as well. Since emotional connections are not restricted to sexual preferences, this could result in a wider SOR in women.[9,11] This finding could also stem from the possibility that more men than women are reluctant to divulge their sexual orientation, if it is deviant, from fear of being discriminated and ostracized.[18]

Sexual drive was significantly higher in males. So was attraction to their preferred sex, same or other.[11,18,20–22] Men are more likely to be thinking of sexual acts and feel aroused than women, irrespective of sexual orientation. Women desire for emotional intimacy over mere physical needs, which is why they may need more stimulation to feel sexually aroused. Females feel an intrinsic need to focus on the consequences of a sexual relationship as well, over and above just the sexual act. Men are more likely to report the sexual acts as the end-goals of sexual activity and are less likely to indulge in the emotional build-up that women require.[23] Testosterone levels play a determining role in the activation of the sexual system, and physiologically higher levels of testosterone in men is also an important reason underlying higher sex drive in men.[24]

MSO and SOR were both seen to be significantly higher in females than men in our study—a finding which is well supported by prior studies.[9,10,11,25] Evidences suggest that sexual orientation has both genetic and environmental influences. While men and women have equal genetic effects, we can infer that women are more influenced by environmental factors than men are.[25] Although, sex-type behavior is encouraged in children as well, “tom boyish” behavior in girls is often accepted and even indulged, but “sissy” behavior in boys is universally condemned. Being a sociocultural influence, this may also explain a higher MSO and SOR in women.[26] Sex drive was found to be significantly higher in men as compared to women. Low levels of sex drive are a commonly observed feature in women, globally. Besides medical reasons, cognitive and emotional factors play a role in determining sexual desire. Women are societally expected to take a less aggressive stance on sex, and this is manifested in them exhibiting more sexual conservatism than men.[22,24]

Our study points out that OS attraction was higher in females and SS attraction was higher in males.[27-29] The discrepancy in females having both a higher SOR and MSO while having more inclination toward the opposite sex can be explained by the fact that more heterosexual women are willing to participate in homosexual and bisexual interactions than heterosexual men; despite the same sex attraction being higher in men (deeming them homosexual) than in women. This behavior of heterosexual women is often termed as “situational homosexuality”.[28,29] There is evidence to suggest that attitudes of men about the concept of homosexuality and bisexuality are more unfavorable than that of women, as has also been seen in our study.[4,30]

Limitations

The sample size, being modest, could not provide a better representation of the variables being tested across and within the two genders considered in this study. A larger sample size will help in generalization of the findings. Only two genders were analyzed in this study, and the study could not be inclusive of the entire spectrum due to restraints in availability of variation in a medical college. The method of sample collection was convenience sampling, which gave way to biased results. Due to fear of discrimination or stigmatization, many volunteers may not have been honest in answering the questions of the study.

CONCLUSION

This study helps establish that gender roles are not restricted to the respective gender type. With increasing levels of education and awareness, women are not ashamed to take on an ambitious and aggressive stance; similarly, men are adopting the softer feminine skills. Shedding gender roles can encourage people to feel comfortable in their own skin, and optimize their happiness and societal contributions.

It ascertains that even though sexual orientation is an individualistic preference, heterosexual trends predominate. It also deems women to be more tolerant of non-heterosexual orientations than men. Till date, concepts of altered gender-roles or deviant sexual orientations have not found absolute acceptance in society. Broadening societal perspectives is not an easy and overnight task, and mandates thorough and insightful work to be done right from the grassroots level of primary education. It requires careful inputs from government bodies, and incorporation of sex education in not only schools, but also in mass education programs, and corporate and non-governmental institutions.

Counsellors should be mandatorily available at schools and colleges for any pupil who is confused about their sexual orientation or preferences. Parental counselling should also be an option for those students who are not finding acceptance at home. Students should be regularly monitored for any behavioral shifts and declining academic performances, and should be made to feel safe enough to disclose the need for acquiring sex education or any distress related to their preferences. They should be ensured an environment in school which is free from harassment and bullying, in case they wish to disclose their non-conformance to the dominant orientations.

There is a gaping need for more scientific study and research in this domain to open the public eye to the concepts of homosexuality, bisexuality, and gender non-conformation being mere ways of life. Awareness programs and educating the masses about the same are also important measures that should be undertaken, particularly in a country like India. This study paves the way for further studies and researches to be conducted in this domain in order to not only alleviate misconceptions of the general population but to also make it easier for gender non-conforming and non-heterosexual individuals to peacefully exist as an integral part of our society.

Declaration of patient consent

The authors certify that they have obtained all appropriate subjects consent forms. In the form the subjects has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The subjects understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.