On the Science of Changing Sex

Autistic Sky

Posted in Brain Sex, Confirming Two Type Taxonomy by Kay Brown on September 21, 2014

For the past several years, evidence has been accumulating that there is a fairly high comorbitity between transsexuality / transgenderism and the autism spectrum.  Interestingly, and perhaps not totally surprisingly, among MTF transwomen, it appears to be exclusively found in the non-exclusively androphilic population.  This fits the Freund/Blanchard taxonomy and more importantly, Blanchard’s prediction that “non-homosexual” (with respect to natal sex) MTF transwomen would exhibit neurological / brain differences from control males but these differences would NOT be a shift toward female like brains.

Autism and autism spectrum disorders are found in four to five  times as many men as women.  There are a number of theories as to why this happens, including the rather intriguing “hypermasculine brain hypothesis”, in which a link between the slight differences between men and women, as groups, having different cognitive and social behaviors and the apparent similarity, or rather, exaggeration of these differences between men and women, found in those on the autism spectrum.  If autism is a form of hypermasculinization, it would not surprise us to learn that FTM transmen were more autistic-like than most women… and that is what one group of researchers found.

Using a 50 item, Likert scored, instrument called the Autism Spectrum Quotient (AQ), Jones, et Al., found that FTM transmen as a group, scored 23.2, higher than control women AND men!  This puts about half of the FTM onto the high functioning autism spectrum!!   (The lower AQ cut-off for ASD is 23.)  Non-exclusively-androphilic transwomen scored essentially the same as the control men, while exclusively androphilic transwomen scored essentially the same as the control women, and definitely (statistically significant: p<0.03 ) below both the control men and non-androphilic transwomen.

Group:               Men                  Women       FTM                 Non-Androphilic           Androphilic
.                                                                                                     MTF  N=129                   MTF N=69

Score (SD):       17.8 (6.8)        15.4 (5.7)     23.2 (9.1)        17.4 (7.4)                         15.0 (5.6)

The implication is clear, FTM’s are masculine, perhaps even hypermasculine, while the data also supports the Freund/Blanchard two type taxonomy for MTF transwomen.  In the discussion section of the paper, the authors remarked,

“Interestingly, with the 198 transwomen group, there were 6 individuals (i.e. 3%) with a diagnosis of AS. This rate is about 3 times as many as in the general population.”

These authors didn’t state what the sexuality of the six AS individuals were; but if they conform to the greater likelihood that they were non-androphilic, found in other papers, the incidence rate for such non-androphilic transwomen would be closer to five times the rate found in the general population, however, that is only about twice as high as that found in the male population.


Jones, et Al, “Female-To-Male Transsexual People and Autistic Traits”, J. Autism Dev. Discord. DOI: 10.1007/s10803-011-1227-8

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Autogynephilic vs. Even More Autogynephilic

Posted in Science Criticism by Kay Brown on September 12, 2014

The $64K question about the Freund/Blanchard two type taxonomy is, “Is it, in fact, taxonic?”  That is to say, “Are there in fact two types of MTF transsexuals with each having a different etiology?”  The evidence pointing to it is formidable;  If one is to try to prove this to be incorrect the evidence to counter it would have to be even more formidable and convincing.  A recent paper by Veale attempts and claims to do just that, but fails utterly upon examination, as we shall see.  What she has done is to demonstrate that the difference between exclusively gynephilic and bisexual/pseudo androphilic transsexuals is purely dimensional and not taxonic.

But first, we need to define what is meant by taxonic, and what is not taxonic.  As Gangestad explains it,

“Meehl defined a taxon as “a nonarbitrary class whose existence is conjectured as an empirical question, not a mere semantic convenience”. A domain containing taxa is taxonic. Examples include biological sex, biological species, some disease entities (e.g., measles), and some ideological systems in politics or religion (Meehl, 1992). Many taxa are characterized by their causal simplicity. Taxonic domains are more likely than dimensional ones to have specific etiologies, including dichotomous necessary causal factors. For example, infectious diseases are taxa, and their causes consist of specific microbes. (More complex causal processes, such as thresholds and polarization effects, “may also underlie taxa” .) The existence of taxa can be supported either by the demonstration of requisite causal processes or by formal mathematical taxometric methods, which decide whether latent taxa underlie a set of candidate indicators of a conjectured taxon based on numerical relations between them. If so, the formal-numerical taxa that are thereby defined are empirical. Their causal basis must be discovered through additional research, and, thereby, taxometric findings can guide future inquiry into the causes of variation in the domain.”

Turning to the Freund/Blanchard taxonomy, as Veale explains it,

“Blanchard (1989) proposed that there are two distinct types (taxa) of male-to-female (MF) transsexuals and these distinctions are characterized by their sexuality: ‘‘autogynephilic’’ or ‘‘homosexual.’’ According to Blanchard, autogynephilic MF transsexuals are sexually attracted to females (gynephilic), both sexes (bisexual), or neither sex (analloerotic); they are not unusually feminine in childhood; and prior to transitioning often live outwardly successful lives as males, frequently marrying and having children. These MF transsexuals also experience autogynephilia—a term which Blanchard used to refer to ‘‘a male’s propensity to be sexually aroused by the thought of himself as a female’’. Homosexual MF transsexuals are exclusively sexually attracted to males (androphilic), do not experience autogynephilia, are highly feminine in their childhood, do not generally have success with attempts to live in the male role, and tend to present for treatment of their gender dysphoria at a younger age. By splitting MF transsexuals into these two groups based on their sexual orientation, Blanchard 1988,1989) and others (Freund, Steiner, & Chan,1982; Johnson &Hunt, 1990; Nuttbrock et al., 2011a; Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005) have found evidence for the average differences between these groups that Blanchard proposed. However, these differences do not necessarily imply a typology exists. These results could also have been reached if there was a nontaxonic latent structure with a correlation between the sexual orientation ofMF transsexuals and these other differences. Although Blanchard (1985a) found some evidence for a taxonic latent structure of the sexuality of MF transsexuals by obtaining cut-off scores for classifying MF transsexuals into two groups using an earlier version of the taxometric procedures described in this article, he did not specifically test whether the sexuality of MF transsexuals was taxonic or dimensional.”

Veale acknowledges that there are other data that suggest, strongly I would argue, that there are clearly two taxa within the MTF transsexual population.  (See FAQ for list of data supporting the two type taxonic structure in MTF transwomen.  Also see my blog category “Supporting the Two Type Taxonomy” for essays.)  She only directly lists the fraternal birth order effect, which exclusive androphilic transsexuals share with conventional gay men, but NOT autogynephilc transsexuals.  This is important, in that Gangestad demonstrated that sexual orientation roughly correlated with a latent taxa in the general population.  Thus, there IS a taxonic structure to be considered here… and if so, we need to ask what would a non-taxonic structure among the transsexual population look like?

What is not acknowledged in Veale’s paper, but should be, is that clinical experience shows that autogynephilia also exists in male individuals who do not exhibit gender dysphoria sufficient to motivate them to transition.  We call these men, “Cross-Dressers” (CD) or “transvestites” (TV).  From long clinical observation, it has been noted that there does not appear to be a sharp line between such autogynephilic individuals, that indeed most autogynephilic transsexuals had careers that exactly match those of CD/TV men before transition.  That is also to say, that there appears to be a smooth, dimensional (non-taxonic) spectrum from mildly autogynephilic men to autogynephilic transwomen.  Also from societal and clinical observation, we note that exclusively androphilic transwomen population appears to smoothly blend toward feminine gay male “drag queens” to “effeminate” gay men, with no obvious gaps in the populations.  That is also to say, that there appears to be a smooth, dimensional (non-taxonic) spectrum from mildly feminine gay men to exclusively androphilic transwomen.  If Veale is right, than that would imply that heterosexual cross-dressers are members of the same taxon as feminine gay men.  Although I don’t believe this to be correct, it has a certain superficial theoretical appeal in that cross-dressers and autogynephilic transwomen both claim that their behavior is related to a ‘feminine essence’.  Hypothesis were meant to be tested.  I will come back to this after further examination of Veale’s study below.

In order to test whether Blanchard’s hypothesis is correct, she used statistical procedures proposed by Meehl; MAXCOV and MAMBAC.  I’m not going to even try to explain how these work.  But there are a few points to using these techniques that should be noted as they will figure prominently in the reasons why Veale failed to demonstrate that Blanchard’s hypothesis is incorrect.  First, the bare minimum number of subjects in the study needs to be 300.  The second is that the minimum number of subjects in the smaller of the two suspected taxons must be at least 30, and that the measures used to differentiate the suspected taxons must be valid.  Veale collected the needed 300 transwomen, but she failed to reach the needed minimum of 30 exclusive androphilic transswomen; worse, she failed to differentiate between bisexual/psuedo-androphilic and exclusely androphilic transwomen, using an invalid measure, as Lawrence showed in her critique of the Veale study,

In this commentary on Veale’s article, which incorporates a reanalysis of some of her data, I will argue that her critique of Blanchard’s typology was invalid, because:
1. Veale’s measures of sexual orientation and autogynephilia were not well constructed, which probably interfered with the accurate identification of participants’ sexual orientations and artificially lowered estimates of their autogynephilic arousal.
2. In her taxometric analysis,Veale employed several measures that were unrelated to the defining features of Blanchard’s typology. This rendered her analysis invalid as a confirmation or disconfirmation of Blanchard’s typology: Whatever typology Veale was examining, it was not Blanchard’s typology.
3. Even if Veale had used well-constructed measures of sexual orientation and autogynephilia and had conducted her taxometric analysis utilizing the defining features of Blanchard’s typology, the number of genuinely androphilic participants she was able to recruit—probably 18 (5.8 %) at most, and possibly even fewer—was too small to be reliably detectable through taxometric analysis. If the structure of Veale’s data appears to be dimensional rather than taxonic, this is because her participants consisted almost exclusively of only one of the two MtF transsexual types: nonhomosexuals (or nonandrophiles).

I’m far less concerned about the construction of Veale’s novel measures of autogynephilia, as almost any measures that meet the minimum required correlations with Blanchard’s Core Autogynephilic Scale would do for a taxonometric analysis.  But the real deal killer to her study was that she incorrectly included so many clearly non-exclusively androphilic transwomen in the “exclusively androphilic” category.  How do we know this?  My suspicions were first raised by the low effect size regarding core autogynephilia and sexual orientation.  From Veale:

Sexual Orientation:   Androphilic               Nonandrophilic
.                                         (n=36)                           (n=272)
Core                                 Value (SD)
autogynephilia          14.08 (14.66)              19.00  (12.21)

The values are nearly the same, especially considering the very large range of scores (standard deviation).  These score differences strike me as being very much like the differences in reported autogynephilia found between exclusive gynephiles and bisexuals and asexuals in previous studies, rather than the larger differences between non-androphilies and androphiles.  If a large number of the putative androphiles were in fact bisexual and asexual, I would expect the scores to look exactly like this.  Lawrence also suspected this to be the case as she corresponded with Veale to obtain the raw data used to classify the subjects into sexual orientation categories.  From this, she demonstrated that at least half (and likely more) of the 36 putatively ‘androphilic’ subjects were decidedly bisexual instead,

“I have reorganized these supposedly androphilic informants into three groups, based on their self-reported gynephilia before age 16 (‘‘degree to which, until the age of 16, you felt sexually attracted to females’’; Veale, 2005, p. 129) and within each of these groups, based on their self-reported androphilia before age 16 (‘‘degree to which, until the age of 16, you felt sexually attracted to males’’; Veale, 2005, p. 129). My reasoning is that some of Veale’s purported androphiles were probably actually pseudo-androphiles or bisexuals—that is, their fundamental sexual attraction was towards females, but at some point they developed a secondary sexual interest in males as a consequence of their autogynephilic sexuality—and that the easiest way to detect these persons would be to look for informants who reported moderate or greater levels of gynephilia or very low levels of androphilia or both during adolescence.

First, consider the 12 informants with Reference numbers 1–12 in Table 1: All reported sexual attraction to females at least ‘‘occasionally’’ before age 16, even though their total Androphilia scores were high and their total Gynephilia scores were low. Not surprisingly, however, their mean Core Autogynephilia score—24.0—was also high, compared to a mean of only 19.0 in the 272 informants whom Veale categorized as nonandrophilic. Moreover, the mean Autogynephilic Interpersonal Fantasy score of these 12 informants—10.9—was also high, compared to a mean of only 8.2 in Veale’s 272 nominally nonandrophilic informants. Based on their early history of gynephilia and their high mean Core Autogynephilia and Autogynephilic Interpersonal Fantasy scores, I believe there is good reason to conclude that these 12 informants were actually pseudo-androphilic or bisexual, rather than genuinely androphilic as Veale alleged.

Next, consider the six informants with Reference numbers 13–16 and 24–25 in Table 1. Although these informants reported little sexual attraction to females before age 16, they also reported ‘‘rarely’’ or ‘‘never’’ experiencing sexual attraction to males before age 16; this suggests that they developed significant sexual attraction to males rather late in life. The mean total Androphilia score of these six informants—11.8—was also somewhat lower than that of the rest of the nominally androphilic group that reported little gynephilia (Reference numbers 17–23 and 26–36; n=18), with a mean total Androphilia score of 16.4. Again not surprisingly, the mean Core Autogynephilia score of these 6 informants was 18.3, nearly equal to that of the 272 nominally nonandrophilic informants, 19.0, and substantially higher than that of the rest of the nominally androphilic group that reported little gynephilia (n=18), 6.1. However, the mean Autogynephilic Interpersonal Fantasy score of these six informants, 6.5, was similar to that of the rest of the nominally androphilic group that reported little gynephilia (n=18), 6.9. Although the case here is not quite as strong as for the 12 informants who reported significant gynephilia before age 16, I believe that most or all of these 6 informants who rarely or never experienced sexual attraction to males before age 16 were also pseudo-androphilic or bisexual, rather than genuinely androphilic as Veale alleged.

There are also a few other specific supposed androphiles whose androphilia seems questionable. For example, consider the informant with Reference number 30,whose total Gynephilia score of 8 reflected her being aroused by females in her current sexual fantasies ‘‘almost all the time,’’ currently feeling sexually attracted to females ‘‘occasionally,’’ and having been conscious of sexual arousal to females while in physical contact with them ‘‘occasionally’’: Given her Core Autogynephilia score of 37 and Autogynephilic Interpersonal Fantasy score of 13, one might suspect that she was actually pseudo-androphilic or bisexual. Or consider the informants with Reference numbers 18 and 26, whose total Androphilia scores of 9 both reflected the identical pattern of only ‘‘occasional’’ attraction to males before age 16 and currently, sexual arousal to males in their current sexual fantasies only ‘‘sometimes,’’ and having been conscious of sexual arousal to males while in physical contact with them only ‘‘occasionally’’ : Here one might suspect mild pseudo-androphilic or bisexual ideation in fundamentally analloerotic individuals.”

From this analysis, Lawrence contents (and I whole heartedly concur) that 18 of these individuals were not exclusive androphiles, and three more were very likely not.  Personally, I would say that these additional three are definitely not.   Given that this would leave, at best, only 18, and likely less, androphilic individuals, the number is definitely too low to be detected as a taxon using the techniques in Veale’s study.  Further, given that most of the putatively androphilic individuals were in fact non-androphilic, Veale’s study does successfully demonstrate that the various non-androphilic categories are dimentional and non-taxonic, supporting Blanchard’s hypothesis.

Lawrence pointed out that Veale’s method of obtaining her subjects was prone to ascertainment bias.  Simply put, one does not find androphilic transwomen at autogynephilically dominated venues such as online forums and support groups.  Veale herself recommended that a “more representitive” sample would be needed for future studies.

Suggestions for future studies.

Hypothesis were meant to be tested.

Lawrence has criticized Veale’s use of her novel “attraction to feminine males” and to “attraction to transgender fiction” scales.  Veale has previously shown an interest in developing these as a means of exploring autogynephilic sexuality, as the former is based on the observation that many autogynephiles are gynandromorphophilic and that many autogynephiles like to write and share autogynephilically inspired erotica.  While I think these are worthy areas to explore, I have to concur with Lawrence that these are not the appropriate scales to use for future taxonometric analysis tests in MTF transwomen.  Instead I would highly recommend using Blanchard’s Autogynephilia Scale and the Childhood Gender Non-conformity (CGN) Scale from Gangestad, as I believe that these will show that the Freund/Blanchard categorization of MTF transsexuals is taxonic with the two types being autogynephilic and “homosexual”.  My prediction is that there will be a very high negative correlation between CA and CGN scales that will show a taxonic structure over sexual orientation.  Sexual orientation should be based on pre-SRS behavior, not on self-report, which has been shown repeatedly, to be unreliable and subject to social desirability bias in autogynephilic transwomen.

For a dichotomous separation of exclusively androphilic and non-androphilic transwomen, I recommend a multi-factorial sieve.  First, if they self report being gynephilic, bisexual, or asexual: believe them, they are non-androphilic.  Next, of the remainder, ask these two questions, “Are you now, or have you ever been, married to a woman?” and “Have you ever fathered a child?”; if yes, then they are non-androphilic.  (Lawrence previously used marital status to exclude bisexuals from androphiles.)  Finally, of the remainder, survey their actual sexual history with these two items, “Estimate how many times you have had sexual intercourse with a woman” and “Estimate how many times you had receptive sexual contact with a man’s penis before SRS (excluding  cross-dressed/feminized males)”.  A validation study may be needed to determine appropriate cut-offs for the first question.  I would be tempted to use “zero” (0), but that may be overly aggressive… but I would be very surprised if genuinely exclusive androphiles had more than a nominal experimental number, say three at most.  The second question supports the first, and also allows discrimination of celibate analloerotic individuals.  I expect that for androphilic transwomen, older than say 2o, the number of sexual contacts with men will be greatly higher than the number of vaginal intercourse experiences.

For a continuous androphilic scale, (moderately) free from social desirability bias, take the number of vaginal intercourse experiences and subtract it from the number of sexual entercouters with men.  This scale will be negative for sexually experienced gynephiles and positive for androphiles.


Gangestad, Steven W.; Bailey, J. Michael; Martin, Nicholas G., “Taxometric analyses of sexual orientation and gender identity”
Journal of Personality and Social Psychology, Vol 78(6), Jun 2000, 1109-1121. doi: 10.1037/0022-3514.78.6.1109

Jaimie F. Veale, “Evidence Against a Typology: A Taxometric Analysis of the Sexuality of Male-to-Female Transsexuals” Archives Sexual Behavior
DOI 10.1007/s10508-014-0275-5

Anne A. Lawrence, “Veale’s (2014) Critique of Blanchard’s Typology Was Invalid” Archive Sexual Behavior
DOI 10.1007/s10508-014-0383-2

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The More Things Change…

Posted in Editorial by Kay Brown on September 7, 2014

…The More They Stay the Same

APA_logoRecently, the Diagnostic & Statistics Manual, usually called by its initials, the DSM, of the American Psychiatric Association, considered by most physicians and even researchers, to be the single most important document on psychiatric conditions, was updated.  The new DSM V has an updated section on transsexual/transgender diagnoses and description.  In several ways, it was both an improvement, and a set back, for transfolk.

First, the improvement and a bit of history.  Decades ago, during the days that in my history class I called, ‘The Clinic Years”, the days when nearly all North American and European transfolk were dependent upon organized clinics for SRS, often associated with universities such as John Hopkins and Stanford, they typically excluded people that they thought fell outside of the “classic transsexual” diagnoses.  If you were a heterosexual MTF, and especially if you admitted to being sexually aroused by cross-dressing, you were not “transsexual” you were simply a “transvestite”, period.  But one clinic dispensed with this restriction, led by Norman Fisk, M.D.  Dr. Fisk coined a new term and a description of a syndrome that he described as “liberalizing” the allowable indications for HRT and SRS, “Gender Dysphoria”.  As Anne Lawrence described it:

“Fisk (1974a, b; Laub & Fisk, 1974) distinguished several types of male patients who sought sex reassignment at the Stanford University gender program. He used the term gender dysphoria syndrome, rather than transsexualism, to refer to these patients’ diagnosis. In Fisk’s typology, the number of recognized typological categories and their exact names varied slightly from one article to another. It appears that persons in only three of Fisk’s typological categories, however, were considered appropriate candidates for SRS in the Stanford program (Laub & Fisk, 1974): classic transsexualism of Benjamin (a reference to Benjamin, 1966), effeminate homosexuality, and transvestism. Only patients in these three categories, for example, were selected for inclusion in a follow-up descriptive study of applicants to the Stanford program (Dixen, Maddever, Van Maasdam, & Edwards, 1984); consequently, only these categories are included in Table 2. Other typological categories described by Fisk included persons with psychosis, extreme sociopathy and psychopathy, and inadequate/schizoid personality (1974b; Laub & Fisk, 1974). Classic MtF transsexualism was characterized by onset in early childhood, life-long feminine behavior, exclusive androphilia, absence of sexual arousal with cross-dressing, and perhaps a disinterest in genital sexuality (Fisk, 1974a; Laub & Fisk, 1974). Effeminate homosexuality progressing to gender dysphoria syndrome was characterized by androphilia, episodic nonerotic cross-dressing, and onset of gender dysphoria in adulthood (Laub & Fisk, 1974). Transvestism progressing to gender dysphoria syndrome was characterized by erotic arousal with cross-dressing, gynephilia, and onset of gender dysphoria in adulthood (Laub & Fisk, 1974).”

Here, I get to share a bit of my personal history, in that I was diagnosed as “transsexual” by Dr. Fisk in early 1975, when I was 17 years old.  So I have cherished memories of having had a grand total of six hours talking to him… but in those six hours, I got a glimpse into the mind that cut through the confusion of the differing types of candidates for sex reassignment and sought to offer such liberalized palliative medicine.  Yet, I can also tell you from those six hours, two of which were in the company of my parents (one hour each, separately, given that they were in the process of an unhappy divorce) that Fisk was a VERY skeptical man.  He dug into my history, sexuality, and aspirations with a vengeance.  I’m betting he did so with everyone.  In fact, the very first half hour spent with him, I got the very distinct impression that he was ready to believe that every word out of my mouth would be a lie.  At the time, I couldn’t understand why that should be, given that at 17, I was very naïve about the state of the on going debate in medical and scientific circles… and especially unknowing of how autogynephilic transwomen were lying to the clinics, including to Dr. Fisk.  I think it was meeting my mother, and hearing her very bitter, angry, and even hateful confirmation of my personal history and behavior since early childhood that led him to believe me.  I share this to put some color on Fisk’s support of liberalizing the diagnoses with a new inclusive term and syndrome.  Dr. Fisk supported HRT and SRS for “older transitioners” not because he believed their narritives, but because he recognized that they were in just as much of a quandary and in pain as the younger androphilic, non-autogynephilic, MTF transkids.  He was a hero.

So, back to the DSM.  Looking at the history of changes in the DSM over the decades, one can detect an undercurrent of the tides, the ebb and flow, between pragmatic science based medicine and political / social positioning.  When trans issues were first described in the DSM, it was “Transsexualism”, from the DSM, as described by Anne Lawrence (personal communication),

“Transsexualism was characterized as a “heterogeneous disorder” (p. 261), and four subtypes were recognized:

“The disorder is subdivided according to the predominant prior sexual history, which is coded in the fifth digit [e.g., 302.53] as 1 = asexual, 2 = homosexual (same anatomic sex), 3 = heterosexual (opposite anatomic sex), and 0 = unspecified.” (p. 262)

This section goes on to explain that “In the third group, ‘heterosexual,’ the individual claims to have had an active heterosexual life.” (p. 262)

In the section “Predisposing Factors (p. 263), the DSM-III recognizes that “Some cases of Transvestism evolve into Transsexualism.” Finally, in the section on “Differential Diagnosis” (p. 263), it is noted that “In both Transvestism and Transsexualism there may be cross-dressing. However, in Transvestism that has not evolved into Transsexualism there is no wish to be rid of one’s own genitals.”

The diagnostic criteria for Transsexualism (pp. 263-264) are admirably brief and uncomplicated:

1. Sense of discomfort and inappropriateness about one’s anatomic sex.

2. Wish to be rid of one’s own genitals and to live as a member of the other sex.

3. The disturbance has been continuous (not limited to periods of stress) for at least two years.

4. Absence of physical intersex or genetic abnormality.

5. Not due to another mental disorder, such as Schizophrenia.”

But later, the DSM changed the name of the disorder to “Gender Identity Disorder” which causes a distortion in therapy for all concerned because it focuses on “identity” on not on the source of their disorder.  It is even more of a distortion of the description of the etiological processes.  This was somewhat improved in the DSM-IV-TR, in that it used sexual orientation specifiers and an explanation of autogynephilia as a phenomena and an etiological origin of late transitioning transwomen’s late developing “gender identity disorder”.

Now, four decades later, the DSM has finally caught up to Dr. Fisk by using the term Gender Dysphoria Disorder.

This is the good news, in that the diagnoses speaks directly to the actual ‘pain’ of the condition, rather than to the totally inaccurate and misleading concept of a Gender Identity Disorder.  It is also good in that the history of the term goes back to Fisk’s papers that specifically describe how it incudes autogynephilic males.  However, the bad news is that the DSM no longer adequately describes autogynephilia and how it is etiologically related to gender dysphoria… and worse, still places too much emphasis on the concept of  gender identity mismatch as the cause of gender dysphoria in autogynephilic transwomen, rather than the result of autogynephilic gender dysphora,  as the science shows.  However, this reliance on “gender identity” is now euphemistically cloaked in the term “experienced / expressed gender”.

There are other problems with it, as Lawrence explains,

“…MtF and FtM transsexuals and the clinicians who treat them have traditionally recognized that a profound sense of ‘‘wrong embodiment’’—distress related to biologic sex and sexed body characteristics—is almost always a prominent feature of transsexualism and GD, in part because such wrong embodiment usually makes it difficult or impossible to ‘‘live and be accepted as a member of the opposite sex’’ (World Health Organization, 1992, p. 365). This “trapped in the wrong body’’ metaphor is not mere poetic rhetoric but offers an authentic description of transsexuals’ subjective experience. … This understanding has been largely, if not quite completely, abandoned in the DSM-5. It has been replaced by an emphasis on ‘‘assigned gender,’’ a change that seems to have occurred entirely for political and social reasons, not for scientific or clinical ones. In the DSM-5, all the clinical indicators of GD—even those that refer to biologic sex characteristics—are now conceptualized as being clinically relevant only by virtue of their evincing an ‘‘incongruence between one’s experienced/expressed gender and assigned gender’’ (APA, 2013, p. 452; the neologism ‘‘experienced/expressed gender’’ is essentially synonymous with ‘‘gender identity’’). In this formulation, the principal thing that feels wrong in transsexualism and GD is not one’s biologic sex but one’s assigned gender. This same perspective is, as we shall see, also reflected in the Subwork group members’ implicit position that effective treatment of transsexualism and GD does not require changing sexed body characteristics but only changing nominal gender assignment, as evidenced by their contention that undergoing gender transition—the only absolute criterion for which is ‘‘full-time living in the desired gender’’ (APA, 2013, p. 453)—automatically results in loss of the GD diagnosis.”

I’m not sure that this was their intent… but taken literally, one’s GD diagnoses, and thus any medical necessity justification for performing, and certainly third-party financing of, sex reassignment surgery or much needed ongoing therapeutic support services, is eliminated the moment that one is socially living as, or perceived as being, the opposite sex!  This is a bizarre result of the latest rewrite, one that Lawrence contends was done at the behest of “late transitioning” transsexuals themselves, in an effort to rid themselves of the stigma of a psychiatric diagnoses… one that is ended the moment that they transition full time.  Hopefully, the next interim revision will correct this mistake.

(Note 9/11/2014:  This essay has been edited to correct an error with respect to the history of the DSM III, thanks Anne.)


Fisk, N. (1974a). Gender dysphoria syndrome: The conceptualization that liberalizes indications for total gender reorientation and implies a broadly based multi-dimensional rehabilitative regimen [Editorial comment]. Western Journal of Medicine, 120, 386–391.

Fisk, N. (1974b). Gender dysphoria syndrome (the how, what, and why of a disease). In D. R Laub & P. Gandy (Eds.), Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome (pp. 7–14). Stanford, CA: Stanford University Press.

Laub, D. R., & Fisk, N. M. (1974). A rehabilitation program for gender dysphoria syndrome by surgical sex change. Plastic and Reconstructive Surgery, 53, 388–403.

Lawrence, A. A. (2010). Sexual orientation versus age of onset as bases for typologies (subtypes) of gender identity disorder in adolescents and adults. Archives of Sexual Behavior, 39, 514-545.

Lawrence, A., “Gender Assignment Dysphoria in the DSM-5″, Archives of Sexual Behavior, DOI 10.1007/s10508-013-0249-z


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The Last N!gg3r…

Posted in Editorial by Kay Brown on August 15, 2014

My husband has been trying to get me to write a book by this title for 17 years.  It started when we were dating.  At some point in a courtship, there comes a time when it just seems right to stay at home and enjoy each other’s company, rather than go out.  It was just such a night, our first night simply staying at his house, when he suggested that we watch some television and cuddle together quietly.  I resisted, saying, “I’m sorry, I’d rather not… I just can’t seem to watch a single night of TV and not be exposed to tranny-trashing.”  He thought I was WAY over exaggerating… but sure enough, later that evening, during the cartoon section of Saturday Night Live, a character tells another to “take the right at the corner with the transsexual”… cut to street corner scene where we see a very burly, broad-shouldered, hairy-chested man wearing a merry-widow corset, fish-net stockings, and high heels, provocatively poised, obviously “working” the corner.  I looked at my boyfriend/future husband drolly, “Que, Laugh, Track”.

I’m minded to write this essay because for the past several days, we’ve all be subjected to numerous articles lionizing Robin Williams as a hero to the LGBT communities.  Well, he might have been a hero to the LGB, but not to the T.  All I can remember of him is his tranny-trashing.  But more on that later.

Humor has been used since time immemorial to attack, denigrate, humiliate, and dehumanize minority groups.  We have “Pollack”, Asian, “Blond”, Jewish, “women drivers”, “Fag”, and of course, “N-word” jokes.  In the United States, we have a history of an entire genre of denigrating ‘coloreds’, most especially African-Americans… with stereotypes of lazy, shiftless, clueless, careless, Black men and women.  It can be very instructive to review how ugly, and how “entertaining” for racists, it can be, so here’s a great video compilation of some of it, from the mid-20th Century.

Sometimes, the message is more subtle.  The best example of this the way that all women were denigrated in the film Tootsie.  I still recall with horror my first viewing of the film in the theater, in the company of another transwoman, at the personal invitation from a non-trans* person who thought that we should enjoy the film for its trans* theme.  Not so.  First, its not really about trans* anything.  But it is an example of subtle anti-feminist agit-prop.  The underlying message of the film is that any, random, second-rate man is better than all female people ever could be.  The plot is that a has-been ham dresses en-femme drag to pass as a woman… and very soon thereafter becomes a national sensation as a feminist heroine, a role model for all women to emulate.  The, hit-the-audience-over-the-head, message is that any random man makes a better “woman” than all females.  To add insult to injury, Dustin Hoffman has in recent years portrayed his experience as “Tootsie” as having given him insight into women’s lives, that Tootsie was an enlightening feminist film.  (No Mr. Hoffman, it wasn’t and it didn’t.  Instead, you should be apologizing for your role in the film’s production.)

While they have not truly disappeared, offensive stereotypes, images, and jokes about other groups are at least pointed out, and often removed and/or resulted in apologies in the recent decades.  But not so for such offensive stereotypes, images, and jokes portraying transgender people in a negative, often extremely derogatory, manner.  We are, “The Last N!gg3r”.

Which brings me back to Robin Williams, and the underlying messaging of his tranny-trashing jokes and gags.  While they were no doubt not limited to Mrs. Doubtfire, this is one of his most well known films in which the underlying premise of the film, augmented by very pointed jokes, is that transgendered people of all types are to be belittled and dehumanized.

For example, in Mrs. Doubtfire, he sets up a joke in which he switched the phone # in an ad… so that he was the only one calling his wife about the position of nanny to her children… then called up to pretend to be various undesirable caretakers, including a post-op transwoman… which when “she” revealed this fact, his wife is horrified and hangs up… thus, the message is that transwomen are not to be trusted with children and the audience knows and agrees. Que laugh track.

As a transwoman who, in real life, was just such a nanny as a teenager, who later was a foster-mother to two girls, adoptive mother to one of them… and who continues to have contact with children and teens, I’m deeply offended at this message and the manner in which it was delivered.  I’m also deeply concerned that this very message could be delivered and not immediately repudiated.  And even more deeply concerned that this message, though a scurrilous falsehood, is one that many people actually agree with.

Lest we think this is a one off for Williams, in the very same movie, later on, we see a scene in which “Mrs.” Doubtfire is standing up to urinate when his eldest son accidentally discovers him. His instant reaction is horror and the need to protect himself and his younger siblings from this male bodied transgendered person. The gag depends on the audience knowing who Mrs. Doubtfire really is and that it is OK for him to be doing this… after all, he’s not really transgendered, but it wouldn’t be OK for a REAL transgendered person to be working as a nanny.

But Williams (and the film’s writers, producers, actors, etc.) aren’t done educating us on the dangers of transgender people being around children.

In yet another scene, we see our putative hero having to hide the fact that he is dressing as a woman from the social worker coming over to check him out.  While it could be argued that that had he been discovered, it would blow his cover as Mrs. Doubtfire, the real subtext is that it is not OK for a parent to be transgendered in any way;  That the social worker would have, rightly, recommended against him as a parent of his own children.  Nowhere in the film was there a parenthetical comment that this discrimination against transgender natural parents is wrong or unacceptable.  In fact, given the above scenes (and others in the film) the subtext is clear:

The entire premise of Mrs. Doubtfire is that transgender people are not to be trusted with children, neither their own, nor others.  This underlying message is not funny, but is dangerous.  This false stereotype has caused many late transitioning transfolk to lose parental rights, visitation rights, etc.  It is unknown how many transkids have lost opportunities to be foster-parents or adopt.

I’m saddened by Mr. William’s untimely death.  No one should have to turn to suicide and I’m sorry to see such talent lost… But more because I will never get to hear that apology he owes to me, and others, as a transwoman who cares deeply about children.  Perhaps we can get one from Harvey Fierstein, who should have known better?


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One Size Fits All…

Posted in Editorial by Kay Brown on July 9, 2014

“One Size Fits All”… and other lies… Or  “Why it matters”

Beyond mere scientific curiosity, there are other compelling reasons why we need to recognize the two types of transsexuals as distinct and having separate etiologies and life arcs.  Research on appropriate treatment protocols is confounded when we don’t segregate them.  Treatment itself is less effective and potentially counter productive when using the wrong protocol, or when using a ‘one-size-fits-all’, middle of the road protocol.  Finally, we dishonor who we truly are when we don’t recognize the differences.

Consider that our present protocols for treating gender dysphoric teenagers is a muddled attempt to reconcile the experiences of autogynephilic (AGP) MTF adults and transkids, both FtM and the minority MTF feminine androphilic.  If MTF “late transitioners” did not exist at all, would we be as concerned about attempting to delay puberty as a reversible treatment, given that transkid teenagers rarely have regrets or negative outcomes when given full HRT instead?  But we do have AGP teens for whom transition and HRT are not warranted, who go on to live very satisfactory lives as heterosexual cross-dressers.  If we fully recognized and diagnosed the two populations separately as teens and young adults, we would have very different treatment protocols.

Consider also, that our present protocols for adults have a requirement that a candidate for sex reassignment surgery have been living full time as their new sex before surgery, as though that fact somehow guaranteed that post-operative regret would not occur… or that surgery is simply providing genitals that match the social gender in which the client is living.  Neither is the case!  Sex reassignment surgery may, in fact I would strongly argue, is not contra-indicated by still living as one’s birth gender.  If we didn’t have the example of transkids for whom living in their new gender and sex reassignment surgery are intimately linked, would we have this requirement?

It’s possible that without the existence and example of feminine androphilic MTF transkids, whom many AGP transwomen attempt to emulate closely, Western Society might not have developed and accepted the medical category “transsexual”.  But now that we have decades of data that show that AGP transwomen are the majority, and that that majority does find improvement (at least palliatively in most cases), should we not review the assumptions that were made in the early years that only “true” transsexuals, those who needed to both live full time and rid themselves of their unused genitalia, are the only ones who would benefit from HRT and sex reassignment surgery?

Might the original purpose of the “real life test” have been not simply to reduce post-operative regret, but was (wrongly it turned out) a means of weeding out “transvestites” (autogynephiles) who were thought to not be able to pass such tests?

I would argue strongly that there is absolutely no association with living full time and lack of post-op regret.  Further, I would argue that for many AGP individuals, the “real life test” requirement is needlessly socially and professionally destructive.  How many AGP individuals would have benefited from HRT and/or sex reassignment surgery to rid themselves of the anatomic-autogynephilically induced gender dysphoria without having needed to live as women full time?  How many of them would have found a life of integration far better?  A life of the “bi-gender” individual, one who is professionally and socially a man during the weekday, but socially and sexually a woman during the evenings and weekends?  Our present protocols discount these people.  They must make a choice between no surgery, or up-ending their professional and social lives.  How many individuals have been falsely declared to have been treatment failures because after SRS, they “de-transitioned”, having obtained their true objective and now free to live their lives without the so called “Standards of Care” dictating their lives?

In therapy, the two types have very different needs.  First, most transkids do not need therapy.  But our Standards of Care (at least as practiced, if not as written) require that one have been evaluated by a therapist or psychiatrist before any medical interventions.  Why should a feminine androphilic transkid be treated differently than any other young woman?  Why should she need to get “permission” before having breast implants and not a natal female?  Could it be because she is conflated with autogynephiles for whom many practitioners are concerned may regret such interventions?  What of FtMs?  Many natal females have breast reduction surgery, but aren’t required to obtain letters from therapists before hand.  I argue that our protocols for transgendered people have been developed with experience of autogynephilic MTFs, for whom such evaluations and therapies are recommended.

Autogynephiles suffer from severe shame and guilt.  Many cross-dressers report a cycle of purging, throwing away their feminine wardrobes in self-loathing.  Many autogynephilic transwomen have had similar histories, but rarely discuss this or other autogynphilic experiences with their therapists, rightly or wrongly, assuming that the therapist is wearing their “gate-keeper” hat and might not “OK” them for HRT or SRS if that were known.  Because both the AGP transsexual community and their therapists fail to face head on the issue of autogynephilia, this shame and guilt remains untreated.  Instead, the client is left with secret denial or other defenses.  Because she has not faced her own autogynephilia, she may stigmatize others who are processing their autogynephilic experiences, shutting down group therapy discussions on the matter and even attacking other transwomen in public forums, harming the transgendered community at large.  Worse, for the individual, is that the shame, guilt, and denial are lurking in her psyche, waiting for some dark moment to come crashing to the fore, when her defenses fail, and the reality of her autogynephilic sexuality come crashing upon her.  The result may be catastrophic, perhaps even fatal.

The suicide rate among transgendered people is well known to be high.  Medical intervention is intended to alleviate suffering; but because the two types are not fully differentiated and because autogynephilia is not openly acknowledged, AGP transsexuals remain at risk for mental heath problems, especially depression and anxiety.

The two types should never be grouped together for therapy.  The two types have completely different goals and concerns.  Further, there is a very unfortunate tendency for AGP transwomen to attempt to model themselves upon transkids, to the point where they edit and even confabulate histories to match those of transkids, interfering with the therapeutic process.  Conversely, transkids are very often uncomfortable around autogynephiles, leading them to emotionally, and even physically, to withdraw from the group.  Comparing themselves and their experiences to the other type is also very damaging to their self-images, for differing reasons for each type.

Would HRT protocols be different if the types were not conflated?  Consider MPA, a synthetic progestin.  It is well known to sharply reduce libido.  Many AGP transwomen find their autogynephilic arousal intrusive and unwelcome.  For them, MPA may be a welcome addition to estradiol… or even alone.  But for feminine androphilic MTF transkids, reduction in libido is never desired.  For them, micronized progesterone is a better addition to estradiol.

Would protocols be different for the two regarding fertility?  Many AGP transwomen are already natural parents, having sired children with their wives or girlfriends.  But what of the young AGP transwomen who have not yet sired children?  Would they not benefit from banking their sperm before beginning HRT?  Would the same be right for MTF transkids?  I would argue not.  First, it would mean that they would have to wait for spermatogenesis, which would also mean damaging exposure to endogenous testosterone.  Better to begin HRT without ever being able to generate sperm.  Further, for the slightly older (post-pubertal) transitioning transkid, consider the psychological implications for her future husband… surely if they elect to pursue surrogacy, it should be his sperm, not hers?

For these, and yet other practical reasons, it matters that the two types be officially, scientifically, medically, and socially recognized as distinct.

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I Know What Boys Like…

Posted in Transsexual Theory by Kay Brown on June 29, 2014

♫♫I know what guys want…
They want to touch me,
But I won’t let them.♫♫
-The Waitresses

A while back, I explored one of the very few studies that tested Stoller’s observation that “true” MTF transsexuals, which we now recognize as exclusively androphilic MTF transkids, are “avoidant”.  That is, that though they have intimate relations with their boyfriends before SRS, they refuse to use or allow contact with their pre-operative genitalia.  Stoller (and others) held that non-exclusive androphilic women would not be “avoidant”, but would find pleasure in the use of their male genitals prior to SRS.  Now a new study explores this behavior.  But sadly, since it comes out of Europe, where they believe that age of onset of gender dysphoria, early or late, is the most important typology, the study failed to explicitly report avoidant behavior by sexual orientation.  However, I hypothesize that Stoller is correct, and that even though we don’t have explicit data in this new study, we will see a direct correlation with the percentage of exclusively androphilic transwomen in the two onset age categories and avoidant behavior.  Data is reported in the number of transwomen for each category except for that reported as percentage:

Sexual Orientation vs. Age of Onset
Onset                                                 Early         Late
Androphilic      N=                             54               20
Non-exclusively Androphilic         53               78
Percentage Androphilic:                51%            20%

Avoidant vs. Age of Onset
Onset                                                Early           Late
Avoidant           N=                            38                15
Pleasure                                             34                47
Percentage Avoidant:                     53%             24%

Note the essentially identical percentages of exclusively androphilic transwomen in each onset category and the percentages of avoidant behavior?  Thus the data supports the hypothesis perfectly.  This of course is not definitive, since we would really like to have seen the direct comparason, but if the numbers had been wildly different between them, it would have supported the null hypothesis.  The null hypothesis still cannot be ruled out… but seriously?  Seriously?

It has been my personal observation, from talking to MTFs, during my entire lifetime, that “avoidant” behavior is near universal in transkids, but very rare in “late transitioning” transwomen.  Such late transitioning transwomen have very often been sexually active with women, married to women, and have had children.  Obviously, the easiest way to have sired children is to have had vaginal intercourse (penile penetration).


S. Cerwenka, et al., “Sexual Behavior of Gender Dysphoric Individuals Before Gender-Confirming Interventions: A European Multicenter Study” (2014)

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Researching Parental Experiences of Transkids

Posted in Editorial by Kay Brown on April 4, 2014

Here is an opportunity for the parents of transkids to give feedback to a researcher looking into their experiences,

“Researchers at Case Western Reserve University are currently conducting an online study of the experiences of families of gender variant, transgender, or otherwise non-cisgender kids ages 10-17. The study involves completing questionnaires online about your experiences with the process of your child disclosing their gender identity to you and/or the process of your child’s transition, as well as questions regarding your emotions, attitudes, and preferences for potential psychotherapy interventions for families of gender variant children. Your child will also complete several brief questionnaires about their emotions and experiences with disclosing their gender identity. To participate, you must be the parent or primary caregiver of a child or teen ages 10-17 who identifies as gender variant, transgender, or otherwise non-cisgender and you yourself must be at least 18 years of age. You will have the option of including your contact information in order to receive a $10 gift card, although providing your contact information is not necessary to participate in the study. The information gathered from this study may help us to better understand the needs of families of gender variant children and ultimately help us to design therapies to help families better cope with the changes associated with their child’s transition.”

Please participate if you qualify, as we need as many voices and as broad range of experiences as possible:

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Becoming Visible

Posted in Editorial by Kay Brown on March 19, 2014

VisibleIf you are a transkid or gender-non-conforming teen living in or near New York City, consider Becoming More Visible.  It’s time to talk about your lives… but only if you are comfortable doing so.  Seriously, if your goal is to live “stealth”, then this is not for you… and I totally support being stealth, truly I do.  It’s your life and your decision.

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A Clinical View

Posted in Confirming Two Type Taxonomy by Kay Brown on February 14, 2014

I have heard and read a number of “late transitioning” transsexuals state that the two type taxonomy is not accepted in the “real world” of today’s gender therapists, the people most intimately knowledgeable of the transsexual population, thus proving that Blanchard’s theory is “wrong”.  Although I have met, during my prior research on our collective history, a few therapists who were completely unaware of Blanchard’s theory, most therapists are VERY well versed in the scientific literature.  Further, as I will show here, those who have been in the field the longest, have a strong psychology background, and have kept up with the literature, have come to understand and write about the two types.  But, many therapists who are fully aware of the issue, choose not to publicize that fact, or they may attempt to smooth over the issue, avoid directly using the word “autogynephilia“, using euphemistic and obscurantist terms instead.  After all, their lively-hood depends on autogynephilic transgendered people coming for help.

One of the most experienced gender therapists is Dr. Anne Vitale, having entered the field in 1978.  In a paper she wrote in 2001, she clearly describes the two types of MTF transsexuals and compares them to FtMs,

“Group One (G1) is best described as those natal males who have a high degree of cross-sexed gender identity. In these individuals, we can hypothesize that the prenatal androgenization process–if there was any at all–was minimal, leaving the default female identity intact. Furthermore, the expression of female identity of those individuals appears impossible or very difficult for them to conceal.

Group Two (G2) is composed of natal females who almost universally report a life- long history of rejecting female dress conventions along with, girls’ toys and activities, and have a strong distaste for their female secondary sex characteristics. These individuals typically take full advantage of the social permissiveness allowed women in many societies to wear their hair short and dress in loose, gender-neutral clothing. These individuals rarely marry, preferring instead to partner with women who may or may not identify as lesbian. Group Two is the mirror image of Group One.

Group Three (G3) is composed of natal males who identify as female but who act and appear normally male.  …  They tend to live secretive lives, often making increasingly stronger attempts to convince themselves and others that they are male.

As a psychotherapist I have found female identified males (G1) to be clinically similar to male-identified females (G2). That is, individuals in both groups have little or no compunction against openly presenting themselves as the other sex. Further, they make little or no effort to engage in what they feel for them would be wrong gendered social practices (i.e., the gender role assigned at birth as the basis of authority). Although I have seen some notable exceptions, especially in male-identified females, these individuals–at the time of presentation for treatment–are rarely married or have children, are rarely involved in the corporate or academic culture and are typically involved in the service industry at a blue- or pink-collar level. With little investment in trying to live as their assigned birth sex and with a lot of practice in living as closely as possible to their desired sex, these individuals report relatively low levels of anxiety about their dilemma. For those who decide transition is in their best interest, they accomplish the change with relatively little difficulty, particularly compared to G3, female-identified males.

The story is very different for Group Three. In the hope of ridding themselves of their dysphoria they tend to invest heavily in typical male activities. Being largely heterosexual, they marry and have children, hold advanced educational degrees and are involved at high levels of corporate and academic cultures. These are the invisible or cloistered gender dysphorics. They develop an aura of deep secrecy based on shame and risk of ridicule and their secret desire to be female is protected at all costs. The risk of being found out adds to the psychological and physiological pressures they experience. Transitioning from this deeply entrenched defensive position is very difficult. The irony here is that gender dysphoric symptoms appear to worsen in direct proportion to their self-enforced entrenchment in the male world. The further an individual gets from believing he can ever live as a female, the more acute and disruptive his dysphoria becomes”

As I’ve noted before, the social consequences for the two types of MTF transsexuals is quite dissimilar.  Before transition, Vitale’s “Group One”, is very visible, but becomes invisible after transition, while the opposite is true for her “Group Three”.  This brings up the matter of ‘Identity Politics’ in the larger ‘Transgender’ world.  Language is important.  For these essays, I’ve often, “held my nose” as I used terminology in the papers I’m citing, so as not to confuse my reader.  Here, Vitale has side-stepped the issue, by inventing de novo, just for the purposes of her paper, totally neutral language that is also completely non-descriptive and had it not been for her carefully describing the characteristics that define and contrast each type, we might not be able to compare her types with other authors.  But here, I can provide that map.  Her “Group One”, as Vitale makes clear, consists of MTF transkids.  Other names have been “core”, “true”, “early onset”, “ego syntonic”, and most controversially, “homosexual”.

“G1 boys, who have a strong feminine core identity, typically develop a sexual interest in other boys during adolescence and prefer girls as peer friends. Although they still desire to be girls, they appear to have significantly less anxiety over not being female then that reported by the boys in G3. I believe this is due to the relatively uninhibited open expression of their femininity. For example Monica was 19 years old when she reported to my office accompanied by her mother. She wore gender-neutral clothing but otherwise presented as female in voice inflection and mannerisms. The problem, of course, was that Monica was genetically male. Monica’s mother related to me that Monica had been more like a girl then a boy all her life. Her and her husband loved her dearly but thought of her more as a daughter then a son. Over the course of treating Monica, it became clear that although she was distressed over her male physiology, she was otherwise emotionally stable and very aware of the seriousness of her situation. Once it became clear that she was her own person and ready to undergo transition, a course of hormone replacement therapy was introduced. With the exception of having to face some extreme religious issues brought up by her much older brother, she accomplished an almost effortless transition from male to female. The presence of family support and little or no investment by the family or Monica in her being male made this transition straight forward.”

Vitale’s use of the phrase “feminine core identity” harks back to earlier work showing that this type of transsexual has developed a female gender identity as a young child, while the other type, had not.  She remarks that this type is very comfortable with their femininity and naturally find the idea of living as a girl to be agreeable.  This is called “ego syntonic” behavior, as opposed to Group Three’s “ego dystonic” behavior, where their desire to be female is unwelcome and out of step with their core identity as male.  Note also the reference to Group One being “emotionally stable”, making a tacit comparison to “Group Three”, who, as Smith put it,

“Homosexual transsexuals were found to be younger when applying for sex reassignment, reported a stronger cross-gender identity in childhood, had a more convincing cross-gender appearance, and functioned psychologically better than nonhomosexual transsexuals. … The more vulnerable nonhomosexual transsexuals may particularly benefit from additional professional guidance before and/or during treatment.”

Compare Vitale’s description of her “Group One” to the one I gave of transkids in a previous essay.

“The prototypical feminine androphilic transsexual was called a “sissy” by her peers growing up.  She avoided rough & tumble activities.  Her primary social circle consisted of one or two girls.  She actively participated in girls games and imaginary play.  … As a young teen, she became interested in girls fashion and make-up, often exploring how she might look as a girl by dressing up and experimenting with make-up, with occasional trips out shopping or hanging out with her friends.  This did not, of course, involve erotic cross-dressing.  She had crushes on boys at school.  … She was hassled, perhaps even bullied, by homophobic boys, but otherwise was reasonably popular in her chosen circle.  She was considered very neat and well dressed in boy’s clothes.  …  As she approached adulthood, looking at her own nature, her potential future, both romantic and economic, made a rational decision to transition to living as a girl so as to grow up to be a woman socially.  Her family may or may not have disowned her in late adolescence.  As she is naturally feminine and passes quite well, she found that she was socially and romantically more successful as a woman.”

Vitale goes on to describe her “Group Three”,

“To add to their confusion, and counter to behavior typically reported in openly gender dysphoric boys, many cloistered boys actually preferred solo play with boys’ toys and had little or no interest in girls’ toys. For example I have heard more than one long-time post-op male-to-female transsexual speak fondly of having spent countless hours playing with an Erector Set or a Lionel model train set-up that their father had helped them build. Others described of designing and making detailed model airplanes, race cars and sailing ships. The more academic of this group report little or no interest in sports and rough and tumble play. To avoid castigation from their peers, they report spending a lot of time reading and studying. However, although these children appeared to be normal boys doing what most people would consider some normal boy activities, they may very well have been doing so while secretly wearing their mother’s or sister’s underwear, fantasizing about being a girl or both if they could manage it.

As sexual maturity advances, Group Three, cloistered gender dysphoric boys, often combine excessive masturbation (one individual reported masturbating up to 5 and even 6 times a day) with an increase in secret cross-dressing activity to release anxiety. In a post-op group I facilitated, Jenna (age 43) spoke fondly of the delight she experienced as a boy when she would find something of her mom’s in the dirty clothes’ hamper in the bathroom. Two others in the group laughingly agreed that they too took many a trip to the bathroom for the same reason. At the same time, in their public life, these boys report employing overtly stereotypical efforts to draw attention from their secret desires to be female by affecting appearances of being normally male. This includes dating girls, participating in individual sports activities such as swimming, running, golf, tennis, and for some, even body building.

Cloistered (G3) gender dysphoric boys appear to others and even to themselves to be heterosexual. Although as a group they are not especially active daters, they clearly prefer to date girls when they do date. Significantly, unlike other boys, their dating motives are markedly different. For these boys, being on a date with a girl is a chance to spend time with a girl in a way not generally allowed under other circumstances. Dating serves two purposes for these boys. The first is social, as it gives them the all-important appearance of being normal. The second is therapeutic. Being close to a girl’s softness, and even her female smell, has a mitigating effect on gender expression deprivation anxiety. The fantasy is not to make love to her but to actually be her.”

Note the rather direct description of use of female clothing as an aid to sexual arousal during masturbation.  We have another name for this behavior, “autogynephilic erotic cross-dressing”.  Note also the reference to dating girls.  Though she calls it “therapeutic”, I believe that she is describing the phenomena of autogynephilia being simultaneously dependent upon and in competition with conventional gynephilia.  Being with a girl has “mitigating effect” on experiencing autogynephilia, which Vitale euphemistically refers to as “gender expression deprivation anxiety”.  I’ve remarked on Vitale’s seeming obtuseness on the issue of recognizing autogynephilic sexuality when she sees it in a previous essay.  This is remarkable, in that even in her own words, she clearly describes autogynephilia, “The fantasy is not to make love to her but to actually be her”.

Very tellingly, as Vitale continues to describe older gender dysphoric individuals, her “Group One” simply disappear from her essay.  This is because, by that age, they have either transitioned and become invisible, or they don’t ever transition.  Simply put, there is no “late transitioning” “Group One” transsexual, while “Group Three” digs in and clings to their socially formed (core) male identity, while trying to ignore the cognitive dissonance created by their growing awareness of their autogynephilically enforced erotic ideal, their “desires to be female”,

“As more information about transition to one’s felt gender identity becomes available to the general public, we are seeing genetic males with strong core female identities and genetic females with strong core male gender identities present in their early twenties with the clear objective to being sexually reassigned.

The cloistered, natal males, on the other hand typically start to realize the seriousness of their dilemma at this age. It is common to hear reports of these individuals increasing the intensity with which they try to rid themselves of the ever-increasing gender-related anxiety. Many individuals paradoxically adopt homophobic, transphobic, and overtly sexist attitudes in the hope that they will override their desires to be female.”

As she describes her “Group Three” as adults, we clearly see the pattern of late transitioning MTF transsexuals,

“For those who continue to struggle inwardly with their gender issues into mid-life, new issues come to the fore. As a time when most people realize that about half of life has been lived and feel the need to make an accounting of who they are and what they have done with their lives, this period can be especially anxiety provoking for the gender-dysphoric individual. Decades of trying to overcome an increasing gender expression deprivation anxiety begin to weigh heavily on the individual. Family and career are now as deeply rooted as they will ever be. The idea of starting over as a member of a different sex has become seemingly impossible. The fact that the need to change sex has increased rather than diminished, despite Herculean efforts, is now undeniable.”

Thus, we see clearly two mutually exclusive clinical patterns described by a veteran gender therapist.  It is painfully obvious that there are two distinctly different types, with two different etiologies and life arcs.  Blanchard’s model of “homosexual” (yes, holding my nose) vs. autogynephilic transsexuality completely explains the clinical experience.


Anne Vitale, “The Gender Variant Phenomenon–A Developmental Review”  http://www.avitale.com/developmentalreview.htm

Yolanda L.S. Smith, Stephanie H.M. van Goozen, A.J. Kuiper, Peggy T. Cohen-Kettenis, “Transsexual subtypes: Clinical and theoretical significance”

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A Grounded Theory…

Posted in Book Reviews by Kay Brown on February 8, 2014

Book Review:  Male Femaling – A grounded theory approach to cross-dressing and sex-changing

malefemalingRichard Ekins’ 1997 book is not light reading, especially Part II, which is rather densely written in “grounded theory” method of sociology.  But it is an important book for sexologists to read and understand since it delves into the world of what Ekins has termed, “male femaling”.  This is a wonderful way of putting it, since it succinctly pulls together catagories that are often treated separately and instills ‘agency’ (if I may be allowed to use post-modernist cant) to these practitioners, placing the phenomena as a verb, rather than treating these people as nouns.

Before I read this book, I was completely unaware of “grounded theory”.  I think it is worth reading up on it at Wikipedia: http://en.wikipedia.org/wiki/Grounded_theory

There one may read that,

“Grounded theory method is a systematic methodology in the social sciences involving the discovery of theory through the analysis of data. … If the researcher’s goal is accurate description, then another method should be chosen since grounded theory is not a descriptive method. Instead it has the goal of generating concepts that explain the way that people resolve their central concerns regardless of time and place. The use of description in a theory generated by the grounded theory method is mainly to illustrate concepts.”

Thus, this book is not simply a travel guide, but a serious attempt to discern the social and introspective means of “meaning”.

To give you a flavor of the denseness of the text, in part of the book, Ekins explores what he calls, “masked awareness”.  This is what most of us would call, “information management”, or simply, secrecy or disclosure, passing or being read.  I’m simplifing here of course, but neccessary to translate this to a more lay reader.  He also makes indiscriminent reference to philosphers, scientists, and pseudo-scientists (e.g. Freud).   He makes a point of showing the “umbilical” relationship between sexologists, their theories, and “male femalers” without explicating how these theories have evolved as the science has moved forward, or how “male femalers” dissimulations have historically distorted some of those theories.  He simply isn’t interested.  He cares more about how these individuals resolve their search for “meaning”.

As I read the book, each and every word, from begining to end, I searched for references and examples of transkids (HSTS).  I found only hints, like Hamlet’s father’s ghost, whispering offstage.  I was dissappointed, as I had hoped that Ekins would compare and contrast transkids from AGPs.  It was only at the very end of the book that I learned that this had been deliberate, as his concluding notes on where he thought others should pick up on his research explains in recommendation 4:

“In my detailed illustrative material, the focus was on male femalers who consider themselves heterosexual or bisexual.  Although homosexual male femalers were quoted, such material is sparse.  The emphasis is, in part, a feature of the arena, but was also, once again, of my own predilictions, training, and abilities.  Certainly, the gay studies literature is a vast one and it largely fell beyond the scope of this study.  I leave to others the possibility of applying the conceptual framework developed here to predominately homosexual male femalers.”

Thus, two conclusions may be drawn from this.  First, Ekins, though he never mentioned it anywhere else, is keenly aware of the profound differences between “homosexual” and “non-homosexual” types.  And second, that though he never mentions the word, this book is ALL about autogynephilia, which he only obliquely refers to as “male femaling impulses” and “erotic femaling”.  The proof of this is found in the very descriptions of what these individuals do in the course of their careers as male femalers, in search of “meaning”.

Ekins divides the “ideal” path into five phases.  Where Ekins used “ideal”, I would have used “prototypical”, as “ideal” would seem to imply a normative value to this sequence, which may or may not apply.  The phases are:

Begining Male Femaling

Fantasying Male Femaling

Doing Male Femaling

Constituting Male Femaling

Consolidating Male Femaling

IF this repetitive use of the term “male femaling” feels odd… it certainly did to me… especially as though it seems to constantly screem, on every page, “MALE … MALE … MALE!”  As though to say, “Get it… these people are forever MALE!!!  Don’t you forget it!”

The illustrative examples used for “Begining Male Femaling” were universally autogynephilic, as this example shows,

“… I was 13 when I stepped, quivering with excitement into a pair of French knickers belonging to my sister.  I ejaculated almost immediately… The feeling was glorious and yet quite alarming and I felt as though I was leaking urine. … Some three days after this first ‘event’ I got home from school to find my mother out.  I went upstairs to do my homework and through the half-opened door of my mother’s bedroom I saw, hanging over a chair, a pair of her pink directoire knickers, obviously discarded in a hurry as she changed before going out.  That soft gleaming bundle turned my whole body and senses into a jelly-like state of desire and longing.  I had to wear them, to try and see if I was all right.  Would it happen again?  My answer was there almost immediately in my swift gathering erection as I struggled out of my clothes.  …”

Likewise, the later phases involved autogynephilic fantasy and enactments, sometimes very overtly erotic, sometimes more genteel, but still recognizably autogynephilic in substance.  In many of these fantasies and enactments, they were scripted, ritualized even.  I think this is a very important aspect of autogynephilic experience that can and does impact how autogynephilia will develop and express itself in the “real world”.  The examples were manifold and various, deeply detailed.  For me… I found myself skimming the pages, as there is nothing more boring than reading about someone else’s erotic scripts, which one does not share.  I suppose that for Ekins this isn’t an issue, given his own self referenced “predilictions”?

I found the section on ‘Private Networking and the Constitution of Meanings’ to be very informative and enlightening.  This may be the most important part of the book, as Ekins demonstrates that peer interactions and the ‘umbilical’ relationship between sexological theories and male femalers influences how one comes to identify oneself and how that subsequently influences one’s career as a male femaler.  Specifically, how does one come to think of oneself as a transvestite / Cross-Dresser or as a transsexual.  Ekins as much as states that there is no substantive or essential difference between them, to which I whole-heartedly must agree.

In the final phase, Ekins lays out three possible paths that a male femaler might take, in typical fashion, ignoring that we already have names for these paths, he calls them, “aparting”, “substituting”, and “integrating”,  I would have called them “closeted cross-dresser”, “transition / transsexual”, and “out / gender fluid”.

“It is instructive to organize the major modes of consolidating around three possible ‘solutions’ to the problems posed by disjuctures between male and male femaling selves and worlds.  I call these ‘aparting’, substituting’, and ‘integrating’.  In ‘aparting’ the emphasis is upon maintaining rigid boundaries between male worlds and male femaling worlds.  In ‘substituting’ the male femaling world increasingly takes over from the male world.  It is in fact, to a greater or lesser extent, substituted for it.  Finally, in ‘integrating’, the attempt is made to transcend previous positions which entailed disjuctures between male and male femaling selves and world, in order to foster the emergence of an ‘integrated’ position which seeks to transcend the conventional arrangement between the sexes.”

This book is mildly dated in that it was written in 1997, before Blanchard’s work become as widely known today.  I would recommend this book for sexologists and therapists, to explicate more fully the lives and search for meanings of autogynephilic cross-dressers and transsexuals.  But I would not recommend it for either the general public or for cross-dressers and transsexuals themselves, unless they have a strong interest in theory.  It just doesn’t read very easily.

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