November 10, 2008
Kelley Winters, Ph.D.
GID Reform Advocates
In the Third Edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM) in 1980, the American Psychiatric Association
explained the reasons for removing the diagnostic category of homosexuality: 
“The crucial issue in determining
whether or not homosexuality per se should be regarded as a mental disorder is
not the etiology of the condition, but its consequences and the definition of
mental disorder.” 
This marked a significant shift in diagnostic policy toward
the consequence of a condition rather than speculation of its cause. Two
decades later, the APA discarded this principle by emphasizing the controversial
and inflammatory theory of “autogynephilia” in the supporting text of Gender
Identity Disorder diagnosis of the DSM-IV-TR:
“Adult males who are sexually
attracted to females, to both males and females, or to neither sex usually
report a history of erotic arousal associated with the thought or image of
oneself as a woman (termed autogynephilia).” 
This statement and its supporting literature, that
hypothesize sexual deviance as a cause of transsexualism, have sparked dissent
among clinicians and researchers and outrage within the transgender and
transsexual community [4-8] While theories around “autogynephilia” seem
exceptionally impervious to contrary evidence, the controversy has raised
questions about tolerance and bias in American Psychiatry-- at what point do
bad stereotypes preclude good science?
The term “autogynephilia,” meaning “love of oneself as a
woman,” was first introduced by Dr. Raymond Blanchard of the Clarke Institute
of Psychiatry, now known as the Centre for Addiction and Mental Health in
Toronto. He is currently chairman of the Paraphilias Subcommittee for the
upcoming DSM-V. Blanchard stated that,
"All gender dysphoric males
who are not sexually oriented toward men are instead sexually oriented toward
the thought or image of themselves as women." 
The absolutism in this statement, in the words “all and
“instead,” seems astonishing.  It reduces a broad continuum of sexuality
among transwomen to two narrow maligning stereotypes: either “homosexual males”
in denial of a “homosexual” identity or pathological narcissistic “males” sexually
attracted to themselves This strict dichotomy stands in contrast to the words
of Dr. Alfred Kinsey, the father of modern sexology:
“The world is not divided into
sheeps and goats. Not all things are black nor all things white. It is a
fundamental of taxonomy that nature rarely deals with discrete categories. Only
the human mind invents categories and tries to force facts into separated
pigeon-holes. The living world is a continuum in each and every one of its
aspects. The sooner we learn this concerning sexual behavior the sooner we
shall reach a sound understanding of the realities of sex.” 
Although the phenomenon described by “autogynephilia,”
arousal to thoughts of being women, has been reported in personal narratives
by some transwomen,  there is no apparent basis for projecting this
stereotype upon all lesbian, bisexual and asexual transwomen. Dr. Blanchard
conflates association with causation by using the phrase “erotic arousal in
association with the thought or image of themselves as women” interchangeably
with “erotically aroused by the thought or image…”  However, “association
with” is not the same as “aroused by.”
What role do birth-assigned women play in their own sexual fantasies? We would not consider it odd or “fetishistic” for non-trans women to be themselves on the stage of their sex lives. Nor would we assume that they are aroused by their self-image as women rather than by their partners. Why are lesbian and bisexual transwomen treated so differently by American psychiatry and psychology? For transwomen born without female anatomy, incongruence of our bodies with our self-identities pose understandable barriers to sexual expression. The desire to surmount these barriers is more accurately described as an adaptive accommodation to a physiological deficiency. Does the image of a female body “interfere” with normal attractions as Blanchard suggests  or does it enable them?
Dr. Blanchard’s studies of clinical patients reporting
“erotic arousal in association with cross-dressing” were presented as
“fetishistic cases.” [15-16] His findings have been criticized by psychologist
and community advocate Dr. Madeline Wyndzen as having never been replicated,
excluding control groups of birth-assigned women, and for confounding causation
with observational data.  For gender dysphoric youth with no access to
medical transition procedures, is cross-dressing a “fetishistic” pathology, or
is it an adaptive coping strategy to an incongruent body? It seems more
plausible that cross-dressing represents an accommodation to conceal or
disguise anatomy which poses barriers to lesbian or bisexual expression or
Dr. Blanchard’s studies omitted control groups of birth-assigned women and the roles that fashion, clothing and lingerie play in their sexual expression and fantasy. For birth-assigned women, sexual expression is accompanied by a $300 billion fashion industry in the U.S.  but without diagnosis of fetishistism or pathology. Dr. Sigmund Freud, however, noted how fashion accompanies sexuality with a metaphorical remark:
“In the world of everyday
experience, we can observe that half of humanity must be classed among the
clothes fetishists. All women, that is, are clothes fetishists. … For them
clothes take the place of parts of the body, and to wear the same clothes means
only to be able to show what the others can show, means only that one can find
in her everything that one can expect from women, an assurance which the woman
can give only in this form.” 
Freud’s observations on the role of clothing in the
expression of womanhood seem relevant to Blanchard’s presumption of
“autogynephilic” pathology in transwomen for whom “clothes take the place of
parts of the body” -- parts that nature did not provide.
What of transwomen who attest attraction to women and
frequently are in very long term relationships, partnerships and marriages with
women? Blanchard’s theory of “autogynephilia,” like Dr. Magnus Hirschfeld’s
“automonosexualism,”  implies that all transwomen not exclusively
attracted to men are incapable of genuine attraction to other women. 
However, clinical literature has long reported 20 to 30 percent of transsexual
women attracted primarily or exclusively to other women [22-23]. These early
figures were likely understated, as attraction to women posed barriers to
access to hormonal and surgical transition care. Nonclinical surveys report
higher rates of same-sex orientation (with regard to affirmed identity, not
assigned birth-sex) [24-25] It seems paradoxical that these women are labeled
as “autogynephiles” on the basis of their attraction to women, while that very
label contradicts the validity of their attraction to women.
How does the “autogynephilia” hypothesis, that “all”
transwomen are attracted to men or “instead” to themselves, explain the
existence of long-term relationships with other women? Here in Colorado,
writer Laurie Cicotello related the story of her remarkable family. In 1997,
Ms. Cicotello testified before the Colorado legislature with her father, Dana,
a transwoman, educator and advocate respected throughout the transgender
community. They spoke in opposition to an anti-gay and lesbian marriage bill
that would have threatened her parents’ legal same-sex marriage of forty years
at the time of this writing. Laurie described how she stood with her parents
later that year, hands clasped together over their heads, before fifty-five
thousand people at the Denver PrideFest Rally. In a state known in the 90s for
religious intolerance of GLBT diversity, Dana proclaimed to the crowd, “I’ve
got your family values, right here!”
Theories of “autogynephilia” not only associate hurtful stereotypes of sexual deviance with transwomen, they presume “erotic anomalies” or self-focused deviance to be the cause of gender dysphoria and the motivation for transition, with both nature and nurture playing secondary roles. Speaking of lesbian, bisexual and asexual transwomen not primarily attracted to men, Dr. Blanchard states:
“This hypothesis asserts that the
various discriminable syndromes of non-homosexual gender dysphoria are the
results of autogynephilia interacting with additional constitutional or experiential
Bailey and Triea recently supported this view that
“nonhomosexual transsexuals experience erotic arousal at the idea of becoming a
woman, and this arousal motivates them to become women.”  However, they nor
Blanchard offer evidence of a causal relationship between a sexual affinity for
one’s-self and gender dysphoria (intense distress with one’s assigned birth-sex
or natal anatomy.) This body of theory seems to proffer the circular reasoning
If “autogynephilia” is associated
with all lesbian and bisexual transsexual women, then it must be the cause of
gender dysphoria for them.
If “autogynephilia” is the cause
of gender dysphoria in lesbian and bisexual transsexual women, then all of
them must be “autogynephilic.”
Proponents of these stereotypes of sexual deviance have not
asked the fundamental questions about how gender identity forms in all human
beings, transgender and cisgender. They neglect to include control groups of
birth-assigned women with their limited, clinical samples of transwomen. They
most often neglect to include nonclinical samples of transitioned women living
full lives in the real world. They fail to consider the similarities between
birth-assigned women and transitioned women of all sexual orientations,
similarities so profound that the existence of large numbers of transitioned
women remains unacknowledged by psychiatric researchers.  Moreover, the
proven efficacy of social and medical transition in relieving the distress of
gender dysphoria and improving quality of lives [30-31] remains unexplained by
“autogynephilic” theories of etiology.
The corollary of “autogynephilia” theory postulates that
straight transwomen attracted to men do not possess female gender identities
but are merely gay men in denial. They are branded by Blanchard with a
maligning label of “homosexual male transsexuals.”  He asserts that
straight and lesbian/bisexual/asexual transwomen are so fundamentally different
that they represent two entirely distinct “disorders,”
“The feminine gender identity that
develops in homosexual males is different from the feminine gender identity
that develops in heterosexual males. In other words, homosexual and
heterosexual men cannot ‘‘catch’’ the same gender identity disorder in the way
that homosexual and heterosexual men can both ‘‘catch’’ the identical strain of
influenza virus. Each class of men is susceptible to its own type of gender
identity disorder and only its own type of gender identity disorder.” 
Dr. Blanchard’s certainty of mutually exclusive transsexual
types based on sexual orientation seems peculiar within sexology, where both
gender identity  and sexual orientation  have long been viewed as
continuous rather than dichotomous. He based this assumption on differences in
“a history of erotic arousal in association with cross-dressing,” in ages of
presentation for “professional help,” and in “degrees of childhood femininity” within
clinical populations. Correlating these attributes to the lack or presence of
attraction to males, Blanchard concluded that “the main varieties of
nonhomosexual gender dysphoria are more similar to each other than any of them
is to the homosexual type.”  However, a recent study of gender-dysphoric MTF
subjects reported no significant difference in scores on a gender identity/gender
dysphoria questionnaire with regard to sexual orientation.  This result is
not explained by Blanchard’s assumption of fundamentally different gender
Blanchard’s analogy of gender variant identities to
communicable disease is offensive and perhaps demonstrative of bias. His
research does not consider the shame and guilt that force gender dysphoric
youth and adults into the closet, often for decades. For example, “degrees of
childhood femininity” may indicate degrees of closeted self-expression far more
than innate femininity. The doctrine of “autogynephilic” dichotomy neglects
different social pressures faced by gender dysphoric youth and adults, based on
their sexual orientations. These differences in social oppression would certainly
impact their ability to emerge from the closet and express their inner
Inferring gender identity based on age of clinical
presentation is especially troubling, given Zucker and Bradley’s observation
that gender variant youth are “invariably” referred by adults and not by
themselves.  Admission to clinics that practice gender-reparative therapy
(attempting to change one’s gender identity or espression) may well indicate
parental intolerance rather than gender identity per se. For MTF youth, dates
of clinical presentation may likely signify the dates they were caught by their
parents in their sisters’ clothes and little more. For any closeted
population, it is wrong to confuse “onset” with presentation to a mental
institution or clinic.
For straight transwomen attracted to men, Dr. Blanchard
states that all “homosexual gender dysphorics are sufficiently similar to be
treated as one diagnostic group.”  The statement makes clear the intent of
“homosexual gender dysphorics” as a term of mental disorder. However the theory
that attraction to men is the sole motivation for transition does not explain
why the vast majority of gay males do not transition. It does not explain
very low rates of surgical regrets for transwomen, with and without
partners or spouses. Nor does it explain very
young children who are painfully distressed with their assigned birth-sex or
why some transition years before adolescence. What then would differentiate
straight transwomen and girls from gay males, if gender dysphoria is
hypothesized to exclude any innate sense of gender identity?
Perhaps the model of “homosexual gender dysphoria” assumes
that living as transsexual women is somehow socially advantageous to living as
gay men. To the contrary, gay men possess greater social status, economic
privilege and civil rights protection than transwomen in the U.S. and much of
the world. For example, 20 states currently prohibit workplace discrimination
based on sexual orientation, while only 12 include protection based on gender
identity. 88 percent of U.S. Fortune 500 employers prohibit discrimination
based on sexual orientation versus 25 percent that include gender identity. 
It seems farfetched that “all” straight transwomen who forfeit social status to
transition would be driven only by attraction to men.
To Be Continued—
Autogynephilia: The Infallible Derogatory Hypothesis,
 Diagnostic nomenclature of homosexuality was actually
removed from the DSM in intermediate stages over a fourteen year span.
Homosexuality per se was replaced by Sexual Orientation Disturbance in the
seventh printing of the DSM-I in 1973 and by Ego-Dystonic Homosexuality in the
DSM-III in 1980. This was removed from the DSM-III-R in 1987. While APA policy
now affirms that same sex orientation is no longer regarded as mental disorder,
two diagnostic categories remain in the current DSM-IV-TR that may be used to
diagnose homosexuality as mental illness: Sexual Disorder Not Otherwise
Specified and Gender Identity Disorder of Children.
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 Human Rights Campaign, Inc., The State of the Work Place
Copyright © 2008 Kelley Winters, GID Reform Advocates