Further Research Studies of Autogynephilia in Transsexuals
After Blanchard proposed the concept of autogynephilia and the MtF transsexual typology associated with it (Blanchard,
1989a
,
1989b
), he continued to conduct research to extend the concept, develop the theory associated with it, and explore its clinical manifestations and therapeutic implications. His work resulted in several important publications in the early 1990s (Blanchard,
1991
,
1992
,
1993a
,
1993b
,
1993c
; Freund & Blanchard,
1993
). Autogynephilia subsequently received little attention for several years. Eventually, however, clinicians and researchers again began to recognize and study autogynephilia in transsexuals and examine the diagnostic and therapeutic implications of the concept of autogynephilia.
Different Types of Autogynephilia
Blanchard (
1991
) addressed the topic of autogynephilia in a major review article that also introduced new concepts and new data. He observed that there appeared to be four broad, nonexclusive categories of autogynephilic fantasies and behaviors: physiologic
, involving female physiologic functions (e.g., pregnancy, lactation, or menstruation); behavioral
, involving engaging in stereotypically feminine behaviors; anatomic
, involving having female anatomic features; and transvestic
, involving wearing women’s clothing. He noted that “the most common behavioral fantasies of adult autogynephilic men involve the thought of themselves, as women, engaging in sexual intercourse or other erotic activities” (p. 237), especially with male partners. Blanchard then presented an important case history, that of Philip, an autogynephilic man whose favorite erotic fantasy was having a woman’s body but who had never cross-dressed as an adult. Philip’s case demonstrated that “when a patient’s primary sexual object is the thought of himself with a woman’s body, there may be little overt paraphilic behavior” (p. 239). The article presented new data about the co-occurrence of anatomic autogynephilia, transvestism, and fetishism (sexual attraction to specific inanimate objects): 90% of men with anatomic autogynephilia reported co-occurring transvestism, and 55% reported co-occurring fetishism. These results were consistent with the recognized tendency of paraphilic sexual interests to co-occur or cluster (Abel & Osborn,
1992
; Gosselin & Wilson,
1980
).
Etiological Conjectures
Blanchard’s
1991
review article also contained an important section called “Etiological Conjectures” (pp. 246–248), in which Blanchard theorized about the etiologies of autogynephilia and transsexualism in nonhomosexual men. Regarding the former, Blanchard suggested that anatomic autogynephilia, transvestism, and fetishism for female garments all involved “a kind of error in locating heterosexual targets in the environment” (p. 246). He presented his ideas on this topic in greater detail in an article that appeared 2 years later (Freund & Blanchard,
1993
); because his formulation is a complicated one, I will defer a detailed explanation until I discuss that article later in this chapter.
Blanchard (
1991
) further theorized that nonhomosexual MtF transsexualism has its origin in autogynephilic sexual arousal but can eventually develop a sustaining force of its own, one in which sexual arousal per se plays little or no part. His analysis is important enough to quote at length:
Any viable theory relating the etiologies of autogynephilia and transsexualism must explain the following well-established observation: Gender dysphoria, in young nonhomosexual males, usually appears along with, or subsequent to, autogynephilia; in later years, however, autogynephilic sexual arousal may diminish or disappear, while the transsexual wish remains or grows even stronger. Such histories are often produced by gender dysphoric patients, but one does not have to rely on self-report to accept that the transsexual motive may attain, or inherently possess, some independence from autogynephilia. The same conclusion is suggested by the fact that surgical castration and estrogen treatment—which decrease libido in gender dysphorics as in other men—usually have no effect on the desire to live as a female or the resolve to remain in that role.
One may speculate that the above developmental sequence reflects the operation, in autogynephilic men, of certain normal heterosexual behaviors. Many men, after years of marriage, are less excited by their wives than they were initially but continue to be deeply attached to them; in other words, pair-bonding, once established, is not necessarily dependent on the continuation of high levels of sexual attraction. It is therefore feasible that the continuing desire to have a female body, after the disappearance of sexual response to that thought, has some analog in the permanent love-bond that may remain between two people after their initial strong sexual attraction has largely disappeared. (p. 248)
Blanchard was making the point that nonhomosexual MtF transsexualism starts out as an erotic phenomenon and remains a sexual phenomenon in the broadest sense. However, the transsexual wish could eventually be sustained by something resembling pair-bonding—a form of attachment—after the erotic elements that characterized its early phase diminished or disappeared, just as a conventional romantic relationship can be sustained by pair-bonding or attachment after the intense erotic attraction of its early phase begins to fade.
Blanchard’s idea that nonhomosexual MtF transsexuals could develop something resembling pair-bonded relationships with their idealized images of themselves as female-bodied persons might sound bizarre to anyone who has not experienced autogynephilia firsthand, but Blanchard was not the first investigator to make such a suggestion. Buckner (
1970
) had previously observed that the typical heterosexual transvestite also “acts toward himself in a way that a normal person acts toward a socio-sexually significant other” (p. 381). Buckner added that
When a male adopts this pattern [of masturbation with articles of feminine clothing] and elaborates it into an entire feminine identity, he finds it gratifying in both sexual and social ways. When it becomes fixed in his identity, he begins to relate toward himself in some particulars as if he were his own wife. (p. 387)
In other words, a pattern of cross-gender behavior that begins with erotic cross-dressing can evolve to a point at which the heterosexual transvestite seems to be engaged in something resembling a pair-bonded relationship with the feminine aspect of himself.
Buckner’s (
1970
) concept of an elaborated “entire feminine identity” offers another key to understanding this phenomenon. I have previously noted that the term cross-gender identity
is aspirational, at least as it is often operationally defined: It denotes the gender that the gender dysphoric person wants
to become, not the gender that he or she already is
. But with time and lived experience in the opposite gender role, the cross-gender identity of a gender dysphoric man need not remain wholly aspirational: It can become a well-developed, highly valued part of his self-system and can eventually supplant his original male gender identity and become his (or her) dominant gender identity. Both Docter (
1988
) and Doorn, Poortinga, and Verschoor (
1994
) conceptualized the development of “secondary” or “late-onset” MtF transsexualism—roughly synonymous with nonhomosexual MtF transsexualism—as reflecting the ascendency of an increasingly powerful and esteemed female gender identity within the self-system of a gender dysphoric man. Whether one prefers to think of the genesis and continuation of nonhomosexual MtF transsexualism in terms of something resembling attachment (or pair-bonding) to the image of one’s female-bodied self or in terms of the ascendency of a new, cherished female gender identity within one’s self-system is not terribly important. Both represent attempts to put into words something that is hard to understand and adequately describe, even for those of us who have experienced it: the process by which a man’s erotic desire to turn his body into a facsimile of a female body eventually gives rise to a strongly held, highly valued cross-gender identity and the process by which that new identity—that image of himself as a female—becomes the focus of his desire, admiration, idealization, attachment, and love—the same emotions that he might experience for an actual female partner.
A few years later, Blanchard (
1993c
) would express these same ideas slightly differently in his observation that the “behavior and motivation [underlying nonhomosexual MtF transsexualism] is subjectively experienced as a desire for physical union with a feminine self-image” (p. 243) and in his theory that “an autogynephile’s desire to unite in the flesh with his feminine self-image corresponds to a heterosexual’s desire to unite in marriage with a female partner” (p. 243).
Autogynephilia Competes with Heterosexual Attraction
Blanchard (
1992
) subsequently examined the relationship between strength of heterosexual attraction and intensity of anatomic autogynephilia in a sample of 427 transvestic or gender dysphoric men. He hypothesized that “autogynephilia arises in association with heterosexuality but also competes with it” (p. 273) and this is exactly what the data revealed: The highest levels of autogynephilia were associated with intermediate levels of heterosexual attraction. Blanchard interpreted these results as consistent with the theory that autogynephilia is a variant form of heterosexuality that also competes with heterosexual interest. Men with little heterosexual attraction evince low levels of autogynephilia, and autogynephilia increases with increasing heterosexual attraction, at least to a point. Then increasing heterosexual attraction becomes associated with slightly but significantly lower levels of autogynephilia as a result of the theorized competition.
Blanchard (
1992
) further theorized that autogynephilia was competitive with heterosexual attraction in two distinctly different ways. He observed that, although autogynephilia and heterosexual attraction usually coexisted, there were some cases in which autogynephilia was so intense that it effectively replaced heterosexual attraction. Individuals who experienced autogynephilia of this intensity were theoretically heterosexual—they were attracted to female bodies, not male bodies—but they experienced little or no attraction to the female bodies of other people
(i.e., they were analloerotic). Blanchard believed that the relative intensities of alloerotic heterosexual attraction and autogynephilia were largely determined during psychosexual development, so he called this form of competition between autogynephilia and heterosexual attraction developmental competition
(p. 275).
But Blanchard (
1992
) also observed that gender dysphoric men sometimes reported that their autogynephilic fantasies or enactments or their associated feelings of gender dysphoria temporarily became less intense or less compelling when they entered into a new heterosexual relationship or fell in love with a woman. Several case reports of this phenomenon exist in the psychiatric literature (e.g., Marks, Green, & Mataix-Cols,
2000
; Shore,
1984
; Steiner,
1985
). Blanchard referred to this type of competition between autogynephilia and heterosexual attraction as dynamic competition
(p. 275).
Anatomic Autogynephilia Predicts Gender Dysphoria
In 1993, Blanchard published three investigations addressing the relationship between anatomic autogynephilia and gender dysphoria. In the first of these, Blanchard (
1993c
) examined the association between the type of cross-gender self-image that cross-dressing men reported to be most strongly associated with sexual arousal—a nude female, a female clothed in underwear or sleepwear, or a fully clothed female—and the intensity of their gender dysphoria. He discovered that the men who were most sexually aroused by the image of themselves as nude women were significantly more gender dysphoric than the others. He concluded that the results supported “the hypothesis that those nonhomosexual men most aroused sexually by the thought of having a woman’s body are also those most interested in acquiring a woman’s body through some permanent, physical transformation” (p. 241). Blanchard further suggested that “the finding that the specific content of autogynephiles’ erotic fantasies relates to their degree of gender dysphoria has potential relevance for practical clinical prognosis” (p. 248). Specifically, he conjectured that the content of an autogynephilic patient’s sexual fantasies might prove to be a useful prognostic indicator of the likelihood that the patient would eventually decide to pursue sex reassignment. Unfortunately, no subsequent researchers appear to have investigated this intriguing idea.
In a related study, Blanchard (
1993a
) investigated differences in the strength of gender dysphoria in autogynephilic men who were or were not sexually aroused by imagining themselves with various specific female anatomic features (breasts, buttocks, legs, genitals, and face). He found that men who reported being sexually aroused by picturing themselves with female genitals—interestingly, only 86% of the autogynephilic individuals so reported—were significantly more gender dysphoric than those who denied such arousal. These results confirmed that “men who are sexually aroused at the thought of having a vulva are more likely to want to be women” (p. 301). Blanchard went on to explain:
The present study and my previous studies on this topic [Blanchard, 1993b , 1993c ] all point to the conclusion that the female attributes a man imagines when sexually aroused are related to the type and degree of feminization that he desires at other times. This simple and rather intuitive observation runs counter to the prevailing view in the clinical field of gender dysphoria. The majority of workers committed to the care of gender-dysphoric patients has maintained the position that paraphilias and gender identity disorders are completely separate entities, against the minority view that these are related, albeit distinguishable, phenomena. The present study supports the latter position and suggests that—in nonhomosexual men—autogynephilia and gender dysphoria are two sides of the same coin. (p. 306)
Thus, in nonhomosexual men, autogynephilia, gender dysphoria, and cross-gender identity are merely different sides of the same paraphilic (or paraphilia-related) phenomenon.
In the same article, Blanchard (
1993a
) also expanded on his earlier suggestion (Blanchard,
1989a
) that autogynephilia can be considered a sexual orientation. He observed that, paraphilic features notwithstanding,
autogynephilia might be better characterized as an orientation than as a paraphilia. The term orientation encompasses behavior, correlated with sexual behavior but distinct from it, that may ultimately have a greater impact on the life of the individual. For heterosexual and homosexual men, such correlated behavior includes courtship, love, and cohabitation with a partner of the preferred sex; for autogynephilic men, it includes the desire to achieve, with clothing, hormones, or surgery, an appearance like the preferred self-image of their erotic fantasies. (p. 306)
In yet another article, Blanchard (
1993b
) described anatomic autogynephilia and gender dysphoria in men with partial autogynephilia
—men whose “erotic self-images include a mixture of male and female anatomic features, most often women’s breasts and men’s genitals” (p. 71). The article included four case studies of partial autogynephiles who wanted to have female breasts but not female genitals; in most cases they were adamant about wanting to retain their male genitals. Blanchard described these partial autogynephiles as experiencing “agonizing levels of gender dysphoria” (p. 75), presumably because they experienced severe discontent with their secondary sex characteristics, albeit no discontent with their primary sex characteristics (i.e., their genitals).
Analogs of Autogynephilia in Men Attracted to Children, Amputees, and Animals
Blanchard coauthored a seminal article (Freund & Blanchard,
1993
) that described analogs of transvestic and anatomic autogynephilia in men who were pedophilic (sexually attracted to children). This article also described a man who was sexually attracted to anthropomorphic plush animals, masturbated using them, and fantasized becoming a plush animal himself. Freund and Blanchard proposed that there existed a hitherto unrecognized class of paraphilias in which affected men experienced powerful erotic desires to impersonate or make their bodies resemble the types of persons or things to which they felt sexually attracted. Specifically, they theorized that:
For every class of sexual object, there will be small subgroups of men who develop the erotic fantasy of being the desired object, and who develop the sustained wish to transform their own bodies into facsimiles of the desired object. (p. 562)
Freund and Blanchard thought that paraphilias of this kind represented erotic target location errors
. This term reflected their theory that the mental dysfunction underlying these paraphilias involved an error in accurately locating the “target” of one’s erotic interest: specifically, erroneously locating that target in or on one’s own body, rather than in or on the body of another individual. Readers who would like to learn more about erotic target location errors are invited to consult my review article (Lawrence,
2009a
), but an in-depth understanding of the concept is not essential. What is genuinely important is that Freund and Blanchard described pedophilic men who experienced precise analogs of transvestic and anatomic autogynephilia: sexual arousal associated with wearing children’s clothing (or replicas thereof) and imagining themselves to be children.
Thirteen years later, I theorized that men who desired to undergo elective amputation of a healthy limb and were often sexually aroused by the idea of doing so—a phenomenon historically conceptualized as a paraphilia called apotemnophilia
(Money, Jobaris, & Furth,
1977
)—likewise experienced something analogous to anatomic autogynephilia (Lawrence,
2006
). I observed that data from several published reports suggested that these men were almost always sexually attracted to amputees and were often sexually aroused by impersonating amputees; moreover, they displayed a much higher than expected prevalence of transvestism and GID. I proposed that
apotemnophilia may represent the intersection of two distinctly different paraphilic aspects or dimensions. One dimension involves an uncommon erotic target preference: attraction to amputees. The second dimension involves an erotic target location error, in which the individual desires to turn his body into the desired erotic target (or a facsimile thereof), rather than simply desiring that body configuration in another person. (p. 269)
A few years later, I described additional instances of pedophilic men who displayed analogs of transvestic and anatomic autogynephilia (Lawrence,
2009a
). In the same article, I summarized data concerning men who were sexually attracted to anthropomorphic plush animals, liked to costume themselves as plush animals and were sometimes sexually aroused by doing so, and seemed to identify with plush animals or fantasized becoming plush animals. I also presented data about men who were sexually attracted to real animals (i.e., who were zoophilic
) and identified as real animals and about other men who wished they could become real animals (i.e., who experienced species dysphoria
—the belief that they were born as the wrong species; see Beetz,
2004
).
Thus, there is persuasive evidence for the existence of men who are sexually attracted to children, identify as children, are sexually aroused by dressing as children, and want to turn their bodies into facsimiles of children’s bodies; men who are sexually attracted to amputees, identify as amputees, are sexually aroused by impersonating amputees, and want to have surgery to become amputees; men who are sexually attracted to plush animals, seem to identify with plush animals, like to impersonate plush animals and are sometimes sexually aroused by doing so, and probably fantasize about turning their bodies into facsimiles of plush animals; and men who are sexually attracted to real animals, identify as real animals, and may in some cases—although this is speculative—be sexually aroused by the idea of becoming real animals and fantasize about turning their bodies into facsimiles of real animals’ bodies.
How does this information help us to understand the phenomenon of men who are sexually attracted to women, identify as women, are sexually aroused by dressing as women, and want to turn their bodies into facsimiles of women’s bodies—the phenomenon of autogynephilic transsexualism? I believe that the existence of these analogs of autogynephilic transsexualism calls into question the most influential biological and psychoanalytic theories of nonhomosexual MtF transsexualism, because such theories should also be able to account for these analogous phenomena but cannot easily do so. For example: It is plausible that hormonal abnormalities during prenatal development could result in a male-bodied person with a brain that had developed in a female-typical direction (Swaab,
2007
). It is less plausible that a prenatal developmental disturbance could result in a male-bodied person with a brain that had developed like that of an amputee or a plush animal. Turning to psychoanalytic explanations, it is plausible that a boy might attempt to manage unresolved separation anxiety arising in infancy by means of a “reparative fantasy of symbiotic fusion with the mother” (Person & Ovesey,
1974a
, p. 5). It is less plausible that a boy might attempt to manage such unresolved separation anxiety through the fantasy of symbiotic fusion with another child, a plush animal, or an amputee.
I consider it more parsimonious to theorize that autogynephilic MtF transsexualism and the analogous conditions that exist in men who are sexually attracted to children, amputees, plush animals, and perhaps real animals, all represent manifestations of an unusual type of paraphilia in which affected men feel sexually aroused by the idea of impersonating or becoming whatever category of person or thing they find sexually attractive. Their paraphilic desires, in turn, often give rise to strongly held, highly valued alternative identities that ultimately become their dominant identities.
Empirical Studies of Autogynephilia Published After 1993
After the publication of Blanchard’s 1993 articles, no further empirical investigations of autogynephilia were published for approximately 8 years. Docter and Fleming (
2001
) were apparently the first to address the topic again after this hiatus. They used a 70-item questionnaire to measure aspects of transgender behavior in 455 self-described transvestites and 61 self-described MtF transsexuals. Large majorities of both groups had been married to women and only small minorities expressed a preference for male partners, so it is reasonable to assume that most, perhaps nearly all, participants were nonhomosexual (and thus putatively autogynephilic). In an initial factor analysis of the participants’ responses, Docter and Fleming extracted five factors that characterized the transgender behavior of the participants; they called these factors Transgender Identity, Transgender Role, Transgender Sexual Arousal (in effect, a measure of transvestic autogynephilia), Androallure (interest in affectionate, social, or sexual encounters with men), and Pleasure. The authors then conducted a second-order factor analysis, based on the correlation matrix for the five primary factors; this resulted in two Secondary Factors, I and II. Describing the results of this secondary factor analysis, Docter and Fleming observed:
The original factor of Sexual Arousal was most heavily loaded on [Secondary] Factor I. The pattern of loadings for the other three [sic] original factors supports the interpretation of this as a Transvestic Autogynephilia factor—that is, experiencing sexual arousal in association with the thought or image of oneself as a woman. For Secondary Factor II, the highest loading (.57) was the primary factor of Androallure with moderate positive loadings for Identity and Role factors, and a very low loading (.17) for Sexual Arousal. We have named this factor Autogynephilic Pseudobisexuality. (p. 266)
In summary, based on a survey of over 500 mostly nonhomosexual (and putatively primarily autogynephilic) transvestite and MtF transsexual participants, Docter and Fleming independently derived a high-order description of transgender behavior involving two main factors, Transvestic Autogynephilia and Autogynephilic Pseudobisexuality. These two factors closely resembled the two major dimensions of autogynephilia that Blanchard (
1989b
) had described and operationalized in his Core Autogynephilia and Autogynephilic Interpersonal Fantasy scales, which were discussed in
chap. 1
; the principal difference was that Docter and Fleming’s questionnaire had emphasized transvestic autogynephilia, which was consequently emphasized in their Secondary Factor I. These results from Docter and Fleming can be seen as an independent confirmation of Blanchard’s description of the major dimensions of autogynephilia, obtained using a completely different methodology.
In 2003, I published the results of a survey of 232 MtF transsexuals who had undergone SRS with surgeon Toby Meltzer during the period 1994–2000 (Lawrence,
2003
). I observed that about 86% of respondents had experienced one or more episodes of autogynephilic arousal before undergoing SRS and 49% had experienced hundreds of episodes or more. Two years later, in a second article based on data from the same survey, I reported that 89% of the respondents classified as nonhomosexual on the basis of their sexual partnership history reported one or more experiences of autogynephilic arousal before undergoing SRS, vs. 40% in the small number of respondents classified as homosexual (Lawrence,
2005
); there was evidence that some of these supposedly homosexual participants had misreported their partnership histories and were actually nonhomosexual.
Veale, Clarke, and Lomax (
2008
) reported the results of a survey of 234 MtF transsexuals and 127 natal women, about 90% of whom completed survey materials online. The survey questionnaire included modified versions of Blanchard’s (
1989b
) Core Autogynephilia and Autogynephilic Interpersonal Fantasy scales. The authors used cluster analysis to partition their MtF transsexual participants into ostensibly autogynephilic and nonautogynephilic groups, but their analytic procedures were questionable, and both groups obtained mean autogynephilia scores that were equal to or higher than the mean scores obtained by Blanchard’s (
1989b
) nonhomosexual (autogynephilic) participants. As J. Michael Bailey and I observed in a Letter to the Editor commenting on these results, “Veale et al.’s cluster analysis really defined an ‘autogynephilic’ group and an ‘even more autogynephilic’ group” (Lawrence & Bailey,
2009
, p. 174). Consequently, Veale et al.’s claims to have found results that were inconsistent with Blanchard’s typology of MtF transsexualism were unconvincing. Perhaps the most interesting finding from the Veale et al. survey was that autogynephilic arousal was extremely common, perhaps almost universal, in the MtF population that the authors recruited. Veale et al. observed that some natal women endorsed items on their modified autogynephilia scales but conceded that “it is unlikely that these biological females actually experience sexual attraction to oneself as a woman in the way that Blanchard conceptualized it” (p. 595).
Moser (
2009
) conducted a survey of 29 natal women to determine whether any of them had experienced autogynephilic arousal. To this end, he constructed an Autogynephilia Scale for Women, using modified items from Blanchard’s scales measuring cross-gender fetishism (Blanchard,
1985a
) and autogynephilia (Blanchard,
1989b
) and a few items of his own devising. Several of Moser’s informants endorsed some of his survey items, but Moser himself conceded that “It is possible that autogynephilia among MTFs and natal women are different phenomena and the present inventories lack the sophistication to distinguish these differences” (p. 544). I subsequently argued that this was indeed the case, because Moser’s items “fail to adequately assess the essential element of autogynephilia—sexual arousal simply to the thought of being a female—because they do not emphasize that element” (Lawrence,
2010d
, p. 3).
In 2010, I published a study of the relative prevalence of nonhomosexual and homosexual MtF transsexualism across national cultures (Lawrence,
2010c
) that had implications for understanding the phenomenon of autogynephilic transsexualism. In this article, I attempted to explain the observation that nearly all MtF transsexuals in Asian cultures are homosexual, whereas most MtF transsexuals in the USA, Canada, and the UK are nonhomosexual. I demonstrated that differences in a measure of societal individualism
—the degree to which a culture condones its members pursuing personal happiness and self-expression, regardless of the opinions of others—accounted for most of the differences in the relative prevalence of nonhomosexual MtF transsexualism. If one assumes that nonhomosexual MtF transsexualism is equivalent to autogynephilic transsexualism—a justifiable assumption, in my opinion—these results suggest the hypothesis that the permissible expression of autogynephilia
, rather than the prevalence or severity of autogynephilia, primarily accounts for these cross-cultural differences. Undergoing MtF sex reassignment probably feels far more permissible to autogynephilic men living in individualistic Western cultures than to their counterparts in cultures in which individual self-expression is discouraged.
Nuttbrock, Bockting, Mason, et al. (
2011
) investigated the lifetime prevalence of one type of autogynephilia, transvestic fetishism (TF), in 571 MtF transgender persons—not all of whom were transsexual—living in New York City. Their findings were similar to those reported by Blanchard (
1985b
): In their study, 73% of nonhomosexual participants reported a history of TF, compared to only 23% of homosexual participants. Deviations from the predictions of Blanchard’s theory could be accounted for by a combination of misreporting or inaccurate assessment of sexual orientation and underreporting of TF by affected persons (see Lawrence,
2010a
). Nuttbrock, Bockting, Mason, et al., however, chose to emphasize a few areas in which they claimed their results deviated from the predictions of Blanchard’s theory. In particular, they argued—unconvincingly, in my opinion—that age and ethnicity, in addition to sexual orientation, were important predictors of TF. The authors and I debated these issues at length in a series of Letters to the Editor (Lawrence,
2010a
,
2011b
; Nuttbrock, Bockting, Rosenblum, Mason, & Hwahng,
2010
,
2011
); interested readers are referred to these letters for further details.
One of the most revealing passages in the article by Nuttbrock, Bockting, Mason, et al. (
2011
) emphasized that Blanchard’s concept of autogynephilia and the MtF transsexual typology derived from it had social and political implications that transcended issues of scientific validity:
[Blanchard’s] findings have sociopolitical implications far beyond scientific circles because they directly contradict basic tenets of the worldwide transgender movement: sex and gender are deemed to be separate, socially constructed dimensions of personal identity characterized by individual variation and social diversity. (p. 249)
Leaving aside the question of whether there is indeed a worldwide transgender movement and, if so, whether its beliefs are monolithic, the implications of the above statement are clear: The authors believed that Blanchard’s ideas were politically unacceptable, regardless of their scientific validity.
Reviews, Popular Accounts, and Critiques of Autogynephilia
In addition to the empirical investigations of autogynephilia conducted by Blanchard and other researchers, there have been a few reviews, popular accounts, and critiques of the concept of autogynephilia, its meaning and significance, and the MtF transsexual typology and theory of motivation associated with it. In one review article, Blanchard (
2005
) summarized the early history of the concept of autogynephilia. I authored four reviews devoted entirely to autogynephilia (Lawrence,
2004
,
2007
,
2009b
,
2011a
) and a review of erotic target location errors that contained extensive discussions of transvestic and anatomic autogynephilia (Lawrence,
2009a
).
In my review of erotic target location errors (Lawrence,
2009a
), I summarized data on the prevalence of autogynephilia. In a national probability survey, 2.8% of Swedish men reported at least one episode of sexual arousal associated with cross-dressing (Långström & Zucker,
2005
). Other studies have found prevalence rates between 1% and 18% for sexual arousal with cross-dressing or cross-gender fantasy; all of these studies have methodological limitations, but collectively they suggest that perhaps 2–3% of men have engaged in erotic cross-dressing at times and even more have occasionally experienced erotic arousal in association with cross-gender fantasies. However, clinically significant autogynephilic arousal, manifesting as frequent cross-dressing or habitual cross-gender fantasy during sexual activity, is probably much less prevalent. This more intense form of autogynephilia probably affects fewer than 1% of men and perhaps fewer than 0.1%. Autogynephilia that is sufficiently intense to cause severe gender dysphoria and the persistent desire for sex reassignment—autogynephilic transsexualism—is evidently rarer still.
Only a few studies have produced reliable prevalence estimates for MtF transsexualism and severe gender dysphoria in Western countries. In Scotland, the reported prevalence of severe gender dysphoria in men is about 1 in 7,400 (0.014%; Wilson, Sharp & Carr,
1999
). In Belgium, about 1 in 12,900 (0.0078%) adult men has undergone MtF SRS (De Cuypere et al.,
2007
); in the Netherlands, the figure is about 1 in 11,900 (0.0084%; Bakker, van Kesteren, Gooren, & Bezemer,
1993
). In New Zealand, the reported prevalence of MtF transsexualism based on passport data is about 1 in 3,600 (0.028%; Veale,
2008
). Roughly one half to two thirds of the MtF transsexuals and gender dysphoric men in these countries would be expected to be nonhomosexual and presumably autogynephilic (see Lawrence,
2010c
).
In my recent reviews devoted to autogynephilia (Lawrence,
2007
,
2009b
,
2011a
), I emphasized that autogynephilia is not merely an erotic phenomenon but also involves the same feelings of idealization and attachment that characterize romantic love. Extending Blanchard’s (
1989a
,
1993a
) idea that autogynephilia is a sexual orientation as well as a paraphilia, I explained:
Sexual orientations are characterized by feelings of idealization and attachment in addition to feelings of erotic desire. For example, gynephilic men do not merely lust for women: They also—at least most of the time—idealize them, fall in love with them, derive feelings of comfort and security from them, and seek to establish enduring bonds with them. Autogynephilia is much the same: Like other sexual orientations, autogynephilia potentially involves all the feelings and behaviors we associate with the word love , broadly construed. Autogynephilic MtF transsexuals are erotically aroused by imagining themselves as female, but they also idealize the thought of being female, experience feelings of comfort and security from their autogynephilic fantasies and behaviors, and usually want to bond permanently with their idealized feminine self-images by completely embodying and enacting them (i.e., by undergoing hormone therapy and sex reassignment surgery). (Lawrence, 2011a , pp. 140–141)
To put this conclusion more succinctly: Autogynephilic MtF transsexuals are men who love women and want to become what they love (Lawrence,
2007
).
The best known popular account of autogynephilia and the MtF transsexual typology associated with it appeared in the book The man who would be queen
(Bailey,
2003
). The book and its author incurred the wrath of some transgender activists and their allies, who took issue with the opinions and attitudes expressed in the book (Dreger,
2008
; Lawrence,
2008
). I authored two reviews of autogynephilia (Lawrence,
1998
,
2000
) that were intended for nonprofessional audiences but were structured as academic articles (e.g., they contained in-text literature citations). Finally, two critiques of autogynephilia have recently been published in second-line academic journals (Moser,
2010
; Serano,
2010
).
Case Histories of Autogynephilic Transsexualism Are Rare
Although Blanchard’s theory that “nonhomosexual MtF transsexualism equals autogynephilic transsexualism” was groundbreaking, and the MtF transsexual typology derived from it and implicit theory of transsexual motivation associated with it had obvious clinical implications, Blanchard’s formulation was not immediately influential, and some clinicians still do not accept it. His theory contradicted the conventional wisdom that transsexualism is unrelated to erotic desire and is exclusively about the desire to live in the opposite gender role, and this may be partly responsible for the theory’s limited influence and acceptance. But probably Blanchard’s theory also simply seemed too theoretical
to many clinicians. It is important to remember that, with only two exceptions (i.e., Blanchard, Clemmensen, et al.,
1985
; Blanchard et al.,
1986
), the theory of autogynephilia and the concepts associated with it were developed and validated almost exclusively from survey data that were routinely collected in the institution where Blanchard worked. Although Blanchard’s clinical experience undoubtedly informed his theories, his articles about autogynephilia included few case histories or clinical vignettes to illustrate his ideas. The only notable case history was that of Philip, the anatomic autogynephile who did not cross-dress, which appeared in two early articles and a later one (Blanchard,
1991
,
1993b
,
2005
). There were also a few brief descriptions of anatomic and behavioral autogynephilic fantasies (e.g., Blanchard,
1993c
). One article (Blanchard) included four case histories of men with partial autogynephilia, but none of these men was transsexual by usual definitions (i.e., none wanted to undergo SRS). Blanchard also wrote a book chapter (Blanchard,
1990
) that contained three detailed case histories illustrating heterosexual, analloerotic, and bisexual MtF transsexualism; although he cited two of his own articles in which he had used the term autogynephilia (Blanchard,
1989a
,
1989b
), none of the case histories were presented as instances of autogynephilic transsexualism, nor did the word autogynephilia appear anywhere in the chapter.
Only a few subsequent case histories of autogynephilic transsexualism have appeared in the professional literature. Ekins and King (
2001
) presented the case of Janice, a nonhomosexual MtF transsexual who was aware of Blanchard’s theory and who identified as autogynephilic. Janice experienced sexual arousal in association with cross-dressing long before puberty and was gender dysphoric from an early age, but her autogynephilic feelings led her to doubt that she was genuinely transsexual. She used feminization fantasies to facilitate coitus with her wife. She eventually underwent SRS at age 41 and continued to experience autogynephilic arousal thereafter; her fantasies involving anatomic autogynephilia are set forth in detail. I described a 38-year-old nonhomosexual MtF transsexual patient who identified with the concept of autogynephilia and reported a strong interest in having sex with men (Lawrence,
2004
). The patient acknowledged that her interest did not represent genuine androphilia but merely reflected “the way in which being with a man sexually made her feel like a desirable woman” (p. 80).
Barrett (
2007
) presented three brief case histories of men with gender identity concerns and supposed autogynephilia. Barrett, however, considered autogynephilia to be one of the differential diagnoses in MtF transsexualism—that is, one of several “non-transsexual disorders of gender identity” (p. 35) that clinicians needed to differentiate from genuine transsexualism. Perhaps for that reason, none of Barrett’s case histories of autogynephilia involved men who intensely desired to undergo sex reassignment and live as women. The first of these histories (SM) was presented as one “in which the autogynaephillic [sic] drive is rather clear” (p. 35), but Barrett never described any of the patient’s autogynephilic fantasies, so the basis for this judgment seemed anything but clear. Barrett’s other two cases (DW and DM; pp. 36–37) included cursory descriptions of the patients’ histories of sexual arousal with cross-dressing, but what Barrett really emphasized was that these patients wanted to have female anatomic features but did not want to live in an unequivocally feminine gender role. Barrett seemed to believe that the hallmark of autogynephilia was the desire for physical feminization accompanied by “a fundamentally unchanged life, in a male gender role” (p. 36)—in short, pure anatomic autogynephilia that was unaccompanied by any significant cross-gender identification. Men who expressed an unequivocal wish to live as women seemingly did not qualify as autogynephilic in Barrett’s view, even if they had extensive histories of sexual arousal in association with cross-dressing. Barrett recognized the existence of “heterosexual male secondary transsexuals” (p. 22) with such histories, but his descriptions of them did not mention anything resembling anatomic autogynephilia; perhaps for this reason, Barrett did not characterize nonhomosexual secondary MtF transsexuals as autogynephilic, even when they described evident transvestic autogynephilia.
Finally, there is an unusual case history of “autogynophillia” [sic] in a 44-year-old man who displayed transvestic fetishism and expressed a desire for SRS (Duisin, Barisić, & Nikolić-Balkoski,
2009
). Unfortunately, the authors did not describe the patient’s autogynephilic fantasies and behaviors in much detail, limiting the value of this report.
Missing Discourses and Forbidden Narratives
Although “the study of autogynephilia is, more than anything, the study of what people say about their experiences” (Blanchard,
2005
, p. 439), hardly any MtF transsexuals themselves have said much about their experiences of autogynephilia, at least until quite recently. As of the mid-1990s, only a few first-person narratives by MtF transsexuals contained descriptions of sexual arousal in association with cross-dressing or the thought or image of having a female body, and none that I am aware of actually used the term autogynephilia. Works of erotic fiction could be seen as exceptions to this pattern: Erotic stories containing explicitly autogynephilic themes and written as first-person narratives are not uncommon, especially on the Internet. But these erotic stories do not purport to be genuinely autobiographical; indeed, many are highly implausible. They can be easily dismissed as fabrications that are designed to satisfy the prurient interests of fetishistic transvestites but are of no significance to “real” MtF transsexuals.
Perhaps the scarcity of first-person descriptions of autogynephilia by MtF transsexuals reflects the belief that experiencing sexual arousal in association with cross-dressing or cross-gender fantasy disqualifies one from being genuinely transsexual. Whatever the explanation, it is almost impossible to find an autobiographical account in which a MtF transsexual explicitly states, “Yes, I was sexually aroused by the idea of having a woman’s body, and this was part of the reason that I sought SRS.” Thus, first-person descriptions of autogynephilia—especially anatomic autogynephilia—by MtF transsexuals appear to constitute “missing discourses” (cf. Fine,
1988
) or “forbidden narratives” (cf. Church,
1995
).
This narrative vacuum leaves severely gender dysphoric men who experience autogynephilia without viable MtF transsexual role models. The autobiography of Christine Jorgensen (
1967
) was a beacon of hope for many MtF transsexuals because it was a story with which they could identify. But gender dysphoric men who experience autogynephilia, especially anatomic autogynephilia, do not yet have a Christine Jorgensen with whose story they
can identify. At present, they have only a few autobiographical shards that seem at all relevant to their circumstances. Let us briefly consider what these consist of.
Hunt (
1978
), a nonhomosexual MtF transsexual who had undergone SRS, authored an autobiography in which she explicitly described autogynephilic arousal and its close resemblance to heterosexual desire:
I was feverishly interested in [girls]. I studied their hair, their clothes, their figures. And I brooded about the increasing differences between us. I seethed with envy while at the same time becoming sexually aroused—I wanted to possess them even as I wanted to become them. In my nighttime fantasies, as I masturbated or floated towards sleep, I combined the two compulsions, dreaming of sex but with myself as the girl. (p. 60)
In an autobiographical essay, Bornstein (
1995
), a nonhomosexual MtF transsexual who had undergone SRS, repeatedly quoted from erotica written for heterosexual cross-dressers and confided that “I never stopped reading those porno books. I still have a small collection of them.” (p. 232). Bornstein also observed that, 7 years after undergoing SRS, she continued to be aroused by the image of herself as a female:
It’s been 7 years, and y’know what? I still get a thrill when I look at myself in the mirror and I see girl not boy. (p. 238)
In a detailed account of her SRS experience, Griggs (
1998
), another MtF transsexual, discussed her lifelong analloeroticism and obligatory reliance on fantasies of being female to achieve orgasm during masturbation. Based on a subsequent autobiographical work (Griggs,
2004
), in which she described one long-term nonsexual relationship with a man and two long-term relationships with women, Griggs’ sexual orientation appeared to be nonhomosexual. She wrote:
When I lived as a man, I had no desire to have intercourse with a woman. I likewise had no inclination for a homosexual relationship with a man. Erotic imagery was invariably contingent on my being female, and even during masturbation, whether the object of my desire was man or woman, I could not reach a climax without imagining that I was female. This is still true. When confronted as a teenager by the reality that I was male, my private experience of sexuality was void, and the resulting appetite, or specifically the lack of it, was vaguely questioned by friends, family, and the women I dated. (Griggs, 1998 , p. 50)
Griggs did not
state, however, that the “object of her desire” during masturbation was her image of herself as a female. Rather, the supposed object of her desire was another “man or woman,” despite her report of having felt no desire for either men or women earlier in her life. Thus, her description of what could be interpreted as anatomic autogynephilia is equivocal.
McCloskey (
1999
), a MtF transsexual whose history is consistent with a nonhomosexual orientation—she was not effeminate in childhood, married a woman and fathered two children, and underwent SRS at age 53—authored an autobiography in which she described her lengthy history of cross-gender fetishism. Prior to gender transition, she had identified as “just a heterosexual cross-dresser” (p. 48), “just a guy who gets off dressing occasionally as a woman” (p. 50). Until about a year before she underwent SRS in 1996, her cross-dressing had routinely been associated with sexual arousal and, presumably, masturbation:
Until the spring of 1995, each of the five thousand episodes [of cross-dressing] was associated with quick male sex. (p. 16)
McCloskey also offered a third-person description of her preferred erotic materials, which included images of feminized men whose male genitalia were not visible. She implied that this preference reflected her erotic fantasy of undergoing “complete” (i.e., genital) sex reassignment:
His preoccupation with gender crossing showed up in the pornographic magazines he used. There are two kinds of crossdressing magazines, those that portray men in dresses with private parts showing and those that portray them hidden. He could never get aroused by the ones with private parts showing. His fantasy was of complete transformation. (p. 19)
This impressive candor notwithstanding, McCloskey subsequently stated that she rejected Blanchard’s ideas about autogynephilia (“it’s a mistaken theory, with no scientific basis”; McCloskey,
2008
, p. 467) and claimed that the concept of autogynephilia was inapplicable to her (e.g., she described herself as “exhibiting no ‘autogynephilia’”; McCloskey,
2003
, para. 26).
Zander (
2003
), a nonhomosexual MtF transsexual—she identified as lesbian before and after undergoing SRS—discussed her simultaneous feelings of lust and envy toward attractive women in a collection of autobiographical essays. She described experiencing
a slightly schizophrenic feeling whenever I met an attractive girl. The spontaneous male reflex (don’t tell me it’s not biological!) “If I could only have sex with her!,” instantaneously followed by “and have such a body!”. I used to call this my “Have her and be her” fantasy, and for decades it dominated my response to attractive women. (p. 104)
There are also a few examples of narratives by nonhomosexual MtF transsexuals in which erotic arousal associated with cross-dressing is described but is deemphasized or implied to be of little significance. Richards (Richards & Ames,
1983
), a nonhomosexual MtF transsexual—she was not effeminate during childhood, married a woman, and fathered a child—described unequivocal erotic arousal associated with cross-dressing between the ages of 6 and 13 (she did not specify her exact age) in her autobiography. She denied, however, that she masturbated while cross-dressed or even that her erotic arousal was related to cross-gender ideation:
My forays into my sister’s wardrobe were happening with greater frequency. It would be natural to think that this cross-dressing must have been associated with some sexual activity. In fact it was not. I would sometimes get an erection as I pulled on some silky underthing, but this was pretty much a response to the soft touch of the fabric. It was not associated with the transformation to a girl. The same thing might happen as I dried myself with a soft towel after a bath. It is peculiar indeed that I could control the desire to masturbate but not the desire to dress in my sister’s clothes. I did have wet dreams; so the mechanism was in perfectly good shape. (p. 27)
Cummings (
1992
), another nonhomosexual MtF transsexual—she was not effeminate as a child, was unambiguously sexually attracted to women, and identified as a heterosexual transvestite for many years—likewise described sexual arousal, erection, and ejaculation in association with cross-dressing. However, she seemed to downplay the significance of these occurrences and portrayed herself as an unwilling victim of her own erotic reflexes:
Was there a sexual component to this dressing up? Yes and no. I was ambushed by orgasm in a way I found quite antipathetic. Because my routine involved dressing up and standing in front of the mirror while I admired my feminised reflection, I wanted the image to be as female as possible and would, as most transvestites learn to do, pull my genitals back and clamp them between my thighs. Adolescence combined with friction tended to create an erection, quite the reverse of what I wanted and this in turn often resulted in orgasm and ejaculation. Contrary to what one might imagine, this ruined my enjoyment. Of course the moment of orgasm was pleasurable but it was only a moment and the consequent ejaculation called an immediate halt to my activity, partly because I had to prevent any semen from soiling my sister’s clothes and partly because I disliked intensely the presence of the sticky fluid on my body. I would hastily undress and wash myself. (p. 11)
The narratives by autogynephilic transsexuals that I will introduce in the next chapter were collected with the intention of addressing the scarcity of accounts by MtF transsexuals of their autogynephilic feelings and desires. My goal was to make an anthology of these missing discourses and forbidden narratives available to anyone who might find such accounts valuable: in particular, clinicians seeking to better understand their nonhomosexual MtF transsexual clients and nonhomosexual MtF transsexuals seeking to better understand themselves.
References
Abel, G. G., & Osborn, C. (1992). The paraphilias. The extent and nature of sexually deviant and criminal behavior. The Psychiatric Clinics of North America, 15
, 675–687.
PubMed
Bailey, J. M. (2003). The man who would be queen: The science of gender-bending and transsexualism
. Washington, DC: Joseph Henry Press.
Barrett, J. (2007). Transsexual and other disorders of gender identity
. Oxford: Radcliffe Publishing.
Beetz, A. M. (2004). Bestiality/zoophilia: A scarcely investigated phenomenon between crime, paraphilia, and love. Journal of Forensic Psychology Practice, 4
(2), 1–36.
CrossRef
Blanchard, R. (1985a). Research methods for the typological study of gender disorders in males. In B. W. Steiner (Ed.), Gender dysphoria: Development, research, management
(pp. 227–257). New York: Plenum.
CrossRef
Blanchard, R. (1990). Gender identity disorders in adult men. In R. Blanchard & B. Steiner (Eds.), Clinical management of gender identity disorders in children and adults
(pp. 49–76). Washington DC: American Psychiatric Press.
Blanchard, R. (1991). Clinical observations and systematic studies of autogynephilia. Journal of Sex & Marital Therapy, 17
, 235–251.
CrossRef
Blanchard, R. (1993a). Partial versus complete autogynephilia and gender dysphoria. Journal of Sex & Marital Therapy, 19
, 301–307.
CrossRef
Blanchard, R. (1993b). The she-male phenomenon and the concept of partial autogynephilia. Journal of Sex & Marital Therapy, 19
, 69–76.
CrossRef
Blanchard, R., Racansky, I. G., & Steiner, B. W. (1986). Phallometric detection of fetishistic arousal in heterosexual male cross-dressers. Journal of Sex Research, 22
, 452–462.
CrossRef
Bornstein, K. (1995). Gender outlaw: On men, women, and the rest of us
. New York: Vintage.
Buckner, H. T. (1970). The transvestic career path. Psychiatry, 33
, 381–389.
PubMed
Church, K. (1995). Forbidden narratives: Critical autobiography as social science
. Amsterdam: Gordon and Breach.
Cummings, K. (1992). Katherine’s diary: The story of a transsexual
. Port Melbourne, Australia: William Heinemann Australia.
Docter, R. F. (1988). Transvestites and transsexuals: Toward a theory of cross-gender behavior
. New York: Plenum.
Duisin, D., Barisić, J., & Nikolić-Balkoski, G. (2009). Case report of autogynophillia [sic]: family, ethical and surgical implications. Psychiatria Danubina, 21
, 242–245.
PubMed
Ekins, R., & King, D. (2001). Transgendering, migrating and love of oneself as a woman: A contribution to a sociology of autogynephilia. International Journal of Transgenderism, 5
(3). Available at
http://www.iiav.nl/ezines/web/IJT/97-03/numbers/symposion/ijtvo05no03_01.html
Fine, M. (1988). Sexuality, schooling, and adolescent females: The missing discourse of desire. Harvard Educational Review, 58
, 29–54.
Gosselin, C., & Wilson, G. (1980). Sexual variations: Fetishism, sadomasochism, transvestism
. New York: Simon and Schuster.
Griggs, C. (1998). S/he: Changing sex and changing clothes
. Oxford: Berg.
Griggs, C. (2004). Journal of a sex change: Passage through Trinidad
. Oxford: Berg.
Hunt, N. (1978). Mirror image: The odyssey of a male-to-female transsexual
. New York: Holt, Rinehart, and Winston.
Jorgensen, C. (1967). Christine Jorgensen: A personal autobiography
. New York: Paul S. Eriksson.
Långström, N., & Zucker, K. J. (2005). Transvestic fetishism in the general population: Prevalence and correlates. Journal of Sex & Marital Therapy, 31
, 87–95.
CrossRef
Lawrence, A. A. (1998). Men trapped in men’s bodies: An introduction to the concept of autogynephilia. Transgender Tapestry, 1
(85), 65–68.
Lawrence, A. A. (2000). Sexuality and transsexuality: A new introduction to autogynephilia. Transgender Tapestry, 1
(92), 17–23. 9–30.
Lawrence, A. A. (2004). Autogynephilia: A paraphilic model of gender identity disorder. Journal of Gay & Lesbian Psychotherapy, 8
(1/2), 69–87.
Lawrence, A. A. (2009b). Transgenderism in nonhomosexual males as a paraphilic phenomenon: Implications for case conceptualization and treatment. Sexual and Relationship Therapy, 24
, 188–206.
CrossRef
Lawrence, A. A. (2010a). A validation of Blanchard’s typology: Comment on Nuttbrock et al. (2010) [Letter to the editor]. Archives of Sexual Behavior, 39
, 1011–1015.
Lawrence, A. A., & Bailey, J. M. (2008). Transsexual groups in Veale et al. (2008) are “autogynephilic” and “even more autogynephilic” [Letter to the editor]. Archives of Sexual Behavior, 38
, 173.
CrossRef
McCloskey, D. N. (1999). Crossing: A memoir
. Chicago: University of Chicago Press.
McCloskey, D. (2003, November). Queer science: A data-bending psychologist confirms what he already knew about gays and transsexuals [Book review]. Reason Online
. Available at
http://reason.com/archives/2003/11/01/queer-science
Money, J., Jobaris, R., & Furth, G. (1977). Apotemnophilia: Two cases of self-demand amputation as a paraphilia. Journal of Sex Research, 13
, 115–125.
CrossRef
Nuttbrock, L., Bockting, W., Rosenblum, A., Mason, M., & Hwahng, S. (2011). Sexual arousal associated with private as compared to public feminine dressing among male-to-female transgender persons: A further response to Lawrence (2011) [Letter to the Editor]. Archives of Sexual Behavior, 40
, 1093–1096.
CrossRef
Person, E., & Ovesey, L. (1974a). The transsexual syndrome in males. I. Primary transsexualism. American Journal of Psychotherapy, 28
, 4–20.
PubMed
Richards, R., & Ames, J. (1983). Second serve
. New York: Stein and Day.
Serano, J. M. (2010). The case against autogynephilia. International Journal of Transgenderism, 12
, 176–187.
CrossRef
Steiner, B. W. (1985). Transsexuals, transvestites, and their partners. In B. W. Steiner (Ed.), Gender dysphoria: Development, research, management
(pp. 351–364). New York: Plenum.
CrossRef
Swaab, D. F. (2007). Sexual differentiation of the brain and behavior. Best Practice & Research. Clinical Endocrinology & Metabolism, 21
, 431–444.
CrossRef
Wilson, P., Sharp, C., & Carr, S. (1999). The prevalence of gender dysphoria in Scotland: A primary care study. The British Journal of General Practice, 49
, 991–992.
PubMed
Zander, E. (2003). TransActions
. Stockholm, Sweden: Periskop Förlag.