Information for Health Care Professionals
Or, The Care and Feeding of the Two Types of Transsexuals
There is a crying need for Science Based Medicine for transgender/transsexual people. Recent developments in our understanding of the etiology of gender dysphoria and development of gender incongruent identity have not yet been properly incorporated into the Standards of Care (WPATH SOC) but has been implemented in in the Diagnostic and Statistics Manual (DSM V). The care giving community has been slow to update its protocols. The reasons for this are two-fold, one is the expected lag between research findings and dissemination of knowledge, the other is that of active and vitriolic antipathy towards those findings by a vocal minority within the client population.
The first and foremost finding is that we now have an abundance of fully replicated studies that clearly show that there are two independent syndromes that lead to two separate ‘transgender spectrums’ for each natal sex, especially for Male-To-Female transsexuals. That such two different syndromes existed has long been speculated upon by clinicians (Benjamin, Green, Person, Stoller, Fisk, Vitale, etc.) but beginning with Buhrich (1978) followed by Freund (1982) and most importantly, Blanchard (1985) who coined the term ‘autogynephilia’, our understanding of the etiological underpinning of the two syndromes has accelerated more recently by properly conducted statistical surveys by Smith (2005), Lawrence (2005), and Nuttbrock (2011).
Although both types exhibit what would appear to be the same key symptom, gender dysphoria (a term coined by Norman Fisk in the early ’70s specifically to unite the two types under a unitary diagnoses), and benefit from similar medical protocols (Hormone Replacement Therapy/HRT & Sex Reassignment Surgery/SRS, breast reduction or augmentation, as indicated, etc.), they otherwise have very different psychotherapy and social support needs. Because these needs are so divergent if one is misapplying what works for one to the other, distressing and counter productive result may, indeed for MTFs, often occur, it is critical that an early differential diagnoses be made. Thus, it is useful here to describe the prototypical presentation for each.
See essay on the DSM V description of the two types.
Caitlyn Jenner beginning transition
The single most commonly encountered, in the Western nations at least, is the Autogynephilic (AGP) transgendered Male-To-Female type. The prototypical autogynephilic (“Non-Homosexual” or “Late Onset”) transsexual was accepted as a boy as a child. She was often a “loner”, finding her hobbies and reading to be more rewarding, but still willing and ready to participate in rough & tumble play. She often envied girls and observed them more often than most boys. As she entered puberty, she began erotic cross-dressing in private, often masturbating while crossed-dressed, usually with lingerie. She found this shameful and hid her cross-dressing as best she could. She entertained thoughts of living as a woman, often in very idealized, socially stereotyped, situations. As a young adult, she dated women, often finding it necessary to imagine that she was female to “perform”. She typically hid this fact from her dates. In an effort to deny her autogynephilic desire for femininity, she may have chosen to pursue a stereotypically masculine, or even hyper-masculine, career such as the military. She fell in love and found that the previously growing desire to live as a woman abated for a while. She married and had children. Her need to cross-dress and use autogynephilic ideation later returned, as the first blush of their romance matured into committed love. She agonized about it obsessively, trying alternatively to push it out of her thoughts and trying to appease it by cross-dressing. In public, she chose to dress and groom herself in stereotypically and unmistakably masculine fashion, with perhaps even a full beard. At one point, perhaps in her early 30s, or in her late 50s, a set-back or other significant personal change brought all of these feelings to the fore… and she made the fateful decision that she could no longer ignore her sexuality. After having tried to ignore the cognitive dissonance between her successful social identity as a man, husband, and father, and her obligatory autogynephilic image of being female, concluded that the female image is her “true” self. She then made steps to begin counseling with a gender therapist, obtained prescription for feminizing hormones, began electrolysis and other procedures to effect a more feminine appearance, and then began the painful steps to living full-time socially as a “transsexual”, since she didn’t pass very well and had too many social connections who know of her previous status as a man to be truly stealth. She had SRS within a short time of nominally living as a woman, as she was impatient, feeling like she had waited long enough in her previous life as a man. Her wife most likely demanded a divorce.
The key diagnostic feature here is that of autogynephilia, sexual arousal and romantic attachment to the thought of being female/feminine. Autogynephilia is an Erotic Target Location Error in which one’s usual uncomplicated sexual orientation, gynephilia (attraction to women), is mapped onto oneself instead of sought after in others. The word comes from “auto”, meaning ‘self’, “gyne”, meaning ‘female’, and “philia” meaning ‘love’. In other words, the “love of oneself as a woman”. In the simplest analysis, autogynephilia is a set of sexual interests and behaviors that includes the more commonly understood term, transvestism / cross-dresser on one end of the ‘transgender spectrum’ and AGP transsexual on the other.
Although they may appear to be a different taxon to an inexperienced clinician, there is a subset of autogynephilic transgendered population for whom their autogynephilia overshadows their underlying gynephilia, typically presenting younger and as “asexual”, that is to say, that they show no or only limited romantic interest in other people.
Before transition, the natural behavior of autogynephilic MTF transsexuals is gender typical, easily passing as typical straight men, often marrying women, fathering children, and successful in stereotypically masculine and even hyper-masculine (e.g. Navy Seal) careers. It is not uncommon for them to exhibit homophobic and sexist attitudes. As it takes years for the cross-gender identity to form and establish itself, the modal age for transition is 35 to 40 years old, the mean is between 40 to 45, with a range of early 20’s to very old age. After transition, they may identify as lesbian, asexual, bisexual, or even straight women, including marrying men. Thinking about autogynephilic MTF transsexuals as “male bodied people who love women and (romantically) want to become what they love” offers a more accurate and more richly informative way to understand them.
In stark contrast, the prototypical MTF feminine androphilic (“homosexual” or “early onset”) MTF 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. Her parents were embarrassed by her femininity, and may or may not have sought professional help in trying to discourage her behavior. 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. Her peers thought she might be homosexual. She was hassled, perhaps even bullied, by homophobic boys, but otherwise was reasonably popular in her chosen circle. She sought out opportunities to interact with small children and infants, taking on babysitting jobs. 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. She actively dated men while pre-op, but assiduously avoided direct contact with her penis, finding that emotionally uncomfortable. Being young and lacking capital, she lived several years as a woman, taking feminizing hormones, before having SRS to improve her sex life, replacing genitalia that she didn’t use with those that she did. She may or may not have found a husband and adopted children.
Transsexuals of this type tend to be notably hypomasculine in appearance, one average, than typical males, even before any medical interventions. They tend to be shorter, lighter, less muscular, with more feminine faces, suggesting that during perinatal development, they experienced less androgen exposure that effected both their brains and their appearance.
The key diagnostic features are sustained femininity beginning in early childhood that persists into adolescence and exclusive androphilia (sexual and romantic attraction to men) and an absence of autogynephilia. The median age of transition for MTF of this type is 20 years old, with a range of early puberty to mid 20’s. More than 95% transition full-time before the age of 25 and it is unheard of to find one who transitions full time after age 30. Thinking about these individuals as so like girls/women that they might as well be that sex offers a straight forward and insightful way of viewing them.
Similar to the above, the most common Female-to-Male (FtM) type was called a “tomboy” growing up. Most of his friends were boys and other ‘tomboyish’ girls, playing boy games, into stories and images of masculine heroes (or villains), loved loud, boisterous rough and tumble games. He typically hated playing girl games, especially “house” or other make-believe games. He hated to dress up in feminine clothes. As a teen, he was interested in sports, athletics, skate-boards, fast cars or motorcycles, and pretty GIRLS! As a young adult, he may have identified as a “butch” lesbian, but hated his body. He easily slid over to living as a man and began taking HRT and had top surgery. He may or may not have had bottom surgery. He dated both straight and bisexual identified women.
The key diagnostic features are sustained masculinity begining in early childhood that persisted into adolescence and exclusive gynephilia (sexual and romantic attraction to women). The median age of transition is 25 to 30 with a range of early puberty to late-30s.
The rarest type of transsexual is the bisexual or gay male identified FtM type. Before transition, the natural behavior of non-homosexual / autoandrophilic FtM may be quite variable, but is usually less “butch” than exclusively gynephilic FtM transsexuals. Their families would likely describe them as having been very typical girls, with some tomboyish interests, comfortable being feminine (dresses, make-up, nail polish, etc.). Their sexuality is most likely to be also variable over time, where they may find men or women more attractive as partners at different times in their lives. Overt erotic cross-dressing occurs only rarely, but other aspects of autoandrophilia may be found in their fantasy life (e.g. erotic interest in Yaoi Manga) or having idealized crushes on FtM transmen.
The key diagnostic features are conventional femininity to mild transient tomboyishness in early childhood and androphilia. Although autoandrophilic, finding direct evidence to it is difficult without deeply exploring their sexual fantasy life.
Looking at the etiological features we note two types for both sexes, extreme gender atypicality vs. Erotic Target Location Error.
Having described the two types, we now turn to recommendations regarding differential treatment. First and foremost is that the two types should NEVER be placed in the same therapy or support groups, especially the two MTF types. Some organizations already have practices which do this as an accidental effect by segregating by age, usually a cut-off from 18 up to 25 and under only in their youth group. The ’25 and under only’ group can be problematic as this only statistically separates the majority of the AGP transwomen. Due to the relatively greater number of AGP transwomen, a sizable number of under 25 autogynephiles will be included in the youth group with negative consequences for all. On the other hand, although using a lower age cut-off may dramatically limit the number of AGP transwomen joining, for early onset / androphilic type, on-going support groups, requiring the now older than this cut-off requires early onset transwomen to associate with older AGPs will have even greater negative consequences. The only real solution is accurate differential diagnoses and segregation on that basis.
One of the most serious negative consequences of combining the two types of MTF transgender/transsexuals is that of sexual objectification and harassment. Autogynephiles are also gynandromorphophilic. That is, they experience a specific sexual attraction to transgendered people, especially those who are pre-op, young, and naturally feminine in appearance and behavior, to wit, early onset transsexuals in transition. This sexual attraction actually exceeds their attraction to women. Imagine the consequences of encouraging open and explicit discussions of sex and gender experiences in a group of comparatively masculine individuals used to lifelong male privilege while including young, naive, feminine individuals who are their most desirable sexual and romantic potential partners who do not as a general rule welcome such attention from autogynephiles.
A less obvious, but potentially counter productive consequence of mixing the two types is that the two types will compare and contrast their own experiences and motivations to negative effect. For the AGP type, they will be confronted with clear evidence that they do not live up to their idealization of “transsexuality” and femininity. Under such circumstances, envy and jealousy often arise, disrupting the goals of therapy. For the early onset type, having been incorrectly informed that they are meeting with their peers, may look upon the, by stark contrast, masculine (in both appearance and behavior) AGPs and create a falsely negative and confusing impression of themselves. For both groups, the confusion caused by discussing essentially incompatible histories and goals will disrupt any hoped for process. In fact, anger and resentment on both sides may arise, as one group tries to deny obvious autogynephilic motivations and natural gender typicality, attempt to mimic the other’s history of gender atypicality and the other is required to pretend that their experiences are comparable lest they be seen as less than supportive, potentially invoking angry, spiteful responses. One group will express their grief and anger about having been ill-treated growing up for being naturally gender atypical, but expound on how transition has helped them be better accepted by society, while the other group complains that previously they held positions of respect but they now find that a transphobic society treats them worse for having attempted to live as women, but fail to pass.
Even having separated the two groups, a common problem encountered by both types is that of muddled conflation of the two groups experiences and goals:
The problems of early onset transsexuals of both sexes are primarily social, not personal; they transition to improve their social status, as gender atypical individuals often experience discrimination and social exclusion. If anything, the most common personal issue is that of grieving, loneliness, and isolation from disapproving family. These are young people who have been obviously gender atypical since birth. This may mean that their family is disapproving and may have even disowned their child. Thus, early onset transsexuals often fall into two subsets, with differing life arcs, depending upon the level of familial support, both emotional and material. They are not exploring their inner sense of “gender identity”, which usually implicitly matched their gender atypical behavior since early childhood. They are living with the consequences of their long history of outward gender atypical presentation and sexual orientation. When they decide to “transition” it is not a big decision or change. It usually involves very little disruption to their lives, save for some potential additional disapproval from family or church; contrarily, most experience a social blossoming.
Because some early onset transsexuals experience familial rejection, they are a very high risk of self-harming behaviors running from self-sabotage, substance abuse, risky sexual behaviors, cutting, to suicidal ideation and attempted suicide. These youths need social support services but in many localities, the fact that they are transsexual works against them as they are often placed in wrong sex segregated group homes or unsupportive foster families. Social workers may have a very poor understanding the needs of gender atypical youth and feel uncomfortable working with them. The caring health worker should be aware of these difficulties and provide educational materials and advocate for their clients.
As with all health issues, prevention is better than cure. Health care providers are in a unique position to offer help to families with gender atypical children and teens understand and support their child before relations deteriorate. For early onset MTF transsexuals, because of their exclusive androphilia, they are at very high risk of HIV and HPV infection and should be counseled on safer sex practices, use of PrEP, and anti-HPV vaccination.
The problems of autogynephilic and autoandrophilic transsexuals on the other hand are primarily personal, not social… at least before transition. Most have very successful social lives, careers, marriages, family relationships. They are exploring their shifting inner sense of “gender identity” as they face the incongruity of their outwardly socially successful integration as one sex with their inner and usually secret desire to be the other sex. They are at war with themselves, as they deal with the guilt and shame, the dissonance of being socially successful as one sex, while always, in their inner sex life, obligatorily the other. When they decide to “transition” it really is a big decision and even bigger life change; most experience severe family and often career disruption, along with a sudden introduction to the social stigma of being notably gender atypical, in both behavior and appearance, in their new nominal gender role, unable to pass.
Gender therapists often conflate the two groups, making the common mistake that AGP and AAP transexuals are dealing with their gender atypicality, failing to recognize their autogynephilia or autoandrophilia, while simultaneously mistaking the early onset group as dealing with conflicted inner gender identity. For example, suggesting to an early onset transwoman that she perform some female gender affirming act in the privacy of her home will only be met with either confusion or derision, as her issues are social, not personal. Suggesting that a member of one group read the autobiographies of the other is less than helpful, for the same reason that combining the two groups for support is a bad idea.
Another mistake that gender therapists make is in regard to the heterosexual female partners, parents, siblings, and children of autogynephilic MTF transgender people when they, in effect by proxy, insist that these women and other family members accept the edited gender histories of their AGP clients. A common behavior of autogynephilic transwomen in transition is to ‘retcon’, edit, their recollections and understanding of their sexual and gendered history to seem more “classically transsexual”, more like their early onset type in their childhood gender atypicality, denying their actual history of having been conventionally gender typical but secretly autogynephilically motivated. They may outright deny autogynephilic sexual arousal to cross-dressing which may have been witnessed by parents and/or wives. Therapists, in their laudable goal of helping their clients accept themselves as they transition, fail to stress that while these edited idealizations of their client’s history may be comforting to their clients, they are emotionally abusive to their client’s wives and sometimes their parents. Further, in the long run, this edited history and denial of autogynephilia set up their clients for an emotional crisis when that denial mechanism fails, perhaps with even fatal results.
Clinicians involved in family therapy where one partner is AGP or AAP will often find themselves in an invidious position as the non-trans individual experiences severe loss and grief that must be acknowledged while the trans individual expects their partner to be supportive, happy, even celebratory during their transition process. The obvious mismatch between expectations, needs, and the ability to meet those needs lead to acrimony. Additionally, many non-trans individuals involved find the social, sartorial, and somatic changes in their partner to be sexually repulsive. The unhappy statistical truth is that such relationships are far more likely to end than to find a resolution that allows the intimate relationship to continue. Interviews with ex-spouses often point out that they felt that clinicians failed to be supportive of their needs and put those of the transitioning spouse above theirs. The wise clinician will avoid these situations as there is rarely any way to resolve both spouses needs within the relationship. The best that can be accomplished is to lay the ground work for mutual respect for each in a post separation / divorce relationship. This last is especially important if there are children involved.
Finally, it is important to know that autogynephilic MTF transsexuals are at elevated risk of co-morbid psychiatric illnesses, from severe anxiety, depression, to psychotic mental illnesses.
With greater understanding compassion for the true nature of both types of transsexual / transgender people, we should see better long-term results from therapy.
Book Reviews:
The Praeger Handbook of Transsexuality – Changing Gender to Match Mindset
Further Reading:
Essay on elevated co-morbid mental illness in transgendered individuals
American Psychological Association Guidelines on Treating Transkids
Clinical Experience and Descriptions of the Two Types
Essay on sexual objectification and harassment in mixed MTF types in therapy.
Advice to Parents of Transgender Children
Advice to the Wives and Girlfriends of Autogynephiles
Recommendations for Treatment of Transkids by Transkids
Essay on Difficulties Mixing HSTS & AAP FtM Transmen in Support Groups
On the Science of Changing Sex 