The idea that one’s sex is a “feeling,” not a fact, has permeated our culture and is leaving casualties in its wake. “Gender dysphoria” should be treated with psychotherapy, not surgery. This is a new article by Dr. Paul McHugh, re-blogged from the Witherspoon Institute’s “Public Discourse.”
For forty years as the University Distinguished Service Professor of Psychiatry at Johns Hopkins Medical School—twenty-six of which were also spent as Psychiatrist in Chief of Johns Hopkins Hospital—I’ve been studying people who claim to be transgender. Over that time, I’ve watched the phenomenon change and expand in remarkable ways.
A rare issue of a few men—both homosexual and heterosexual men, including some who sought sex-change surgery because they were erotically aroused by the thought or image of themselves as women—has spread to include women as well as men. Even young boys and girls have begun to present themselves as of the opposite sex. Over the last ten or fifteen years, this phenomenon has increased in prevalence, seemingly exponentially. Now, almost everyone has heard of or met such a person.
Publicity, especially from early examples such as “Christine” Jorgenson, “Jan” Morris, and “Renee” Richards, has promoted the idea that one’s biological sex is a choice, leading to widespread cultural acceptance of the concept. And, that idea, quickly accepted in the 1980s, has since run through the American public like a revelation or “meme” affecting much of our thought about sex.
The champions of this meme, encouraged by their alliance with the broader LGBT movement, claim that whether you are a man or a woman, a boy or a girl, is more of a disposition or feeling about yourself than a fact of nature. And, much like any other feeling, it can change at any time, and for all sorts of reasons. Therefore, no one could predict who would swap this fact of their makeup, nor could one justifiably criticize such a decision.
At Johns Hopkins, after pioneering sex-change surgery, we demonstrated that the practice brought no important benefits. As a result, we stopped offering that form of treatment in the 1970s. Our efforts, though, had little influence on the emergence of this new idea about sex, or upon the expansion of the number of “transgendered” among young and old.
Olympic Athlete Turned “Pin-Up” Girl
This history may clarify some aspects of the latest high-profile transgender claimant. Bruce Jenner, the 1976 Olympic decathlon champion, is turning away from his titular identity as one of the “world’s greatest male athletes.” Jenner announced recently that he “identifies as a woman” and, with medical and surgical help, is busy reconstructing his physique.
I have not met or examined Jenner, but his behavior resembles that of some of the transgender males we have studied over the years. These men wanted to display themselves in sexy ways, wearing provocative female garb. More often than not, while claiming to be a woman in a man’s body, they declared themselves to be “lesbians” (attracted to other women). The photograph of the posed, corseted, breast-boosted Bruce Jenner (a man in his mid-sixties, but flaunting himself as if a “pin-up” girl in her twenties or thirties) on the cover of Vanity Fair suggests that he may fit the behavioral mold that Ray Blanchard has dubbed an expression of “autogynephilia”—from gynephilia (attracted to women) and auto (in the form of oneself).
The Emperor’s New Clothes
But the meme—that your sex is a feeling, not a biological fact, and can change at any time—marches on through our society. In a way, it’s reminiscent of the Hans Christian Andersen tale, The Emperor’s New Clothes. In that tale, the Emperor, believing that he wore an outfit of special beauty imperceptible to the rude or uncultured, paraded naked through his town to the huzzahs of courtiers and citizens anxious about their reputations. Many onlookers to the contemporary transgender parade, knowing that a disfavored opinion is worse than bad taste today, similarly fear to identify it as a misapprehension.
I am ever trying to be the boy among the bystanders who points to what’s real. I do so not only because truth matters, but also because overlooked amid the hoopla—enhanced now by Bruce Jenner’s celebrity and Annie Leibovitz’s photography—stand many victims. Think, for example, of the parents whom no one—not doctors, schools, nor even churches—will help to rescue their children from these strange notions of being transgendered and the problematic lives these notions herald. These youngsters now far outnumber the Bruce Jenner type of transgender. Although they may be encouraged by his public reception, these children generally come to their ideas about their sex not through erotic interests but through a variety of youthful psychosocial conflicts and concerns.
First, though, let us address the basic assumption of the contemporary parade: the idea that exchange of one’s sex is possible. It, like the storied Emperor, is starkly, nakedly false. Transgendered men do not become women, nor do transgendered women become men. All (including Bruce Jenner) become feminized men or masculinized women, counterfeits or impersonators of the sex with which they “identify.” In that lies their problematic future.
When “the tumult and shouting dies,” it proves not easy nor wise to live in a counterfeit sexual garb. The most thorough follow-up of sex-reassigned people—extending over thirty years and conducted in Sweden, where the culture is strongly supportive of the transgendered—documents their lifelong mental unrest. Ten to fifteen years after surgical reassignment, the suicide rate of those who had undergone sex-reassignment surgery rose to twenty times that of comparable peers.
How to Treat Gender Dysphoria
So how should we make sense of this matter today? As with any mental phenomenon, what’s crucial is noting its fundamental characteristic and then identifying the many ways in which that characteristic can manifest itself.
The central issue with all transgender subjects is one of assumption—the assumption that one’s sexual nature is misaligned with one’s biological sex. This problematic assumption comes about in several different ways, and these distinctions in its generation determine how to manage and treat it.
Based on the photographic evidence one might guess Bruce Jenner falls into the group of men who come to their disordered assumption through being sexually aroused by the image of themselves as women. He could have been treated for this misaligned arousal with psychotherapy and medication. Instead, he found his way to surgeons who worked him over as he wished. Others have already commented on his stereotypic caricature of women as decorative “babes” (“I look forward to wearing nail polish until it chips off,” he said to Diane Sawyer)—a view that understandably infuriates feminists—and his odd sense that only feelings, not facts, matter here.
For his sake, however, I do hope that he receives regular, attentive follow-up care, as his psychological serenity in the future is doubtful. Future men with similar feelings and intentions should be treated for those feelings rather than being encouraged to undergo bodily changes. Group therapies are now available for them.
Most young boys and girls who come seeking sex-reassignment are utterly different from Jenner. They have no erotic interest driving their quest. Rather, they come with psychosocial issues—conflicts over the prospects, expectations, and roles that they sense are attached to their given sex—and presume that sex-reassignment will ease or resolve them.
The grim fact is that most of these youngsters do not find therapists willing to assess and guide them in ways that permit them to work out their conflicts and correct their assumptions. Rather, they and their families find only “gender counselors” who encourage them in their sexual misassumptions.
Those with Gender Dysphoria Need Evidence-Based Care
There are several reasons for this absence of coherence in our mental health system. Important among them is the fact that both the state and federal governments are actively seeking to block any treatments that can be construed as challenging the assumptions and choices of transgendered youngsters. “As part of our dedication to protecting America’s youth, this administration supports efforts to ban the use of conversion therapy for minors,” said Valerie Jarrett, a senior advisor to President Obama.
In two states, a doctor who would look into the psychological history of a transgendered boy or girl in search of a resolvable conflict could lose his or her license to practice medicine. By contrast, such a physician would not be penalized if he or she started such a patient on hormones that would block puberty and might stunt growth.
What is needed now is public clamor for coherent science—biological and therapeutic science—examining the real effects of these efforts to “support” transgendering. Although much is made of a rare “intersex” individual, no evidence supports the claim that people such as Bruce Jenner have a biological source for their transgender assumptions. Plenty of evidence demonstrates that with him and most others, transgendering is a psychological rather than a biological matter.
In fact, gender dysphoria—the official psychiatric term for feeling oneself to be of the opposite sex—belongs in the family of similarly disordered assumptions about the body, such as anorexia nervosa and body dysmorphic disorder. Its treatment should not be directed at the body as with surgery and hormones any more than one treats obesity-fearing anorexic patients with liposuction. The treatment should strive to correct the false, problematic nature of the assumption and to resolve the psychosocial conflicts provoking it. With youngsters, this is best done in family therapy.
The larger issue is the meme itself. The idea that one’s sex is fluid and a matter open to choice runs unquestioned through our culture and is reflected everywhere in the media, the theater, the classroom, and in many medical clinics. It has taken on cult-like features: its own special lingo, internet chat rooms providing slick answers to new recruits, and clubs for easy access to dresses and styles supporting the sex change. It is doing much damage to families, adolescents, and children and should be confronted as an opinion without biological foundation wherever it emerges.
But gird your loins if you would confront this matter. Hell hath no fury like a vested interest masquerading as a moral principle.
There is no such thing as a “woman trapped in a man’s body.” This is a fantasy that men use to excuse their behavior because they don’t want to admit they’re sexually aroused by the thought of themselves dressed and behaving stereotypically “as women.” Heterosexual males who claim to be “transgender” or “transsexual” are really in the throes of passionate autogynephilia, “a male’s propensity to be attracted to the thought or image of himself as a woman.” This is most commonly expressed in the form of fetishistic cross-dressing, though there are variations and degrees. Men who decide to “transition” (i.e. transsexuals) are those who have been caught up in all the sexy excitement. The fantasy becomes sort of a fixed idea that takes over everyday life. With the encouragement of their doctors and shrinks (which is always part of the fantasy), these men take the fantasy too far.
No matter how badly their wives and children may be hurt by it (and it’s amazing how often there are young children in these families), these guys are unstoppable and will renounce their families and traumatize their young kids, just for the chance to mutilate their bodies and imitate cartoonish images of women and pierce the veil of (i.e. rape) real women’s space and hang out with other dudes with similar sexy interests and wear wigs on top of their damn bald heads every day and constantly have to shave their faces, arms, chests, backs etc in a usually-futile effort to “pass” as a woman. They insist that they really are women, just because they say so and have taken estrogen and/or had various unnecessary surgeries, or even just because they say so. These men are so obsessed that they rant with extreme shrillness and violent posturing about “zomg haet crimez11!1!!” if anyone calmly tells them what’s really going on in their confused autogynephiliac minds. It is profoundly embarrassing for these fellows to really look within and own the fact that they get a boner (or used to get a boner) when they imagined themselves prancing around in prom gowns or being “forcibly feminized” or using the women’s toilet in a shopping mall while dressed “en femme” (tee-hee!) or taking a walk around the suburban neighborhood at 3 am wearing red high-heels.
A COMMON UNDERSTANDING OF male-to-female transsexualism is that all MtF transsexuals are, essentially, women trapped in men’s bodies. The standard narrative of men who become women goes something like this: “I have always felt that I was born in the wrong body. I have always been feminine in my interests and feelings. My desire to change sex is about my gender identity and not my sexuality.” This narrative, which Dreger (2007) has termed “the feminine essence narrative,” represents both what most laypeople believe to be true as well as what transsexuals are likely to say publicly. The narrative has been extended to an etiological theory, which Lawrence (2007b) has called “the brainsex theory of transsexualism. ” The transsexual advocacy website, transsexual.org, puts this theory succinctly: “A transsexual is a person in which the sex-related structures of the brain that define gender identity are exactly opposite the physical sex organs of the body. ”
The standard, feminine essence narrative, and the associated brain-sex theory, are incorrect, in the sense that they do not represent reality, even if they do correspond with many transsexual individuals’ beliefs and identities. The best scientific evidence (discussed below) indicates that there are two distinct subtypes of MtF transsexuals, and that the feminine essence narrative at best approximates the life history of only one subtype. Paradoxically, this explanation of MtF transsexualism persists because it is the explanation preferred by the other subtype, to which it does not apply at all. The popularity of the feminine essence narrative reflects factors other than the strength of scientific support. Its persistence has likely had negative consequences for both science and transsexuals themselves. .
Two Kinds of Male-to-Female Transsexuals
The classification system of MtF transsexuals that we believe to be correct was developed by the psychologist Ray Blanchard in a series of studies conducted at the Clarke Institute of Psychiatry in Toronto and published between 1985 and 1995. (Blanchard’s relevant oeuvre includes more than 20 articles; we provide only a summary of his conclusions.) Blanchard’s studies reported data on hundreds of transsexual males (that is, males who hoped to become or had become women), as well as other individuals who were male with respect to birth sex and did not desire sex reassignment surgery, but who sometimes presented themselves, or thought of themselves, as female. Participants in these studies were representative of gender patients in Canada, and were probably also quite similar to patients seen in the United States and Western Europe. Blanchard’s goal was to make sense out of the diversity of patients that gender clinics saw.
With respect to sexual orientation, Blanchard studied four groups of seemingly diverse male participants: homosexual (entirely attracted to other males), bisexual, heterosexual, and asexual. In three key studies, Blanchard (1985, 1988, 1989a) showed that homosexual transsexuals were different in a number of respects from members of the three other groups, and that members of the latter groups did not differ much among themselves. These differences included age of presentation at the gender clinic, history of childhood femininity, and most importantly, history of erotic arousal in association with cross-dressing and crossgender fantasy. These findings supported the division of MtF transsexualism into two types: homosexual and non-homosexual. Blanchard’s work provided a parsimonious and compelling taxonomy for the apparent sexual diversity among MtF transsexuals, reducing the four types of MtF transsexuals to two fundamentally distinct subtypes.
Autogynephilic Male-to-Female Transsexualism. Arguably, Blanchard’s most important contribution was recognizing and elaborating the phenomenon that united the three non-homosexual transsexual subtypes: autogynephilia. Autogynephilia is “a male’s propensity to be attracted to the thought or image of himself as a woman” (Blanchard 2005). One common manifestation of autogynephilia is fetishistic cross-dressing, which is an extremely common antecedent to seeking sex reassignment among non-homosexual (but not homosexual) transsexuals (Blanchard, Clemmensen, and Steiner 1987). Some autogynephilic individuals, however, do not cross-dress fetishistically. Indeed, a seminal case in Blanchard’s conceptualization was “Philip,” who did not cross-dress but fantasized sexually about being a nude woman by focusing on desired anatomical features (Blanchard 1991). Autogynephilia may be conceived as inner-directed heterosexuality. That is, autogynephilic males are like heterosexual men, except that their primary sexual attraction is to the image or idea of themselves as women.
Blanchard hypothesized that non-homosexual transsexuals are motivated by autogynephilia. That is, non-homosexual transsexuals experience erotic arousal at the idea of becoming a woman, and this arousal motivates them to become women. (We agree with Lawrence’s recent theoretical modification [2007a] hypothesizing that romantic attachment can play an important role in some cases. It is probable, however, that such attachment is usually preceded by substantial erotic arousal to the idea of being a woman. )
Not all autogynephilic males become transsexuals. Autogynephilic interests run a gamut from cross-dressing to engaging in stereotypic female activities (e. g. , knitting alongside other women) to possessing female breasts and genitalia. It is the latter interest that is most strongly associated with autogynephilic transsexualism (Blanchard 1993b). Other than the precise nature of their autogynephilic fantasy, there is no obvious difference between non-homosexual crossdressers who will become transsexuals and those who will not. They are all autogynephiles. Blanchard’s work also clarified the diversity of self-reported sexual orientations among non-homosexual transsexuals (Blanchard 1989a). Autogynephilia (inner-directed heterosexuality) appears to compete with outward-directed heterosexuality. Many autogynephilic transsexuals experience enough outward directed heterosexuality to label themselves as heterosexual pre- transition. Those whose autogynephilia is strong enough that they experience no other-directed sexual feelings identify as asexual. Finally, a common aspect of autogynephilia is the erotic fantasy of being admired, in the female persona, by another person.
Autogynephiles for whom this fantasy is sufficiently strong tend to identify as bisexual. However, this bisexuality is not characterized by equal or even similar kinds of attraction to male and female bodies. Blanchard (1989b) thus suggests that it be characterized as “pseudobisexuality. ” Autogynephilia appears to be a paraphilia. Paraphilias are unusual, intense, and persistent erotic interests. The concept of paraphilia is a controversial one, with some arguing that it is merely a word used to stigmatize sexual behavior that most people find undesirable (Moser 2001). Some paraphilias (e. g. , pedophilia and sadism) are harmful to other people, while others (e. g. , autogynephilia and fetishism) are not. Two non-obvious facts about paraphilias suggest that the label paraphilia may represent more than a mere value judgment. First, paraphilias are found nearly exclusively in males (APA 2000, p. 568). Second, at least some paraphilias tend to occur together. Autogynephilia, for example, appears to be correlated with other paraphilias, especially masochism (Lawrence 2006). Advertisements of dominatrixes frequently offer services to cross-dressers, and autogynephilic males are more likely than other males to become sexually aroused to stimuli depicting masochistic themes (Chivers and Blanchard 1996; Wilson and Gosselin 1980). Of men who die practicing the dangerous masochistic activity of autoerotic asphyxia, approximately 25% are cross-dressed, a much higher percentage than one would expect based on the number of non-homosexual crossdressers in the general population (Blanchard and Hucker 1991).
Homosexual Male-to-Female Transsexualism. Homosexual MtF transsexuals are much easier than autogynephilic transsexuals for most people to comprehend. Homosexual transsexuals are best understood as a subset of homosexual males who were very feminine from early childhood. In some ways, then, they do appear to fit the feminine essence narrative: they had male bodies as children, but behaviorally and psychologically they were different, in some respects, from typical boys and more similar to typical girls. Most males who begin life as extremely feminine boys, even those whose femininity includes the wish to become girls, do not become transsexual. In the contemporary United States, most become homosexual men (Bailey and Zucker 1995; Green 1987; Zuger 1984). Homosexual MtF transsexuals, in contrast, persist in their wish to become female (Bailey 2003; Blanchard 1990). The reasons for this atypical persistence are unclear. However, these individuals often have a difficult time socially, romantically, and sexually, and their transition appears to be largely motivated by a desire to improve their lives in these domains.
As their label implies, homosexual MtF transsexuals are homosexual with respect to their birth sex. That is, they are attracted exclusively to men. Although some writers have objected to the use of the word homosexual to refer to individuals who have sex with men as women (e. g. , Gooren 2006),we retain the terminology because it emphasizes the fact that homosexual MtFs are a subset of, and developmentally related to, other homosexual males. Furthermore, it emphasizes the most efficient and practical way of distinguishing homosexual and autogynephilic transsexuals. Homosexual transsexuals are unambiguously, exclusively and intensely attracted to attractive men; autogynephilic transsexuals have some other pattern of sexual attraction. That is, an MtF transsexual who reports attraction to both men and women, or a history of sexual attraction to women, or considerable sexual experience with women, or attraction to neither men nor women—any clearly non-homosexual pattern—is almost certainly autogynephilic (Blanchard 1989a; Blanchard, Clemmensen, and Steiner 1987).
Evidence for the Feminine Essence Narrative and Brain-Sex Theory
The main theory competing with Blanchard’s theory of MtF classification is the theory that all MtF transsexuals have a (probably innate) female gender identity. By this theory, homosexual and non-homosexual transsexuals have different sexual orientations because sexual orientation and gender identity are distinct, perhaps even uncorrelated, phenomena. Both homosexual and non-homosexual transsexuals share the same psychological condition, female gender identity, which they experience in similar ways. Furthermore, both kinds of transsexuals, as well as natal women, have in common neural circuitry that differs from that of nontranssexual men, and that causes female gender identity.
Transsexual Narratives. The claim that MtF transsexuals are “women trapped in men’s bodies” is commonly made both by and about transsexuals. The evidentiary value of such claims depends on their plausibility and the lack of alternative, more plausible explanations. Non-homosexual MtF transsexuals are not especially feminine in their interests and behaviors compared with most women (Herman-Jeglínska, Grabowska, and Dulko 2002; Lippa 2001) or with homosexual MtF transsexuals (Bailey 2003; Blanchard 1988). Furthermore, they often acknowledge autogynephilia (Lawrence 2005), such as fetishistic cross-dressing (in contrast to most women and homosexual MtF transsexuals [APA 2000; Blanchard, Clemensen, and Steiner 1987]). Thus, the contention that women and all MtF transsexuals have feminine minds that motivate their feminine identification strikes us as implausible.
The Transsexual Brain Studies. In 1995, Zhou et al. described a sex difference in the size of a brain region, the central subdivision of the bed nucleus of the stria terminalis (BSTc), a collection of cells in the hypothalamus. This article included data from the brains of six MtF transsexuals, whose BSTc volumes were female-typical. A follow-up paper by Kruijver et al. (2000) added another MtF transsexual’s brain and confirmed the earlier finding using different measurement techniques.
These studies have been widely touted by transsexual activists as supporting the brain-sex theory of MtF transsexualism. Furthermore, a remarkable statement by the British group, the Gender Identity Research and Education Society (GIRES 2006), appeared to base its support of transsexual treatment and rights largely on the studies and their alleged implication that “transsexualism is a neuro-developmental condition of the brain. ” Several of the signatories of this statement are distinguished researchers. The transsexual brain studies have also received considerable scientific attention. As of February 1, 2007, the study by Zhou et al. (1995) has been cited by 117 scholarly articles, and that of Kruijver et al. (2000) has been cited by 43 scholarly articles. In contrast, Blanchard’s three most highly cited autogynephilia-related studies (Blanchard 1985, 1989b; Blanchard, Clemmensen, and Steiner 1987) have each earned 38 such citations.
In our view, the influence of the transsexual brain studies is disproportionate compared with their scientific value to understanding the etiology of MtF transsexualism. Their relevance as support for the feminine essence narrative, as opposed to Blanchard’s theory, is extremely weak—indeed, it is arguably absent. There are several important limitations that prevent the brain studies from being relevant in this regard (Lawrence 2007b). The most critical problem is that neither study includes the necessary hormonal controls to exclude the possibility that the feminization of the BSTc in MtFs was due to hormone treatment, especially estrogen therapy, received for transsexualism. Recent research shows that the volume of the hypothalamus is highly dependent on such hormonal treatment, with smaller volumes associated with estrogenic treatment (Hulshoff Pol et al. 2006). We concur with Lawrence (2007b) that this is the most likely explanation of the Zhou et al. (1995) and Kruijver et al. (2000) findings. Certainly those findings should be regarded cautiously until a study has ruled out the concern regarding hormonal treatment.
Evidence from Sex-Reassigned Children. In principle, the feminine essence narrative and brain sex theory could be instantiated by selecting a normal girl, medically masculinizing her body, and rearing her as a boy from an early age. If anyone could be a female trapped in a male body, or have a female brain in a male body, it would be a female such as this. What we know about such cases suggests that they are similar to homosexual, and different from non-homosexual, MtF transsexuals. There have been a few rare cases of females born with virilized genitalia due to prenatal maternal use of a progestin, in which the attempt was made to rear them as boys. The second author of this article is one such case, and she has known two others personally. All three cases were quite similar in presentation to homosexual MtF transsexuals: noticeably feminine presentation and interests, early expression of dissatisfaction with the male role, and sexual interest in males. None of these cases had signs of autogynephilia, such as fetishistic cross-dressing. Finally, their decisions to transition were made on the basis of optimizing sexual and social functioning, rather than because of a deep conviction that they were women trapped in men’s bodies.
Blanchard’s Theory Versus the Feminine Essence Narrative
We believe that Blanchard’s theory of MtF transsexualism is far better supported, and far more likely to be true, than the feminine essence narrative and the associated brain-sex theory. It is based on far more data, with respect to the number of both studies and subjects; no published scientific data in the peer-reviewed literature contradict it; and other investigators in other countries have obtained similar findings (Smith et al. 2005). It also provides a plausible explanation for phenomena that are problematic for the feminine essence narrative (e. g. , fetishistic cross-dressing and lack of early femininity among non-homosexual transsexuals). Why, then, has Blanchard’s theory remained underappreciated, compared with the standard, feminine essence narrative? In the remainder of this section, we try to explain this. First, however, we wish to emphasize some important respects in which the two approaches to MtF transsexualism do not differ. Perhaps most importantly, both proponents of the feminine essence narrative and of Blanchard’s theory support the treatment of transsexuals by sex reassignment surgery. Indeed, Blanchard (2000) has been a consistent advocate of such treatment for both homosexual and autogynephilic transsexuals, as has one of the authors of this article (Bailey 2003).
In addition, proponents of both theories see the histories people tell of their lives as an important source of understanding. In a recent paper on autogynephilia, Blanchard (2005) quotes extensively from self-reports of people with autogynephilia, primarily from collections compiled by Lawrence (Lawrence 1999a, 1999b). We ourselves have learned much about diversity among MtF transsexuals from our own interactions with members of each type. We believe, however, that in this domain, as in others, people’s own narratives do not always correspond to the true reasons for their choices and behaviors. Finally, proponents of both theories recognize that MtF transsexuals are a diverse population who differ among themselves in many ways due to life circumstances and personal characteristics. Nonetheless,we maintain that those who promote the feminine essence narrative fail to acknowledge one important source of that diversity, the distinction between homosexual and autogynephilic MtF transsexuals.
Denial of Autogynephilia. Few non-homosexual transsexuals publicly identify as autogynephilic, and most neither admit a history of sexual arousal to the idea of being a woman, nor accept that such arousal was a motivating factor for their transsexualism. Indeed, although most public transsexual activists appear by their histories and presentations to be non-homosexual MtF transsexuals, they have generally been hostile toward the idea that non-homosexual transsexualism is associated with, and motivated by, autogynephilia. Prominent MtF transsexuals and transgenders who have expressed outrage at the theory include Becky Allison (1998), Christine Burns (2004), Lynn Conway (2006), Andrea James (2006), Deirdre McCloskey (2003), Nancy Nangeroni (Grubb 2004), and Joan Roughgarden (2003). The most visible exception has been Anne Lawrence, a physician, researcher, and psychotherapist, who both identifies as autogynephilic and has done most of the recently published research on autogynephilia. Willow Arune (2004) is another exception.
There are a number of reasons why autogynephilic individuals may prefer the feminine essence narrative as an account of their condition, even if autogynephilia is in fact the driving force. These include the concern (pre-transition) that clinicians will deem them unacceptable for sex reassignment if their transsexualism is erotically motivated, or that people will consider them sexually deviant (Bailey 2003; Lawrence 2004). Because autogynephilia produces a strong desire to imagine oneself as a woman, the feminine essence narrative is intrinsically appealing to autogynephilic individuals, even if it is implausible. In contrast, an explanation based on autogynephilia may be experienced as a narcissistic injury.
Transsexuals who have successfully accomplished the MtF transition sometimes see themselves as mentors to younger people attempting or considering this path. They may feel that public acceptance of the feminine essence narrative will facilitate the transition for these younger individuals. For example, parents may be more accepting of a child whom they think of as a female unfortunately born with a male’s body than of one whom they think of as a male erotically aroused by the idea of being female. Finally, as Lawrence (2007a) notes, postoperative transsexuals whose desire and attachment to being women persists as their sex drive diminishes with age may come to doubt that this desire has anything to do with eroticism. She also explains how this pattern is explicable via autogynephilia.
Attempts to Intimidate Proponents of Blanchard’s Theory. Beyond denying the role of autogynephilia in MtF transsexualism, some transsexual activists have mounted attacks on those who publicly disagree with them. In 2003, the first author published a book, The Man Who Would Be Queen, about male femininity, including MtF transsexualism. The section on transsexualism included summaries of Blanchard’s theory illustrated by transsexual women of both types whom he had met, and who agreed to let their stories be included. Upon publication, there was a firestorm of controversy among some MtF transsexuals.
Most notably, the transsexual activists Lynn Conway (2006) and Andrea James (2006) led an internet “investigation” into the publication of the book. Conway (2004) likened the book to “Nazi propaganda” and said that it was “transsexual women’s worst nightmare. ” As a result of Conway’s and James’s efforts, a number of very public academic, personal, and professional accusations were made against the first author. None of these accusations was true (Bailey 2005). (For an historical investigation into the controversy surrounding The Man Who Would Be Queen, including a description of the substance and the merits of the accusations, see Dreger 2007. ) The attacks on The Man Who Would Be Queen were precisely an attempt to punish the author for writing approvingly about Blanchard’s ideas, and to intimidate others from doing so.
The second author was also attacked by some of the same transsexuals after she helped create the Website transkids. us. This website was created by a group of homosexual transsexuals, or “transkids,” their nonclinical name for themselves, to educate the clinical and research communities in the wake of the controversy regarding The Man Who Would Be Queen. The writings on the site both endorsed Blanchard’s distinction between homosexual and autogynephilic MtF transsexuals and criticized the standard feminine essence narrative as being both false and harmful to homosexual MtF transsexuals. Subsequently, Andrea James (2007) conducted highly personal attacks on individual transkids (including the second author), urging that these transkids be exposed and asserting that they were “fakes” because they would not reveal their identities publicly.
How Denial of Autogynephilia Can Be Harmful
We believe that advocacy for the standard feminine essence narrative, and against Blanchard’s theory, is primarily conducted by, or at least on behalf of, non-homosexual transsexuals who incorrectly deny their autogynephilia. We have outlined why some autogynephilic transsexuals might want to deny that they are autogynephilic, and why they might strongly prefer the standard (but false) feminine essence narrative. Those who advocate on behalf of autogynephilic transsexuals in denial include many gender clinicians; their motives may include their unwillingness to disbelieve or displease their patients and their greater comfort with the idea of facilitating sex reassignment for reasons related to gender than to eroticism (Lawrence 1998). Some clinicians may also think that belief in the feminine essence narrative may be beneficial for their patients’ psychological health and social interactions, even if it does not correspond to the true etiology of their desire for sex reassignment. Nevertheless, there are both scientific and human costs to colluding with autogynephilies in denial by propping up the feminine essence narrative as an explanation for all MtF transsexualism.
Impeding Scientific Progress. Obviously, the extreme, highly personal attacks on those who agree with Blanchard’s theory of transsexualism are likely to deter people from researching, agreeing with, or publicizing the theory. That is, indeed, the intended function of the attacks. Most theories can benefit by scientific criticism, but the attacks on The Man Who Would Be Queen and its author by transgender activists were not scientific criticism. We have argued that Blanchard’s “two types” theory has greater explanatory value than the feminine essence narrative and the associated brain-sex theory. Whether or not we are right, deciding between the two views via political pressure cannot be the right way to advance science. The scientific costs of this pressure include embracing a less plausible theory and failure to advance the better theory. For example, it is possible that some transsexuals’ resistance to the current theory is due to its incompleteness, which prevents it from explaining their inner experiences to their satisfaction (Lawrence 2007a). Progress toward a more complete theory is impeded by the kinds of pressure we have described, but it would be facilitated by thoughtful criticism.
Harm to Homosexual Transsexuals. Clinicians who work with transgender patients and who believe in the feminine essence narrative of MtF transsexualism sometimes take a similar approach to both homosexual and non-homosexual MtF transsexuals. For example, the second author knows transkids whose therapists have offered them, and their families, readings by and about non-homosexual transsexuals (e. g. , She’s Not There, by Jennifer Boylan  and Conundrum by Jan Morris ). The narratives in these readings did not even approximate the transkids’ lives, and the therapists’ assumptions that they did had a highly negative effect on the transkids’ attitudes toward therapy. Inevitably, they dropped out early.
Homosexual and non-homosexual MtF transsexuals have different life issues and goals, and the persistence of the belief that they are similar prevents development of clinical interventions likely to benefit the homosexual subtype. Velasquez (2004) has argued that there is a lack of meaningful therapy for young homosexual transsexuals like herself, and that this is because transkids are not recognized as a subtype distinct from non-homosexual transsexuals. The denial of autogynephilia helps make this possible.
Harm to Autogynephilic Male-to-Female Transsexuals. There are also substantial human costs to autogynephilic transsexuals due to insistence on the false, feminine essence narrative. We consider two groups whom we believe are harmed by embracing the false narrative at the expense of Blanchard’s categorical theory: autogynephiles not in denial, and autogynephiles in denial.
Although few non-homosexual MtF transsexuals publicly identify as autogynephilic, many more do so privately. Of the e-mail correspondence the first author received regarding The Man Who Would Be Queen, about a third was from individuals who understood themselves to be autogynephilic. Some of these individuals said that reading about Blanchard’s theory in the book had been revelatory and that they understood themselves for the first time, and all of them were happy that autogynephilia was being discussed openly. Even before the controversy concerning the book, transsexuals sympathetic to Blanchard’s ideas have found themselves unwelcome in transsexual forums (e. g. , online forums discussing transgender issues). Typically, any endorsement of Blanchard’s theory, or admission of significant autogynephilic motivation, is met with hostility. This hostility appears to emanate primarily from individuals who fit the profile of autogynephiles in denial. The extreme stigmatization of the (true) idea of autogynephilia harms autogynephiles not in denial in obvious ways. It makes it much less likely that they can find resources that help them understand themselves, forces them into the closet, invalidates their self-concepts, and heightens feelings of shame.
Although autogynephiles in denial prefer the standard feminine essence narrative, this does not necessarily mean that wide acceptance of that narrative is in their best interests. In general, it seems likely that the best clinical and personal decisions are made on the basis of accurate conceptualizations. For example, we have noticed that some transsexuals we would classify as autogynephilic have chosen to pursue sex reassignment surgery after being diagnosed as “transsexual” rather than “transvestite,” a diagnostic moment they often recount with a sense of relief. Currently, in the psychiatric nomenclature, the official name for transsexualism is gender identity disorder, highlighting the centrality of gender identity, consistent with the feminine essence narrative (American Psychiatric Association 2000). However, the differential diagnosis between transsexualism (gender identity disorder) and transvestism (“transvestic fetishism” in the DSM) is not clearly meaningful. Both non-homosexual transsexuals and transvestites are motivated by autogynephilia; many (perhaps most) non-homosexual transsexuals were transvestites prior to transitioning; and most importantly, the main difference between the two conditions is that transsexuals, but not transvestites, decide to take steps to achieve women’s bodies. As we have noted, the precise nature of one’s autogynephilic fantasies is a key factor in this decision. It seems detrimental to us that what should be an explicit cost-benefit decision, with important consequences to the lives of autogynephilic patients and their families, might be unduly influenced by a differential diagnosis of questionable validity.
It is unfortunate that the public face of MtF transsexualism is so different from reality. The controversy concerning The Man Who Would Be Queen has raised awareness of Blanchard’s ideas within the transgender community, but it has not yet encouraged open-mindedness to those ideas. Those who value scientific truth and the well-being of transsexuals are advised to do better.
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