The Little Case Study that Autogynephilia Forgot

(a discussion specific to Dr. Ray Blanchard’s model of autogynephilia, and not so much to people who identify as autogynephile because they feel it’s a close representation to their identity.  This is a draft response to the proposed DSM5 changes, in this case specifically to the diagnosis of Transvestic Fetish / Disorder, which I see as the most urgent part to address from the trans side of things)

Everyone has a sexual identity, some mental image of themselves, to take their place in their fantasies.  That sexual self-identity might be more buff or more sultry, might be more muscled or more busty… they never seem to conform to our physical reality.  It’s just a diversion, after all.  There’s no shame in it.  Unless you have a male body and are picturing yourself as female – then, you’re considered mentally ill.  The sexual arousal of a male who pictures himself as a woman is increasingly being labeled “Autogynephilia,” and as of 2010, is proposed to be written into the Diagnostic and Statistical Manual (DSM) as one of two subcategories of Transvestic Fetish (TF, to be renamed “Transvestic Disorder”).

There have been a large number of questions about whether non-damaging consensual sexual activity should be pathologized to begin with, and the revisions to the DSM proposed in 2010 attempt to make a distinction between “paraphilias” and “paraphilic disorders.”  Thus the paraphilias sub-group (led this revision by Dr. Ray Blanchard) still gets the juicy job of defining what “normative” and “non-normative” sexual behaviours are, while still apparently limiting diagnosis-to-treatment paths to those times when the behaviours cause distress or impairment, or hurt others — a paraphilic disorder.  Distinctions can be important.

Starting in the mid 1950s, Dr. Evelyn Hooker started collecting data about homosexuals, having realized that there was a marked difference between those who’d reached self-acceptance and those who sought treatment – that homosexuality itself was not a mental health issue, only the distress wrought by societal stigma.  In the late 1960s, this sentiment slowly grew among select therapists who’d realized that people coming to them to deal with their struggles with guilt were only a part of a larger, healthier picture.  Although political pressure is often credited with the removal of homosexuality from the DSM in 1973, this slow realization also helped fuel the decision.

This is a distinction that Dr. Blanchard, the father of Autogynephilia, would do well to remember, as he is developing a theory about crossdressers while studying both transvestites and transsexuals, and hopelessly conflating the two because of the imbalance between those who he sees seeking treatment, versus those who don’t.

Transsexuals are currently catalogued in the DSM as having Gender Identity Disorder (GID, which is proposed to be renamed Gender Incongruence), which oversimplified is a sense of being a gender opposite their birth sex.  More and more, we’re coming to realize that there is something very real to transsexual identities, whether or not we believe or are familiar with the accumulating medical studies that demonstrate a likelihood of a biological origin or biological component of transsexuality. 1 I tend to believe that transsexuality and many other transgender identities have a similar cause, but are mostly separated by the degree that cross-gender identification is experienced – transsexuals have totally oppositive cross-gender identification, while someone who crossdresses or fits in more as bigendered or genderqueer might have a less intense or dual-gendered identification.  Someone who is further away on the scale and is a non-tactile transvestite may have a cross-gender identification that is submerged to the point that it only surfaces in sexual fantasy (although I don’t know enough about transvestites to know if this is the case for all or some).  But while a difference in degree, it is a difference nonetheless.

Dr. Blanchard conflates transsexuals with crossdressers because he refuses to accept transsexual identities as valid, referring to post-operative transwomen as men without penises.2 But because transsexuals comprise the majority of patients seeking treatment (because GID provides a framework through which they can obtain hormones and surgery, while it’s mostly only crossdressers struggling with shame who will ever seek treatment) and because of a refusal to accept transwomen as women, it becomes easier to equate the two.  Indeed, at times Blanchard seeks to annex transsexuals (particularly those who are not solely androphilic / attracted to men), including this recent footnote in his rationale for the proposed changes to TF / TD: “As a practical matter, the autogynephilic type seems to have a higher risk of developing gender dysphoria. This was confirmed in a secondary data analysis reported by Blanchard (2009c).”3

Because of the existence of the two diagnoses (TF and GID) and some lack of clarity in the concept of Autogynephilia as to where the division lies, it becomes necessary to provide some kind of differentiation, and Blanchard misplaces this by dividing patients by sexual orientation (“homosexual transsexuals” versus “autogynephiles,” to simplify) – in other words, you’re either gay and want to change your body so you can be straight, or you want to change your body because you get turned on by the thought of being a woman.  In reality, transsexuals are often neither ashamed of their sexual orientation (whatever it may be), nor motivated by arousal (otherwise, male-to-female hormone therapy would be very self-defeating!), so this misconception could easily be dispelled just from listening to transsexual experiences.  In the transsexual community, a clear understanding has developed that transsexuality is about who we are, not who we love, and consequently a transsexual might be attracted to a man, a woman, or both.  In the transsexual community (by my observation over the years, anyway), the intensity in which trans identities are experienced does not appear to vary in any significant discernible way purely according to sexual orientation.

Transvestic Disorder (where Autogynephilia is proposed as a subcategory) also has the unique distinction of being the only paraphilia (possibly the only psychiatric disorder?) that is exclusive to one gender.  In the proposed revisions, TF / TD is still defined as recurrent sexual fantasies by a male of having a female body.4 Besides overlooking possible male sexual identities in the female-bodied and/or women who crossdress, studies being done related to autogynephilia fail to include control groups of cisgender (non-transgender) women, making it impossible to know if the difference between a cisgender woman who occasionally dresses up and feels a bit of self-excitement mingled with anticipation and a transvestite who gets turned on by crossdressing (and not all crossdressers do) stems mostly from the different amounts of testosterone produced by the body.  Ultimately, the cisgender woman becomes the little case study that autogynephilia forgot, and with this absence, it is impossible to see “autogynephilic” female sexual identity in context.5

When it comes to defining Autogynephilia, it becomes all about sex fantasies.  Several years ago, I had been diagnosed with Gender Identity Disorder.  I have transitioned and am accepted as female in my everyday life.  Given the wrong therapist, I could have been diagnosed with TF / TD instead.  After all, in my pre-transition sexual fantasies (upon which the diagnosis of TF / TD hinges), I’d always been female… just as in every other moment of self-identification in my life.  After all, what else would I be?  I could never make enough sense from forcing myself into a male identity (sexual or otherwise), so arousal was impossible without a female sexual identity.  But the thought of being female was not of itself a cause of arousal.  Distinctions are important.  I would think it would be much the same for any cisgender woman.  The framework of autogynephilia makes it possible or even likely that one can observe female self-identification in someone who is male-bodied, and assume causality when it’s simply a reflection of a deeper problem.

The diagnosis of GID has traditionally taken into account a spectrum of people who experience gender variance, but the revision clarifies by indicating treatment only for those who feel distressed by their bodies enough to need to change them to reflect their identification as fully male or female.6 Distinctions are important.  However, this puts Transvestic Fetish and Gender Incongruence in a position of competing to be applied to overlapping groups of people, creating a quandary for the therapist.  This has the potential of being resolved entirely by the therapist’s own bias, hinging on whether he or she accepts transsexuals as being genuinely the gender to which they identify, or whether he or she considers this to be fantasy… or for those therapists in between, it will depend on what criteria they will settle upon to determine which identities are “real” and which are not.  For any who doubt this, keep in mind that this has largely been the practice for years of the Centre for Addictions and Mental Health (CAMH), where Blanchard is the Head of Clinical Sexology Services.  At CAMH, it appears that only transsexuals who are at risk of harming themselves and “autogynephiles” who are at risk to themselves because of the distress and anxiety caused by societal stigma are approved for surgery – and then, only after several years of therapy.  The mere admission of a female sexual identity that I’d made above (combined with bisexuality) would have resulted in a diagnosis of autogynephilia in a CAMH framework, regardless of the context I’d given it.

Having two potentially overlapping and competing diagnoses is duplicitous, especially when one (GID / GI) has a long history of study and proven track record for positive outcomes, while the second (TF / TD) integrates a theory that is highly controversial, depends on studies often described as unrepeatable by other researchers,7 and rings so untrue with the communities most at risk of the diagnosis as to generate enormous vitriol that has been leveled at the proponents of the theory.  When it comes right down to it, most people in the trans community do realize that Blanchard and his network of supporters sincerely want to help people, but react to the harm we feel being caused by their misguided attempts to do so.

Distinctions are important.

And returning to Transvestic Fetish / Transvestic Disorder, if we take transsexuals completely out of the equation, then we return to the question of whether mere crossdressing (along with consensual BDSM and a number of other things classified as paraphilia, except for when they affect minors or cause harm) really need to be categorized in the DSM, or (like homosexuality prior to 1973) if researchers are only seeing a part of the equation based on a circumstantial bias in the types of patients they typically see.

With the exception of behaviours that involve minors or cause harm, it’s time to look at the depression, anxiety and distress caused by societal stigma as being depression, anxiety and distress caused by societal stigma, rather than giving causal status to and targeting treatment for a sexual or gender identity.

Of course, I don’t speak for the whole transgender community (as nebulous as that concept can be).  Trans encompasses an enormous set of diverse identities, and there are in fact even a few who do identify as autogynephile (although with the high-profile exception of Dr. Anne Lawrence, even many self-identified autogynephiles take issue with how autogynephilia is defined and treated clinically8).  I speak as an individual who has been through treatment for GID and would be considered one of its many success stories.  I also speak as someone who has been involved in trans communities for years, learned a great deal about varying perspectives (including crossdressers, who are an extremely varied crowd) and while I know I can’t speak for all of them or claim for certain that my answers represent a majority opinion, I can say that I’ve heard a great deal of concerns made regarding the proposed subcategory of Autogynephilia and the diagnosis of Transvestic Fetish.

– Crossposted to TransGroupBlog

(References after the fold)


References:

1. Including (and covering a range of theories / phenomena):

Sexual differentiation of the human brain in relation to gender identity and sexual orientation D.Swaab & A.Garcia-Fulgaras Functional Neurology, Jan-Mar 2009

http://www.ncbi.nlm.nih.gov/pubmed/15724806,

http://www.nature.com/nature/journal/v378/n6552/abs/378068a0.html,

http://weblogs3.nrc.nl/swaab/2009/04/03/the-atypical-brain-development-of-transsexuals/,

http://www.ncbi.nlm.nih.gov/pubmed/15177706?ordinalpos=26&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum,

http://forum.mesomorphosis.com/mens-health-forum/prenatal-exposure-diethylstilbestrol-des-134253671.html

2.Armstrong J. The Body within, the body without. Globe and Mail, 12 June 2004, p. F1.

3. from the dsm5.org revision website, with a footnote referring to Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3.”

4. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=189#

5. Wyndzen MH. A personal and scientific look at a mental illness model of transgenderism. APA Division 44 Newsletter, Spring 2004, p. 3.

6. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=193

7. i.e. Wyndzen MH. A personal and scientific look at a mental illness model of transgenderism. APA Division 44 Newsletter, Spring 2004, p. 3., http://www.genderpsychology.org/autogynephilia/

8. http://autogynephiliac.blogspot.com/2010/01/blanchard-and-dsm-v-redefining.html

  1. Your post says so much. I have always maintained, indeed I said this to someone today, that only another TS can truly understand a TS. It is so sad and unfortunate that those involved in “case studies” – the cis-gendered (Dr. Anne Lawrence aside) – continue to believe that transsexuality can be simply explained as a mental disorder.

    Now will my agreement with your excellent post mark me forever as mentally ill?

  2. Sorry for the late comment, caught this via a link in “MSM Revisited” .

    The true Achilles’ heel of the TF theory: a male that wears a teddy for arousal is disordered but a woman that enjoys strapping on added equipment is not. Boiled down this is simply good old fashioned power structure based sexism, as it means that a “female acting” (submissive) male is disordered. Strong “male-like” behavior is good and should be accepted and encouraged; weak “female-like” behavior is bad and needs to be, well…punished. Autogynephilia then becomes merely a special case. Doctor B, heal thyself…

  3. I find this subject pretty fascinating. I vehemently disagree with Dr. Blanchard, and Dr. Lawrence on most of their findings about autogynephilia, but I’m no researcher – I just know how I feel, and my own motivations behind transitioning. Back when she was still practicing endocrinology, Anne Lawrence was my doctor and secondary mental health professional. I found her “bedside manner” to be pretty abrupt, and sometimes she just struck me as singularly odd (far be it from me to hold that against someone though!) – A lot of people were pretty upset over some of her research, and it wasn’t until years later that I discovered why. I will say, she was quite good at the endocrinology end of things. It’s too bad she doesn’t practice that anymore – it’s the one thing I think she did very well, that wasn’t actually controversial.

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