Making Sense of Autogynephilic Transsexualism
In this final chapter, I offer a broader perspective concerning the nature and implications of autogynephilic transsexualism. My analysis is based on the narratives submitted by the 249 autogynephilic transsexual informants and the 52 nontranssexual autogynephiles, the clinical and research literature, and my experience with transsexual clients. I summarize some of the most important observations and reflections contained in the narratives and suggest how this information might help clinicians in case conceptualization and treatment planning for autogynephilic clients. I address the shame that many of us autogynephilic transsexuals feel about our condition and consider whether anything can be done to reduce it. I examine some of the options available to severely gender dysphoric autogynephilic men and their potential benefits and drawbacks. I describe a possible future treatment for autogynephilic transsexualism and discuss whether and how this treatment might eventually become available. Finally, I propose that, notwithstanding its many limitations, sex reassignment as currently practiced can offer autogynephilic transsexuals a pathway to a life of greater satisfaction, passion, and spiritual fulfillment.
Autogynephilic Transsexualism: Maybe Not So Rare After All?
The critics of Blanchard’s theory of autogynephilic transsexualism have long been forced to concede that some MtF transsexuals believed the theory was valid and accurately described them. But avowedly autogynephilic transsexuals have historically been few in number. This has allowed some critics to get away with suggesting that autogynephilic transsexualism is rare or even “exotic.” I don’t expect the critics to change their stance any time soon; but with the publication of this book, the number of admittedly autogynephilic transsexuals described in the academic literature has probably increased by two orders of magnitude. As one who values diversity, I consider this a positive sign.
I should quickly add that not all of the 249 MtF transsexual informants who admitted to experiencing autogynephilic arousal agreed with Blanchard’s ideas or mine on every point. Roughly 30 of them—about 12%—believed that the autogynephilic arousal they experienced was unimportant, was a manifestation of normal female sexuality, or was an effect rather than a cause of their gender dysphoria. Overall, however, the informants’ narratives were strongly supportive of Blanchard’s ideas.
What Do Autogynephilic Transsexuals Say About Their Condition?
Many of the informants considered the concept of autogynephilia to be a revelation: They reported that it was the first theory they had encountered that actually seemed to describe them. Often they were grateful to have learned about the theory, and they stated that it had improved their understanding of themselves. Many were relieved to discover that other transsexuals shared similar feelings. A few, however, found that recognizing themselves in the theory was disconcerting, as though their comfortable illusions about themselves had been shattered. Several informants reported that their autogynephilic feelings had previously made them doubt that they were really transsexual. Many had been reluctant to admit their feelings to their therapists or had lied to or misled their therapists concerning their feelings—perhaps yet another reason for the widespread but mistaken belief that autogynephilic transsexualism is rare.
Several informants began cross-dressing or having cross-gender fantasies in early childhood, long before puberty. Sometimes these early childhood behaviors and fantasies were accompanied by penile erections, masturbation, or feelings of intense excitement that informants identified as erotic. The erotic feelings associated with cross-dressing or cross-gender fantasies sometimes receded for a few years but typically reappeared at puberty. Autogynephilic erotic feelings commonly, but not invariably, continued throughout the informants’ lives, including after SRS. In spite of their desire to be female, most of the informants denied that they had been feminine boys: Except for their autogynephilic fantasies and behaviors, they usually described themselves as having been unremarkably masculine. Those who mentioned their adult occupations usually reported male-typical ones.
The informants were invariably sexually attracted to women, for whom they felt a confusing mixture of lust and envy. Although they found women’s bodies sexually arousing, many were never able to reach orgasm during heterosexual intercourse without engaging in autogynephilic fantasy: They discovered that the fantasy of being female themselves was more exciting than an actual female partner. Many fantasized about or engaged in sex with men, but only when they imagined themselves to be women; at other times, they found the idea of sex with men unappealing or repugnant.
Some informants found autogynephilic arousal unpleasant. Others were confused or distressed by the rapid but temporary remission of their cross-gender wishes that often occurred immediately following orgasm. Many valued the ability of hormone therapy to reduce their gender dysphoria, but a few experienced an unexpected weakening or disappearance of their cross-gender wishes and desire to pursue sex reassignment after beginning hormone therapy. A significant number of informants reported other co-occurring paraphilic interests. Finally, as noted earlier, some informants offered explanations that attempted to reconcile their autogynephilic feelings and behaviors with traditional theories and beliefs about MtF transsexualism.
How Can Understanding Autogynephilic Transsexualism Inform Clinical Care?
Most clinicians will probably regard the narratives in the previous chapters as fascinating, revealing, and a source of greater knowledge and understanding. Some may wonder, however, how to use this knowledge in their clinical practices with gender dysphoric autogynephilic clients. I believe that a clear understanding of the concept of autogynephilic transsexualism and its clinical manifestations can help practitioners with case conceptualization, formulation of prognostic information for clients, and treatment planning. Clinicians who are interested in a more detailed examination of these issues may wish to consult one of my review articles (Lawrence,
2009b
).
The concept of autogynephilic transsexualism provides a useful model for conceptualizing the etiology and development of the most common form of MtF transsexualism in Western countries. In particular, it convincingly explains why some men who are not naturally feminine and who are sexually attracted to women experience the overpowering desire to turn their bodies into facsimiles of women’s bodies and live as women. Traditional explanations of this phenomenon—ones that do not include the concept of autogynephilia—are inevitably circular and self-referential, as I explained in
chap. 10
. Autogynephilia is a sexual orientation, and men are willing to risk a great deal to express their sexual orientations and attempt to unite themselves with the persons or things they love, lust after, admire, and regard as beautiful.
The concept of autogynephilic transsexualism can also help clinicians account for the elevated prevalence of other paraphilias in nonhomosexual MtF transsexuals. If one theorizes that these transsexuals have something resembling women’s brains in their male bodies, the prevalence of their coexisting paraphilias makes no sense: With the exception of sexual masochism, paraphilias are almost nonexistent in women. But if one theorizes that these transsexuals are, in fact, men with a paraphilic sexual orientation that makes them want to become women, the prevalence of their coexisting paraphilias makes perfect sense. As a few informants observed, co-occurring paraphilias may in some cases be even more powerful and consequential than autogynephilia itself; clinicians who work with autogynephilic transsexual clients should keep this possibility in mind.
Because men’s sexual orientations are believed to be essentially unchangeable in adulthood, clinicians may be puzzled by the tendency of many formerly heterosexual MtF transsexuals to fantasize about engaging in sex with men or, more rarely, to actually do so. The explanation of this phenomenon becomes obvious if clinicians understand that autogynephilic transsexuals may be sexually aroused by the prospect of enacting the traditional female sexual role in relation to male partners, even though they are not sexually attracted to men’s bodies. Autogynephilic transsexuals do not experience a genuine change in their sexual orientations: Their fantasies and behaviors involving male partners are simply manifestations of their autogynephilic sexual orientations.
Moreover, because sexual orientations appear to be immutable in adult men, the autogynephilic sexual orientations of these transsexuals almost certainly cannot be changed, any more than the sexual orientations of ordinary heterosexual or homosexual men can be changed. In my opinion, clinicians should clearly advise their gender dysphoric autogynephilic patients that their condition is not curable: They will be dealing with their autogynephilic feelings, in one form or another, as long as they live. Fortunately, the severe gender dysphoria associated with autogynephilic transsexualism is manageable—and sex reassignment is often a good way of managing it.
The concept of autogynephilic transsexualism can also help clinicians understand the value and potential limitations of feminizing hormone therapy. Cross-sex hormones can help autogynephilic transsexuals more closely approximate the female appearance they desire and can also help control ego-dystonic autogynephilic arousal, which many autogynephilic transsexuals experience. For this reason, most severely gender dysphoric autogynephilic patients are very satisfied with feminizing hormone therapy. However, hormone therapy reduces testosterone levels and thereby reduces the intensity of autogynephilic erotic feelings; this can cause some gender dysphoric autogynephilic men to lose their motivation to continue using hormones. The deciding factors in an individual patient may be intensity of gender dysphoria and strength of cross-gender identity; both of these are outgrowths of autogynephilia, but cross-gender identity usually takes time and experience to consolidate. Patients with more intense gender dysphoria and stronger, better established cross-gender identities usually welcome both the feminization and libido reduction associated with hormone therapy. Patients with less intense gender dysphoria or less well established cross-gender identities often seem to do better on lower doses of hormones, which produce some feminization but are less likely to completely eliminate the autogynephilic erotic feelings that drive the patients’ desire for feminization.
Can Autogynephilic Transsexualism Ever Feel Less Shameful?
Even though I have been one of the most outspoken advocates for Blanchard’s theory of autogynephilic transsexualism, I have never been able to get over my shame about being an autogynephilic transsexual. I regard Blanchard’s theory as brilliant and revelatory. As a clinician and researcher, I appreciate its descriptive, predictive, and heuristic value. I could never have completed sex reassignment without the insight it provided me, and for that I’m very grateful. But I’m not delighted by what the theory tells me about myself, and I doubt that I ever will be. I still feel deeply ashamed: not just about being a transsexual, which feels shameful enough, but about being an autogynephilic transsexual, which feels more shameful still. Sometimes I can put aside my shame for days or weeks, but it always returns, and it always feels agonizing when it does.
Why does the realization that one is a paraphilic man with an erotic motivation for wanting to become a woman feel so shameful? This is the rhetorical question that Meana (
2008
) so innocently but subversively posed:
Why is being a “woman trapped inside a man’s body” any more respectable than being a man who loves womanhood so much he yearns to become the object of his own desire? Why is an erotic motivation any less worthy than an identity performative one? (p. 470)
I think the answer is obvious: The theory of autogynephilic transsexualism forces us to confront the fact that both our essential natures and our motives seem to directly contradict our desired ends. We autogynephilic transsexuals want to be women; but the theory tells us that we are not women and that we don’t even resemble women—not in the least. We would like to believe that our desire to be women springs from our need to express some internal feminine essence; but the theory tells us that we have no internal feminine essence and that our desire to be women actually springs from our paraphilic male sexuality. Many of us—I’m a rare exception—want to be recognizably “normal” women with respect to our sexual orientations, which implies sexual attraction to men; but the theory tells us that we are not really sexually attracted to men and never can be—that any attraction to men we seem to feel is illusory and merely another paraphilic fantasy. All of this is in addition to the shame we would inevitably feel even if we accepted some other
theory of MtF transsexualism (such as the feminine essence theory; see Blanchard,
2008
)—shame about our masculinized bodies, our life histories as men, and our inability to experience so many aspects of normal womanhood.
When we autogynephilic transsexuals become aware of the theory of autogynephilic transsexualism and recognize that it describes us, we have several options for attempting to manage our inevitable shame. We can try to face our shame directly, by acknowledging our sadness and our constant vulnerability to humiliation and despair and by pushing our feelings out of consciousness when they threaten to become overwhelming; this is the strategy I’ve tried to adopt. Or we can embrace one or more explanatory beliefs that acknowledge the fact of our autogynephilic arousal but deny its meaning and significance: for example, that autogynephilic arousal is an effect rather than a cause of our cross-gender wishes, is an epiphenomenon, or is a manifestation of normal female sexuality. Or we can simply engage in denial—the most primitive and most effective defense mechanism of all—by convincing ourselves that the theory must
be invalid because it is so offensive to our sensibilities: Following the example of Winters (
2008
), we can reject the theory because it promotes “stigmatizing and dehumanizing false stereotypes” (para. 7) and is “an affront to human legitimacy and dignity” (para. 10). We can even go farther still and set about the emotionally satisfying business of trying to destroy anyone who dares to speak or write in favor of the theory, which manifests as narcissistic rage (Lawrence,
2008
; see also Dreger,
2008
). None of these strategies works terribly well, and some of them cause great harm to other people, but all of them are perfectly understandable responses to our overwhelming shame.
Would there be any way to make autogynephilic transsexualism feel less shameful, or at least make the shame of it easier to bear? I have a few suggestions: First, it might be beneficial if more personal narratives by self-described autogynephilic transsexuals were to become available. Knowing that one is not alone can potentially reduce shame, or at least make it easier to deal with. This book is a modest step in that direction. Second, it might be helpful if a few charismatic, appealing, or eminent MtF transsexuals were to come out as unapologetically autogynephilic and act as role models for the rest of us. Someone of the stature of Kate Bornstein would be perfect in such a capacity, although I have no idea whether Bornstein identifies as autogynephilic. I will say more about unapologetic autogynephilic transsexualism later in this chapter. Third, it might be useful if autogynephilic transsexuals were to create peer support groups—ideally in the real world, but perhaps first in the virtual world—in which autogynephilic persons could share their experiences. Fourth, publication of educational and self-help resources for autogynephilic children and adolescents and their parents would probably be extremely valuable; I will say more about this later in the chapter. Finally, I believe it would be beneficial if those of us who accept the theory of autogynephilic transsexualism were to more consistently describe autogynephilia as a sexual orientation. This would make it easier to talk about autogynephilic transsexualism in a way that might feel less shameful and that others might find more acceptable or recognizable.
Presenting Autogynephilia as a Sexual Orientation
Explaining autogynephilic transsexualism as a paraphilic phenomenon is factually correct, but this approach is not likely to be easily understandable or especially palatable to most audiences. The concept of paraphilia
will be unfamiliar to many people and will sound vaguely psychopathological to many others; once it has been explained, associations with illegal paraphilias will probably be unavoidable. Attempting to explain autogynephilic transsexualism using the trope of “women trapped in men’s bodies” is an even worse approach: Not only is the explanation inaccurate—autogynephilic transsexuals do not closely resemble women—but the trope is probably not genuinely comprehensible to most people, even though it enjoys some cultural currency. People may recognize the words “woman trapped in a man’s body,” but they arguably can’t really grasp the concept; I know I can’t really grasp it.
Almost all adults in Western countries, however, recognize the concept of sexual orientation
, and many know some basic facts: Sexual orientations exist in more than one variety. Sexual orientations are not chosen and are not modifiable—at least not in men. Sexual orientations determine who (or what) we lust after, but also who (or what) we love and want to unite with in long-term relationships (hence the concept of gay marriage, which is generally comprehensible, if not yet generally accepted). Moreover, it is widely understood that people naturally feel strong desires to express their sexual orientations—to act on them.
Autogynephilia has long been conceptualized as a sexual orientation (e.g., Blanchard,
1989a
,
1993a
), but its advocates, myself among them, have not sufficiently emphasized this point. We should arguably use every opportunity to do so. Autogynephilia, we should explain, is another variety of sexual orientation: It is an unusual variant form of heterosexuality. Like other sexual orientations, it is something we autogynephilic transsexuals did not choose and something we cannot change. It certainly determines what we lust after, but it also determines what we love and want to unite with. And we autogynephilic transsexuals understandably feel strong pressure to express and act on our autogynephilic sexual orientations. Could an explanatory model emphasizing sexual orientation really lead to better understanding and greater acceptance of autogynephilic transsexualism? I believe we should attempt to find out.
Am I Really a Transsexual? Or Just a Transvestite?
The question autogynephilic clients in my practice most often want to have answered, whether they express it directly or indirectly, is: “Am I really a transsexual? Or am I just a transvestite?” Usually they hope that receiving a diagnosis could help them decide how to manage their gender dysphoria. In most cases, they have been thinking for some time about undergoing sex reassignment and living as women, but the prospect is daunting, and they remain hesitant. Often they believe that an authoritative diagnosis might decide the issue for them—not an unreasonable idea, given the established principle of Western medicine that diagnosis informs and sometimes dictates treatment. Usually their reasoning goes something like this: “If I’m really a transsexual, then I could—or should, or must—undergo sex reassignment. But if I’m really just a transvestite, then I shouldn’t—it wouldn’t be appropriate. If I’m just a transvestite, I should try to suppress or otherwise manage my desire to live as a woman.” These clients hope that by receiving a diagnosis, they can avoid having to make this difficult decision themselves: The clinician will, in effect, make the decision for them.
I usually try to convey two messages to such clients, neither of which they are typically pleased to receive. First, it is often very difficult, if not impossible, to draw a clear dividing line between transsexualism and less severe forms of gender dysphoria. Usually it is more useful to try to characterize the nature and severity of the gender problem than to try to decide whether a client is transsexual or not transsexual, except in the most obvious cases. Second, even if one were to make a diagnosis of transsexualism, this would not necessarily dictate a particular treatment plan. Some clearly transsexual, severely gender dysphoric autogynephilic men decide not to undergo sex reassignment and are confident that their decisions are correct, given their particular circumstances. Some less clearly transsexual, less severely gender dysphoric autogynephilic men decide to undergo sex reassignment and are very satisfied with their decisions. Autogynephilic gender dysphoric men must confront and answer the existential question: How do I want to live, given that I have an unchangeable paraphilic sexual orientation? Experienced clinicians can help clients reach their decisions, but ultimately the clients themselves must decide. Often the decision is a very difficult one, in part because none of the available options are genuinely satisfactory.
The Existential Dilemma of the Gender Dysphoric Autogynephile
Consider the plight of the man who experiences anatomic autogynephilia and severe gender dysphoria. Since early childhood, he has secretly wished to be a female. He is erotically aroused by women and is also erotically aroused by the idea of being a woman himself. In both cases, however, his feelings go far beyond simple erotic arousal: He admires women, finds them beautiful, adores their bodies, and habitually falls in love with them. He also envies them and wants to have—wants to embody
—all the admirable, beautiful features he loves in them. He wants to live in a body like theirs and lead a life like theirs.
At the same time, he knows that he is not naturally feminine. When he considers the adjectives that describe the women he habitually falls in love with—agreeable, affiliative, cooperative, empathetic, gentle, graceful, nurturant, pliant, tactful, tender—he realizes that most of these adjectives do not describe him. He tends to be competitive, dominant, independent, linear, logical, and tough-minded. He might wish he were more feminine, but his personality is not naturally feminine. When he is honest with himself, he also realizes that he never falls in love with men and only feels attracted to men when he is in the midst of an autogynephilic reverie. He has cross-dressed for years and still does at times, but he finds that it offers him limited satisfaction: Even wearing sexy women’s attire, he still inhabits his unwanted male body and still has his ugly, embarrassing male genitalia. Falling in love with a woman or having sex with a woman sometimes makes his autogynephilic desires go into remission for a time, but these remissions are always temporary: His autogynephilic feelings always return. And every time he has an orgasm, he is reminded of two facts: Having a woman’s body is the most erotic thing he can imagine—and he doesn’t have one.
His circumstances force him to consider the existential question: Could he live a happier, more meaningful, more rewarding life as a woman—as a transsexual woman? Or would he be better off continuing to live as a man? This is a genuine dilemma, because neither option is really satisfactory. Continuing to live as a man would be the easier, less expensive, and safer option: That way he could keep his job, his reputation, his friends, and perhaps his marriage, if he has one. Continuing to live as a man wouldn’t kill him; he has, after all, done it for years. He could continue to live a life of quiet desperation. But he would still experience significant and often severe gender dysphoria, perhaps every day of his life. Eventually he would become an old man who had never tried to live his dream. He knows that what older adults invariably regret is not what they have done but what they failed to do when they had the opportunity. The thought of wasting the only life he will ever have is sad and frightening.
Alternatively, he could pursue sex reassignment. That way, he could at least tell himself that he had tried to live his dream. And, if he were to succeed in some measure, how great would that be? How many people can say that they achieved, in some measure, what they wanted most? If he successfully transitioned, he would finally be playing on the right team, the women’s team; and those awful male genitalia would be gone forever. But he also knows that he would never have a normal life as a woman: He would always be an oddity, albeit perhaps a fascinating or even admirable oddity. And he could easily lose any of the things that currently make his life comfortable and safe: his job, his reputation, his friends, his family. Moreover, the kind of womanhood he could achieve would inevitably be shoddy and inadequate: He would never be able to completely erase the masculinizing effects of testosterone on his body and brain, nor the masculinizing effects of decades of living in society as a man. For an autogynephilic gender dysphoric man to be willing to try to rebuild his life around his paraphilia by pursuing sex reassignment, despite the genuine risks and inevitable limitations involved, he usually needs to be both very brave and very desperate.
The Value of Devaluing Autogynephilia
Probably it is also easier for an autogynephilic gender dysphoric man to pursue sex reassignment if he doesn’t believe in the concept of autogynephilia—or, more accurately, if he holds one or more explanatory beliefs that make his autogynephilic arousal or the autogynephilic underpinnings of his wish for sex reassignment seem more conventional or acceptable. These beliefs function to reassure him and others that his autogynephilic erotic desire to have a woman’s body isn’t the whole story—and isn’t even an important part of the story. What kinds of explanatory beliefs might be reassuring in this way?
One such belief would be that he really has a “woman’s brain” in his male body. Another would be that autogynephilia is not a paraphilia at all but merely a normal element of female sexuality. Yet another would be that he really had been destined to be attracted to men all along, but that his natural inclinations were suppressed by social conditioning and homophobia. Still another would be that the cross-gender fantasies that he found so exciting earlier in life no longer hold any erotic interest for him, but were merely a temporary mechanism for coping with his gender dysphoria. A final such belief would be that autogynephilia is merely an effect of his cross-gender identification, not the cause of that identification.
Personally, I consider such explanatory beliefs to be implausible at best, but I understand their appeal. I remember looking carefully at an MRI scan of my own brain in 1995, hoping to find a feature I could declare to be female-typical—at that time, the splenium of the corpus callosum was still a focus of interest (see Emory, Williams, Cole, Amparo, & Meyer,
1991
)—and therefore use to justify my desire for sex reassignment. I also remember with chagrin a few weeks during which I tried to convince my therapist and myself that I was actually sexually attracted to men. Explanatory beliefs of this kind function to justify or excuse the autogynephilic erotic desire that both animates and seems to discredit our wish to be women. These explanations make us seem to more closely resemble the “classic” MtF transsexual stereotype: feminine from earliest childhood, never sexually aroused by women’s apparel, and romantically inclined toward men. If we embrace these explanatory beliefs, we can say to ourselves and others, “It may be true that I have experienced autogynephilic erotic arousal, but I have other characteristics that make me a recognizable and somewhat more acceptable kind of MtF transsexual: I have a woman’s brain/only get aroused the same way natal women do/was meant to be attracted to men/no longer experience (much) autogynephilic arousal/had a cross-gender identity that preceded my autogynephilic arousal.” In my clinical practice, I rarely see an autogynephilic gender dysphoric man—whether he identifies as autogynephilic or not—who has decided to pursue SRS and doesn’t hold one or more explanatory beliefs of this kind. As the narratives in
chap. 10
demonstrate, even MtF transsexuals who clearly recognize themselves to be autogynephilic often hold these beliefs.
I’m not ordinarily an advocate for self-deception, but if explanatory beliefs like these make it easier for autogynephilic men who are good candidates for sex reassignment to move forward, I’m willing to condone them. Sex reassignment is often a very effective treatment for severe, persistent gender dysphoria in autogynephilic men. Hormone therapy and SRS usually significantly reduce gender dysphoria; satisfaction following MtF sex reassignment is high and regrets are rare (Gijs & Brewaeys,
2007
; Lawrence,
2003
; Muirhead-Allwood et al.,
1999
). But many autogynephilic gender dysphoric men who would probably benefit from sex reassignment decide not to pursue it because they fear that their autogynephilic feelings disqualify them. If implausible explanatory beliefs make it easier for these transsexuals to justify sex reassignment to themselves or others, I’m not inclined to argue too strenuously.
Unapologetic Autogynephilic Transsexualism?
But what about autogynephilic gender dysphoric men who see themselves more clearly and can’t deceive themselves so easily—who know that they are men with a powerful paraphilic wish to become women and cannot pretend otherwise? They are in a more difficult position: They not only have to grapple with their own shame and sadness about being paraphilic men, but they also have to face the potential disapproval of others without being able to pretend to be different than they truly are. It is still not entirely respectable, even in “transgender friendly” settings, to appear to deviate too far from being a classic MtF transsexual. Although I’m not aware of any formal surveys, I suspect that neither the transgender community nor its professional caregivers, much less the general public, would be completely comfortable with the idea of avowedly, unapologetically paraphilic men undergoing sex reassignment and living as women. Thirty or 40 years ago, mental health professionals who specialized in treating gender identity problems used to argue that paraphilic men—autogynephiles—who sought sex reassignment were not acceptable candidates because they were not genuinely transsexual. Nowadays, their successors seemingly want to argue that paraphilic men—autogynephiles—who seek sex reassignment have become acceptable candidates because they are not genuinely paraphilic! Perhaps this is a measure of progress, but the message remains the same: We do not willingly offer sex reassignment to mere paraphilic men.
Some autogynephilic gender dysphoric men, however, cannot deny the uncomfortable truth that our very best gender specialists seem to insist on denying—that they are, without a doubt, paraphilic men. But autogynephilic gender dysphoric men would have to be very brave to pursue sex reassignment while saying openly, without apology: “We are not women trapped in men’s bodies, nor do we bear any close resemblance to women. We are nothing more or less than men who experience a paraphilic desire to become women. Nevertheless, we are committed to becoming the best possible facsimiles of the women we love and admire, despite the fact that we have the minds and bodies of men. We believe that this path offers us our best hope of overcoming our gender dysphoria and achieving the bodies and social roles in which we can live satisfying, fulfilling lives.”
Call me a romantic, but I think this kind of unapologetic autogynephilic transsexualism sounds both courageous and admirable; I hope that it eventually becomes more prevalent. It seems to me entirely consistent with what Person (
1999
) identified as one of the important trends in contemporary Western societies that serve to legitimize what she called “the shared cultural fantasy of transsexualism” (p. 363). Person called this phenomenon:
Self-Realization as a Cultural Ideal. Once upon a time, an individual accepted certain external realities as unalterable. These realities determined his place in society. As historical changes, both technological and social, accelerated, the individual began to believe more in the alterability of his circumstances and ultimately of his person. The question was not whether to adjust to or rebel against reality but how to discriminate between those realities that needed to be recognized as unalterable and those one might change. We now assume that little of external reality is unalterable, an assumption derived in part from our increasingly astonishing scientific advances. (p. 364)
If the existence and meaning of autogynephilic transsexualism were to become more widely recognized and better understood, then this kind of unapologetic autogynephilic transsexualism might eventually become commonplace. I believe that this would be a very good thing.
Solutions Short of Complete Sex Reassignment
There are several different types of autogynephilia, as described in
chap. 6
, but these types usually tend to co-occur: For example, most men who experience anatomic autogynephilia also experience transvestic and behavioral autogynephilia. Moreover, individuals who experience the anatomic form of autogynephilia usually desire to possess all the elements of female anatomy, not just one or two of them. In some cases, however, individuals with anatomic autogynephilia experience little transvestic or behavioral autogynephilia: They are aroused by the idea of having a female body but not by the idea of dressing or behaving like women. And some are aroused by the idea of having women’s breasts or a vulva but are indifferent to having other female anatomic features. Blanchard (
1993b
) called this latter phenomenon partial autogynephilia; narratives by informants who experienced it were included in
chap. 11
.
Moreover, even men who experience anatomic autogynephilia accompanied by behavioral and transvestic autogynephilia sometimes conclude that undertaking complete sex reassignment and living as women would be impossible or impractical. Some of these men have physical characteristics, such as extreme height, that would not only make it impossible for them to move easily through the world as women—even openly transsexual women—but would not allow them to meet their own minimal standards for an acceptable female appearance. Others have familial or social responsibilities that they would be unable to satisfy if they underwent complete sex reassignment and lived as women. Some of these men nevertheless suffer from severe gender dysphoria and believe that making their bodies more closely resemble women’s bodies would ameliorate it.
Autogynephilic men who want to have women’s breasts but do not want to live in a female-typical gender role usually have no difficulty obtaining what they desire. The current Standards of Care (WPATH,
2011
) make it easy for individuals to qualify for and receive feminizing hormone therapy and surgical breast augmentation, even if they continue to live as men. But autogynephilic gender dysphoric men who want to undergo SRS but do not want to live in a female-typical gender role usually have a harder time qualifying for what they desire under the Standards of Care, which specify that having “lived continuously for at least 12 months in the gender role that is congruent with [one’s] gender identity” (WPATH,
2011
, p. 21) is an eligibility requirement for SRS. The vagueness of the language—what does it mean to live in a gender role that is congruent with one’s gender identity if one identifies as a man but desires to have a woman’s genitals?—potentially allows for some flexibility, of course. But, in the absence of a more explicit imprimatur, I doubt that most clinicians would be comfortable recommending SRS for autogynephilic men who want to live as men or feel that they have no choice but to do so. Some narratives in
chap. 6
demonstrate that it is possible to obtain SRS even if one has spent little or no time living in something resembling a female-typical gender role. Nevertheless, there is no unambiguous language in the Standards of Care that explicitly uncouples eligibility for SRS from the obligation to enact any particular gender role.
For most autogynephilic men, living in a female-typical gender role is the most difficult and daunting aspect of the sex reassignment process and is, in my clinical experience, the one most likely to be associated with severe social or economic losses. If some autogynephilic gender dysphoric men would be content to undergo SRS without living in a female-typical gender role—or were to conclude that this would offer the best compromise between managing their gender dysphoria on the one hand and dealing with the external reality demands imposed by their unsuitable male bodies, their obligations to their families, or their need to earn a living on the other—then I believe they should be allowed and even encouraged to do so, assuming they had been carefully evaluated and were able to give informed consent.
Needless to say, this solution is not what most autogynephilic gender dysphoric men really want; it would appeal to only a minority of individuals. But it would arguably do much to help relieve the gender dysphoria of men who experience severe anatomic autogynephilia but are unwilling or unable to live as women. I hope that the Standards of Care will eventually be modified to state explicitly that individuals can qualify for SRS without changing their gender role or gender presentation. If the autogynephilic motivation behind many requests for SRS were more widely recognized, such an outcome might occur more quickly.
Better Treatment for Severely Gender Dysphoric Autogynephiles?
We autogynephilic transsexuals would probably undertake sex reassignment more readily, and surely with greater success, if treatments to help us achieve facsimiles of female bodies were not so mediocre. The inadequacies of existing treatments result from the fact that exposure of our bodies to high levels of testosterone during puberty produces irreversible physical masculinization, primarily involving the bony skeleton but also other anatomic features. Exposure to testosterone results in the development of male-typical facial and body hair, greater muscularity, increased height, increased size of the shoulders, hands, feet, jaw, and parts of the skull (especially the supraorbital ridge), male-pattern scalp hair loss, deepening of the voice and enlargement of the laryngeal cartilage (Adam’s apple), failure to develop a female-typical pelvic shape, and a variety of more subtle changes affecting body habitus. All of these effects of testosterone combine to create an impression of physical maleness.
It is a little-recognized fact that gender attribution is based primarily on the presence or absence of male-typical anatomic characteristics. To decide whether a person is male or female, we look for signs of masculinization, which are almost always signs of exposure to testosterone. If we observe several signs of masculinization—occasionally one sign is enough—we make a male gender attribution. If we observe few or no signs of masculinization, we make a female gender attribution. Signs of femaleness don’t matter much; signs of maleness are what matter. Kessler and McKenna (
1978
) explained:
In order for a female gender attribution to be made, there must be an absence of anything which can be construed as a “male only” characteristic. In order for a male gender attribution to be made, the presence of at least one “male” sign must be noticed, and one sign may be enough, especially if it is a penis. It is rare to see a person that one thinks is a man and then wonder if one has made a “mistake.” However, it is not uncommon to wonder if someone is “really” a woman. The relative ease with which female-to-male transsexuals “pass” as compared to male-to-female transsexuals underscores this point. It is symbolized by the male-to-female transsexual needing to cover or remove her facial hair in order to be seen as a woman and the female-to-male transsexual having the option of growing a beard or being clean shaven. The female may not have any “male” signs. (pp. 158–159).
Consequently, if we MtF transsexuals want to make our bodies appear more like women’s bodies, most of our efforts must be directed toward erasing the signs of masculinization caused by testosterone exposure during puberty.
Unfortunately, it is impossible to completely erase the masculinizing effects of testosterone, and achieving even partial erasure is very expensive and time-consuming. We MtF transsexuals often spend tens of thousands—occasionally hundreds of thousands—of dollars for facial and body hair removal and for reshaping of our hairlines, foreheads, noses, jaws, laryngeal cartilages, and even our vocal cords. All of this is in addition to the expense of SRS. But there is little we can do about our height, our broad shoulders, our narrow pelvises, and our outsized hands and feet. Even our best attempts at reversing pubertal masculinization are inadequate.
In the past two decades, treatment to prevent irreversible masculinization by testosterone has been offered to a few gender dysphoric adolescent boys, mostly those whose gender dysphoria was initially diagnosed in childhood and had persisted into adolescence. This treatment involves the administration of injectable hormones called gonadotropin-releasing hormone agonists
(GnRH agonists), which prevent the pituitary gland from releasing the hormones (gonadotropins) that stimulate the testes to produce testosterone. GnRH agonists have also been offered to gender dysphoric adolescent girls with similar histories, but this discussion will emphasize the treatment of gender dysphoric boys. Treatment of selected gender dysphoric adolescents with GnRH agonists was pioneered in the Netherlands in the mid-1990s, largely due to the efforts of Dr. Peggy Cohen-Kettenis. Eligibility criteria, treatment protocols, and outcomes of treatment have been described in several recent publications (e.g., de Vries et al.,
2011
; Hembree et al.,
2009
; Kreukels & Cohen-Kettenis,
2011
; Zucker et al.,
2011
).
Treatment with GnRH agonists blocks or delays the physical changes of puberty. The goal of treatment is to buy time for consideration of further treatment options. If the patient’s gender dysphoria continues and the patient wants to undergo MtF sex reassignment in young adulthood, feminizing hormones can be administered and female-typical pubertal development will occur. This results in a young MtF transsexual whose appearance is female-typical, with minimal or no male secondary sex characteristics. If the patient’s gender dysphoria desists and the patient wants to live as a member of his birth sex, GnRH agonists can be withdrawn and a male-typical puberty will result; but no patients treated in the Netherlands have ever chosen this option (de Vries et al.,
2011
).
In the Netherlands, where clinical experience with puberty-blocking hormones is greatest, treatment is currently offered only to children in whom there has been “presence of gender dysphoria from early childhood on” (Cohen-Kettenis, Delemarre-van de Waal, & Gooren,
2008
, p. 1894) or “persistent gender dysphoria since childhood” (de Vries et al.,
2011
, p. 2277). A few years earlier, Cohen-Kettenis and Pfäfflin (
2003
) had further advocated that puberty suppressing treatment be limited to adolescents who “throughout childhood … had demonstrated an intense pattern of cross-gender behavior and identity” (p. 145). These requirements—particularly the requirement of intense cross-gender behavior throughout childhood—imply that few, if any, autogynephilic gender dysphoric adolescents would be eligible for puberty-blocking hormones, based on the Dutch criteria. In fact, almost all of the adolescent boys who have recently received puberty-blocking hormones in the Netherlands have been homosexual (de Vries et al.,
2011
) and thus presumably not autogynephilic.
Recently, Zucker et al. (
2011
) reported the Toronto experience in evaluating adolescents with GID for a recommendation for puberty-blocking hormones. Zucker et al. observed that
one criterion used by the Dutch group is a history of gender dysphoria from early childhood on. Yet in clinics such as ours, we see some adolescents with GID who show little or absolutely no evidence of GID in early childhood. … The gender dysphoria appears to emerge, at least in the eyes of significant others (e.g., parents, therapists who have known the patient since childhood) only after the onset of puberty. It is not clear if this late-onset group should be deemed ineligible for early [puberty-blocking] hormonal therapy. (p. 63)
The Toronto group was, in fact, willing to recommend puberty-blocking hormones for some adolescent boys with adolescent-onset GID and a nonhomosexual orientation (K. J. Zucker, personal communication, May 23, 2012). It appears, then, that autogynephilic gender dysphoric adolescents might in some cases be eligible for treatment under the Toronto criteria (which unfortunately were never explicitly set forth), although Zucker et al. noted that a favorable recommendation was more likely “when parent-report indicated more concurrent cross-gender behavior, [and] when patients … recalled more cross-gender behavior in childhood” (p. 71). It is notable, however, that the Toronto patients were evaluated at a mean age of about 17, which is quite late. The adolescent boys in the Netherlands, in contrast, were evaluated at a mean age of about 13 and began treatment at a mean age of about 14. It is possible that autogynephilic gender dysphoric adolescents experience a significant intensification of gender dysphoria and a consolidation of cross-gender identification between the ages of 13 and 17, which would make them appear to be more suitable candidates for treatment at age 17 than they would have appeared at age 13.
Puberty-Blocking Hormones for Autogynephilic Gender Dysphoric Adolescents?
Could autogynephilic adolescents ever obtain approval for and receive the puberty-blocking hormones that would make their lives so much easier if they eventually decided to transition and live as women? Could they obtain approval early enough to make a real difference—at age 13, rather than at age 17? I would like to hope that the answers would be yes, but I’m far from certain.
What would be necessary for an autogynephilic gender dysphoric adolescent to be approved for and receive puberty-blocking hormones? I can think of three obvious preconditions. First, the adolescent would have to come to clinical attention in early puberty. Ideally this would be facilitated by perceptive, well informed parents who would notice and understand the meaning of their son’s cross-dressing—including the absence of any other signs of overt femininity—and arrange for a clinical evaluation in a non-shaming, non-stigmatizing way. Realistically, however, the adolescent himself would probably need to develop some understanding of his problem and overcome his shame and confusion sufficiently to seek clinical attention on his own. At present, neither of these possibilities could be expected to happen very often, given the complete absence of educational and self-help materials for autogynephilic children and adolescents and their parents. On a more positive note, finding a knowledgeable professional to conduct such an evaluation would be much easier than it used to be, at least in major urban areas.
Second, the adolescent would need to display sufficiently intense gender dysphoria. He might also need to report a credible history of significant gender dysphoria or overt cross-gender behavior in early childhood, depending on the criteria used in the evaluation. Intense current
gender dysphoria presumably would not usually be an issue; the fact of the referral would imply this. Documentation of significant gender dysphoria or overt cross-gender behavior in early childhood might be more problematic; often these will not have been present. Consequently, a typical autogynephilic gender dysphoric adolescent probably would have a better chance of being approved under the Toronto criteria (whatever they turn out to be) than under the Dutch criteria.
Finally, the adolescent would have to agree to undergo—and continue to undergo— treatment with puberty-blocking hormones. In some ways, this might be the biggest obstacle of all. Even intensely gender dysphoric autogynephilic adolescents would probably feel some ambivalence about the prospect of future gender transition, which might preclude or at least render more problematic many of the male-typical behaviors and activities they genuinely enjoy, including heterosexual contact. Some of these adolescents might even hold out hope that their autogynephilic orientation might be curable, which would allow them to live as normal men—a vain hope, I believe, but an understandable one.
Moreover, puberty-blocking hormones would inevitably decrease whatever level of testosterone was already present during early puberty, reducing gender dysphoria but perhaps also reducing much of the adolescent’s desire to continue treatment. Recall that some informants in
chap. 9
reported that they lost the desire to continue feminizing hormone therapy after losing their sex drive as a result of testosterone reduction. Of course, many adult autogynephilic transsexuals who begin feminizing hormone therapy do continue treatment, even after complete loss of their sex drives; but these transsexuals have probably developed strong, persistent cross-gender identities that provide an ongoing impetus to gender transition. Docter’s (
1988
) research suggests that such cross-gender identities take years if not decades to develop. Could autogynephilic adolescents develop strong and persistent cross-gender identities more quickly, given the right circumstances—if, for example, they were given the opportunity to cross-dress freely and openly in a supportive, protective home environment? At present, one can only speculate about this possibility.
I’ll briefly share my own experience: I was intensely gender dysphoric at age 14 (this was in 1965), so much so that I overcame my shame and told my parents about my desire to be a girl. I underwent psychiatric evaluation but was offered no real help. At age 16, I began trying to obtain feminizing hormones on my own. I finally succeeded at age 18—too late to prevent male puberty. If I had been offered puberty-blocking hormones at age 14, I might well have started treatment; but would I have continued? Perhaps, if I had had the knowledge and experience I have now; but quite possibly not, given how little knowledge and experience I had then. In 1965, at age 14, I had too much ignorance, too much shame—and too little experience in cross-gender presentation to have developed a strong, persistent cross-gender identity. I imagine that many intensely gender dysphoric autogynephilic 14-year-olds are in much the same position today, despite the passage of nearly 50 years.
Investigating the Developmental History of Autogynephilic Gender Dysphoria
Although sex reassignment is no panacea, it is arguably the treatment of choice for some intensely gender dysphoric autogynephilic adults. If these individuals could be identified before puberty, helped to understand their autogynephilic feelings, and encouraged to take the steps that might make them eligible for puberty-blocking hormones, their adult outcomes might be significantly improved. Whether such improved outcomes would occur is, of course, unknown. Conducting investigations that could help decide the issue would not be easy; investigators would need to address many challenging practical and ethical issues. Before such investigations could even be considered, however, it would be important to know much more than is currently known about the natural developmental history of autogynephilic gender dysphoria in childhood and adolescence.
According to retrospective self-reports, some boys who later become gender dysphoric autogynephilic men remember wanting to be girls or cross-dressing during early childhood; this was described by several informants in
chap. 5
. Sometimes these cross-gender wishes and behaviors were recalled as having been explicitly erotic, sometimes not. Often these feelings and behaviors were never revealed to parents or caregivers, however. If there existed contemporaneous parental reports of the cross-gender feelings and behaviors of autogynephilic boys in early childhood or adolescence—and if there existed self-reports written by autogynephilic boys during middle childhood or adolescence—then researchers would be in a much better position to understand the developmental history of autogynephilic gender dysphoria and to design possible investigational treatment protocols involving puberty-blocking hormones. If such parental reports and self-reports were supplemented by observations by mental health professionals who had evaluated these autogynephilic boys, our understanding would be even greater.
I believe that the key to accumulating such parental reports, self-reports, and clinical case reports would be the availability of educational and self-help resources for autogynephilic children and adolescents and their parents. These resources could play a crucial role in stimulating and informing the process of data collection. Parents of autogynephilic boys need to know what to look for and how to interpret what they see; they also need to know when to seek professional evaluations for their children. Bright, self-aware autogynephilic boys in middle childhood and adolescence need resources to help them understand what they are feeling and what their feelings mean or might mean; they would also benefit from encouragement to write about their feelings and behaviors or document them in audio or video recordings.
Unfortunately, I have been unable to locate any useful educational or self-help resources designed for autogynephilic children or adolescents or their parents. I am forced to conclude that such resources probably don’t yet exist. There are, of course, books written for the parents of overtly feminine gender-dysphoric male children and adolescents (e.g., Brill & Pepper,
2008
; Krieger,
2011
) and even books that contain advice for overtly feminine adolescent males themselves (e.g., Huegel,
2011
). These books are sensitively written and probably helpful to many overtly feminine boys and male adolescents and their parents. These books do not, however, address the circumstances and needs of autogynephilic children or adolescents or their parents. These books never discuss the furtive cross-dressing in the absence of pervasive cross-gender behavior that most autogynephilic children and adolescents display, much less the erotic arousal that usually accompanies cross-dressing and cross-gender fantasies in these children and adolescents. Needless to say, the terms autogynephilia and transvestic fetishism appear nowhere in these books.
I believe there is a serious unmet need for educational resources that provide honest, forthright explanations of the cross-dressing and cross-gender fantasies that autogynephilic children and adolescents engage in and that explicitly discuss the erotic arousal that accompanies these behaviors and fantasies. I understand that it will not be easy to craft language that sensitively but accurately explains to parents what it might mean if their otherwise masculine 6-year-old son likes to put on his older sister’s panties and gets an erection every time he does so, or that explains to 14-year-old boys what it might mean when they masturbate to fantasies of having bodies like those of the attractive girls in their school or wearing their clothes, rather than (or in addition to) fantasies of caressing those girls’ bodies. But, if someone makes the effort and succeeds in creating such educational resources, autogynephilic children and adolescents and their parents will finally have access to information that can help them appreciate the nature and significance of autogynephilia and understand what can and cannot be done about it. Moreover, such resources could eventually result in the acquisition of a great deal of important data about the natural developmental history of autogynephilia in childhood and adolescence. These data could inform investigations that might eventually give selected autogynephilic adolescents access to treatment that could make their later lives as transsexual women much easier and much more satisfying.
Embracing Life as an Autogynephilic Transsexual Woman
Notwithstanding my earlier description of unapologetic autogynephilic transsexualism as a courageous and admirable stance, I’ve painted a rather grim picture of autogynephilic transsexualism overall. I don’t want to minimize how difficult and painful our condition is. We autogynephilic transsexuals have a paraphilic sexual orientation that affects nearly everything about our lives—and usually not in a good way. Although sex reassignment is often the best solution to our problem and sometimes a life-saving one, it is a mediocre solution at best. Our efforts to create the kinds of bodies we want to live in are painful, expensive, and unsatisfactory. We often suffer terrible losses when we undergo sex reassignment and live as women. Once we have done so, we will never again live normal lives. I invariably tell my patients: Do not undergo sex reassignment if you can find happiness and peace in any other way.
If we do decide to undergo sex reassignment, at least we can console ourselves that our lives as transsexual women will probably be easier than those of our predecessors. Before the phenomenon of transsexualism became widely recognized, it used to be that autogynephilic gender dysphoric men who underwent sex reassignment either passed as natal women (if they were very somatically gifted) or were regarded as men pretending to be women. Nowadays, it is also possible to pass as a “good” or “sincere” transsexual woman: as someone who is known or suspected to have once lived as a man but who conducts herself as an appropriate and recognizable social woman. Few if any MtF transsexuals pass perfectly as natal women, but passing as a sincere transsexual woman is not a bad alternative and is an increasingly viable one in many urban areas of the USA and other Western countries.
When we autogynephilic transsexuals decide to undergo sex reassignment, we make the choice to rebuild our lives around our paraphilia—around the strongest feelings we know. Although this is not an easy path, it does offer some rewards. In one of my favorite “guilty pleasure” films from the 1980s, Heartbreakers
(Roth & Weis,
1984
), Peter Coyote portrays a photorealist artist who paints “pin-ups”: depictions of women in fetish gear, with black leather, garter belts, whips and chains, etc. At first his paintings are not commercially successful, but eventually he finds his muse and his works begin to sell. In one scene, he talks about his interest in fetish depiction with a woman friend, explaining with relish, “Ever since I was a little kid I was into it. I found this magazine in my dad’s closet. It was dirty. Forbidden.” His friend scoffs: “That’s not art. It’s fetish.” He replies, somewhat indignantly, “What’s art? Those are the strongest feelings I know. Those are the most powerful images I know. That’s my art.”
In our postmodern world, with no God above and no hell below, many of us believe that the only meanings our lives can have are the meanings we create ourselves. Some of us might even start to think about our lives as extended works of performance art: unrehearsed, largely improvised, site-specific, one performance only. If we adopt this perspective, I think it makes sense to do what Peter Coyote’s character did in the film I discussed: build our art—our lives—around the strongest feelings we know and the most powerful images we know. For most of us autogynephilic transsexuals, the strongest feelings we know and the most powerful images we know involve ourselves as women. We honor those feelings and images and give them a central place in our lives when we choose to undergo sex reassignment and live as women.
It is also possible to think about the transsexual journey as a kind of spiritual path. We autogynephilic transsexuals strive to become womanly in our bodies, but we can also strive to become womanly in our personalities. The feminine personas we create in the process of sex reassignment function as integral elements of the extended works of performance art that are our lives. We create our feminine personas by trying to express and embody the feminine virtues, whatever we think these are. For me, they include gentleness, nurturance, empathy, agreeableness, cooperation, friendliness, and grace. These qualities do not describe how I am naturally, but they describe the way I want to be and try to be; as such, they define a spiritual path that I attempt to follow. To try to express and embody these feminine virtues in our everyday lives makes us better people—especially if we have spent most of our lives expressing the kind of nerdy masculinity that values things over people, emphasizes competition over cooperation, and sometimes alienates us from our emotions and from other people. The transsexual journey is, in this case, less about finding our “true selves” than our best selves. Autogynephilia is a paraphilic sexual orientation, but it is possible to build a satisfying, passionate, spiritually fulfilling life around it—a life very much worth living.
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