A Clinical View

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”,

Caitlyn Jenner beginning transition

“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.

(Addendum 3/17/2017:  I noted on some fora that people have critiqued this essay and have objected that my mapping of Type 1 and Type 3 to Blanchard’s “homosexual” (androphilic) and autogynephilic is unwarranted and wrong.  However, in an essay written three years before, Vitale wrote,

“…Primary/Secondary terminology has largely been dropped from the literature. It has instead been replaced with sex researcher Ray Blanchard’s more descriptive and non-hierarchical Autogynephilic and Androphilic transsexualism. (More on these classifications in a future work.)”

The above essay was that “future work”.  Vitale, as my analysis shows, fully agrees that the two type taxonomy is correct and has merely substituted terms to make it more palatable to late transitioners.

I’ve also noted a number of comments on transgender forums linking to this essay talking about how they are X% of type one and (100-X)% of type three.  No, it doesn’t work that way.  This is a taxonic distinction, not dimensional.  One is either one or the other, not both, period.  One is not X% pregnant and (100-X)% not pregnant.  One is either pregnant or not, not a mix.)

Additional Reading:

Its important to know that the American Psychiatric Association also recognizes the two types and recommends that they need different case management.

Book Review of The Praeger Handbook of Transsexuality which discusses Vitale’s typology, showing them to be identical to several others.

References:

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

Anne Vitale, “Primary and Secondary Transsexualism: Myths & Facts”
http://www.avitale.com/PrimarySecondary.htm

Yolanda L.S. Smith, Stephanie H.M. van Goozen, A.J. Kuiper, Peggy T. Cohen-Kettenis, “Transsexual subtypes: Clinical and theoretical significance”  https://www.ncbi.nlm.nih.gov/pubmed/16298429

Dragana Duišin, Jasmina Barišić & Gordana Nikolić-Balkoski, “CASE REPORT OF AUTOGYNOPHILLIA – FAMILY, ETHICAL AND SURGICAL IMPLICATIONS
http://hrcak.srce.hr/file/62549