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In discussing theories of causation in relation to sex and gender it is important to note the use of terminology since the terms, sex and gender, are often used interchangeably, especially in daily discourse and in the popular media. For example it is common on official forms to be asked to specify one's gender when it might be more precise to ask about one's sex, which is probably the information that is being sought. The American Psychological Association (APA) defines sex and gender as follows, “Sex usually refers to the biological aspects of maleness or femaleness, whereas gender implies the psychological, behavioral, social and cultural aspects of being male or female, (i.e. masculinity or femininity).” (http://www.apa.org/pi/lgbt/resources/sexuality‐definitions.pdf).

However, having said that, these distinctions can readily break down, and not only in popular usage. The designation of sex is made on the basis of the presence of a complex of structures and processes, including the sex chromosomes, gonads, hormones, external genitalia, and secondary sexual characteristics, and all of these elements can be present in different degrees at birth causing ambiguity about the assignation of sex, or they can be altered by later accidental or deliberate interventions. Thus, even at a biological level, sex is a complex cluster of characteristics, not one simple characteristic. Butler adds to this picture the view of sex as permeated with social meanings such that the distinction between sex as biological and gender as social breaks down (1990). This problem in distinguishing sex and gender has been taken on board by some contemporary theorists. For example, in a more recent paper on “Neurofeminism and feminist neurosciences” Schmitz and Höppner have decided to use the term “sex/gender” (2014). Increasingly then, there is recognition of the difficulties that arise in adopting the traditional definition of sex, which implies that sex is always dimorphic, that there are only two sexes, male and female, and that they do not change over the life course. The use of the terms sex and gender thus remains problematic.

The definition of sexuality or sexual orientation is also a matter for debate. Sexual identity and sexual desires, and behaviors are complex and can also be unstable across the life course. The APA offers a definition of sexual orientation stating that it is, “A component of identity that includes a person's sexual and emotional attraction to another person and the behavior and/or social affiliation that may result from this attraction” (http://www.apa.org/pi/lgbt/resources/sexuality‐definitions.pdf). This definition can be seen as essentialist and certainly the term “sexual orientation” is often used as though an individual's sexuality is fixed and unchanging. Social constructionists will often use the term “sexual preference” indicating a degree of choice and openness (Rosenblum and Travis 2016).

Biologically deterministic theories about sex, gender, and sexual orientation typically see all three as intrinsically linked and mapping neatly onto each other, with common biological origins. Thus, from this perspective, being female implies being feminine and attracted to males. This assumption forms the basis of what Adrienne Rich terms “compulsory heterosexuality,” the view that heterosexuality and attraction to the opposite sex is natural to the female sex and that any deviation from this is therefore unnatural and open to a wide range of hostile responses on the part of heteronormative societies (1980). Transgender people who reject the sex to which they were assigned at birth are an example of the uncoupling of biological sex and gender identity (Chrisler and McCreary 2010). Although it is the case that for centuries, sex, gender, and sexuality have been seen as different facets of the unified biological essence of men and women, increasingly these three elements are seen as separable and as potentially fluid (Diamond 2009), as discussed in a later section of this chapter.