Lessons from Autogynephiles: Eroticism, Motivation, and the Standards of Care

By Anne A. Lawrence, M.D.

Presented at the 16th HBIGDA Symposium, London, UK, August 18, 1999.

It is an honor to appear before you today. Four years ago, I was still living as a man, struggling to make my life conform to the Standards of Care, in order to obtain the physical feminization I so desperately desired. To stand before you as a colleague, addressing the organization that promulgates those Standards, is an occasion for intense reflection.

One of my research interests involves the personal narratives of male-to-female transsexuals who feel that traditional ideas about transsexuality do not accurately describe their experiences and motivations. On Friday, I will be presenting a detailed look at the stories of these supposedly "atypical" transsexuals. Today I will share only a few highlights from their narratives, as they pertain to some problematic aspects of the Standards of Care.

I should explain that I will be using the term "transsexual" in its most literal sense, to mean one who desires to approximate as closely as possible the anatomic characteristics of the opposite sex. Note that the word "gender" does not appear in my definition. This reflects my belief that transsexuality is fundamentally about changing one's anatomy or sex and that sometimes it may have little to do with gender identity or gender role.

My message today is that some biologic males who pursue sex reassignment do so, not primarily because they have a gender problem, but because they have a sex problem, and indeed a sexual problem. I will explain why I have come to believe that male-to-female transsexualism is sometimes the expression of a paraphilia -- an unusual or variant pattern of sexual arousal. I will share the comments of several male-to-female transsexuals who agree that their transsexualism can be accurately understood as representing a paraphilia.

I will explain why I think sex reassignment provides an elegant solution to the existential problems posed by paraphilic transsexualism -- why it makes sense pharmacologically and psychologically. Finally, I will challenge you to consider that if transsexualism is sometimes more a sexual problem than a gender problem, then sex reassignment therapy could be, and arguably should be, independent of gender presentation. Specifically, I will propose that the Real-Life Experience should merely be one optional element of transsexual therapy and that some transsexuals should be allowed to undergo hormone therapy and sex reassignment surgery without a full-time Real-Life Experience.

As you may imagine, I've done a great deal of reading about transsexualism over the past 30 years. But among all the books and papers I've read, one article stands out as having most influenced my thinking about transsexualism. When I first read it in 1994, I experienced a kind of epiphany.

This article's initially unpromising title was "Clinical Observations and Systematic Studies of Autogynephilia." It was written by Ray Blanchard, a clinical psychologist at the Clarke Institute in Toronto.

Blanchard's term "autogynephilia" may be new to some of you. It is derived from Greek, and literally means "love of oneself as a woman." Blanchard formally defined autogynephilia as "the propensity to be sexually aroused by the thought or image of oneself as a woman." His research with hundreds of transsexual subjects led him to conclude that males who seek sex reassignment often do so because they are sexually aroused by idea of being female, or becoming feminized. They seek sex reassignment as a way of accommodating their paraphilia -- which is, in effect, their sexual orientation.

Blanchard published nearly a dozen papers exploring the role of autogynephilia in the lives of biologic males seeking sex reassignment. In his "Clinical Observations" paper, he wrote the following:

"Autogynephilia takes a variety of forms. Some men are most aroused sexually by the idea of wearing women's clothes, and they are primarily interested in wearing women's clothes. Some men are most aroused sexually by the idea of having a woman's body, and they are most interested in acquiring a woman's body. Viewed in this light, the desire for sex reassignment surgery of the latter group appears as logical as the desire of heterosexual men to marry wives, the desire of homosexual men to establish permanent relationships with male partners, and perhaps the desire of other paraphilic men to bond with their paraphilic objects in ways no one has thought to observe."
I think this is one of the most brilliant and insightful analyses in the entire clinical literature devoted to transsexuality. Certainly it spoke to my own experience like nothing I had ever encountered before. It was enlightening and empowering to discover that someone thought feelings of sexual arousal to the idea of having a woman's body were consistent with genuine transsexualism -- and that they provided a logical rationale for seeking sex reassignment.

As I discussed Blanchard's theory with colleagues, I discovered two surprising things. First, his theory was not widely known. Second, many of those who did know about it thought it was not so much wrong as heretical. The intensity of their reactions was astonishing. It was as though thinking about transsexualism as a sexual problem involved such a paradigm shift that it frightened people.

However, I also discovered that Blanchard was not the only clinician who conceived of transsexualism as sometimes representing a paraphilia, or an unusual erotic preference. Clinicians such as Buhrich and McConaghy; Wilson and Gosselin; Jon Meyer; Freund, Steiner, and Chan; Christie Brown; and Abel and Osborn had come to similar conclusions.

About a year ago, I wrote an article summarizing Blanchard's autogynephilia theory. I publishing this on the Internet, and in a magazine called Transgender Tapestry. In my article, I solicited narratives from any transsexuals who recognized autogynephilic feelings within themselves. I was curious to see whether transsexuals from a nonclinical population would report feelings and experiences consistent with Blanchard's ideas.

I have thus far received over 100 narratives. I will share only a few highlights from these today. I think these accounts provide a fascinating window into some little-discussed aspects of the transsexual journey.

Virtually all my transsexual respondents freely acknowledged that they were sexual aroused by their feminization. Virtually all thought that Blanchard's concept of autogynephilia accurately described them. Many admitted that autogynephilic sexual feelings had played a significant part in their decisions to seek sex reassignment. However, they were often unwilling to disclose this fact to their caregivers. Here are some representative comments:

"I am seven months post-operative. I was extremely autogynephilic, but thought I was the only person who felt this way, so I kept quiet about it. My fantasies were of my feminization, which still continue, despite not having testosterone."

"The definition of autogynephilia describes me perfectly. Feminizing my body has always been sexually exciting for me -- even after SRS. However, I never explained this to my therapist, fearing he would not support my planned SRS."

"The central themes of my erotic fantasies were my becoming female and having sex with women as a woman. I knew the psychiatric community would view me as a transvestite. So, I suppressed that information. I am six months post-op now, and still get sexually aroused when I think of the transformation that I just completed."

It may seem surprising that transsexuals are willing to admit that they have a paraphilia. I believe my respondents' candor reflects their relief at learning that they are not alone, and that there is a theory that speaks to their experience. They are gratified that someone has recognized the enormous risk they have taken, in order to integrate their sexuality with the rest of their lives. Their path is risky because at present, there is no medically approved script for seeking sex reassignment as a way of dealing with paraphilic eroticism.

But I think that there should be such a script -- such an acknowledged pathway. Sex reassignment is a logical and effective treatment for paraphilic transsexuality. It can help transsexuals simultaneously express and control their paraphilia, by creating desired feminization, and by moderating ego-dystonic paraphilic arousal. I believe we must begin to look at sex reassignment as a form of sex therapy for this sexual problem, in addition to its accepted role as a treatment for gender identity problems.

One of the most effective ways to treat any paraphilia is to lower testosterone levels. That is why we treat paraphilic sex offenders with antiandrogen medications. Lowering testosterone does not change the direction of paraphilic sexual desires, but it reduces their intensity. Transsexuals often report that their paraphilic sexual feelings can be oppressive, and ego-dystonic. Hormone therapy and genital surgery makes these sexual feelings less painfully intrusive. My respondents often welcomed the reduction in paraphilic arousal resulting from hormone therapy and SRS. Here are two representative comments:

"I asked [my doctor] whether she could give me anything to stop my strong sexual feelings. My compulsion to [cross]dress did not alter -- just my sex drive, which I hated anyway."

"My sexual urges have virtually disappeared since surgery. I hope I get horny again, but I am very happy not to be as driven as I once was."

What about the role of the Real Life Experience in autogynephilic transsexualism? While autogynephilic transsexuals all share a desire to feminize their bodies, I believe they run the gamut in terms of their desire to actually live full-time in female role. Some are obviously eager to live in role, particularly if they can pass reasonably well. Others may find that living in female role works "well enough" for them, even though it may not be their primary motive for transitioning. Still other transsexuals may have little or no desire to actually live full-time as women. Perhaps for some, living in role is not erotically interesting; but more commonly, it is because the practical difficulties simply seem too great. However, transsexuals sometimes acquiesce to living in role, simply to qualify for the hormones and genital surgery they so desperately desire. One of my respondents expressed this sense of resignation in an entry from her diary:
"How sure am I that this is what I want? God knows. I've chickened out before, but I really want to be a woman with breasts and a vagina. I guess I'll have to accept everything else that goes with it. Is this the same as feeling like I am a woman trapped in a man's body? -- possibly not."
To decide to transform one's body, and consequently to accept "everything else that goes with it," is an act of existential courage. It is an admission that the body and sexuality can sometimes be so important that they must be allowed to determine everything else. Individuals who undertake this path essentially rebuild their lives around their paraphilia. In this sense, they may be comparable to "life-style" practitioners of other paraphilias, such as BD/SM. Of course, we should remember that building one's life around one's sexuality is not exactly unknown among persons with more "normal" erotic preferences. Among heterosexuals, it's called "marriage."

Unfortunately, living as a woman is not always easy for biologic males. This is particularly true for those who are unable to pass well -- and especially for those unable to pass at all. These individuals may be desperate to feminize their bodies, but find the requirement of living full-time as women is simply too arduous. Some may need to preserve significant relationships. Some may fear for their personal safety. Some may need to keep their jobs. If we believe that transsexualism is simply about gender, and that genital surgery is simply "gender confirmation surgery," then individuals who cannot or will not live full-time in role are condemned to suffer -- they do not fit our paradigm. And suffer they do. Here is what one respondent wrote:

"I am 43 years old, and I consider myself a transsexual. I want to have a woman's body. For some periods of my life I have lived with less pressure about my transsexualism, but now it is getting very strong. I feel helpless. I have found a surgeon who will perform the surgery for me, and I would live as a man afterwards. I am considering this. I want to transition to live as a woman, but my family situation won't allow it. The pain I feel inside is unbearable sometimes. If I transitioned fully, my wife whom I love would leave me. I have prayed that God would change our bodies -- my wife says she wouldn't care."
But -- if we accept that transsexuality sometimes represents a paraphilia, then other possibilities suggest themselves. If transsexual patients cannot undertake a full-time gender transition, is that any reason to deny them effective treatment for their sexual problem? I contend that it is not. Carefully selected individuals should be allowed to receive hormone therapy and genital surgery without a full-time Real-Life Experience. Our insistence on linking somatic treatments to a particular kind of full-time gender presentation reflects only tradition -- not science. There is in fact no experimental evidence that a full-time Real Life Experience is necessary or desirable prior to SRS. It is merely a tradition that has been enshrined as fact.

Insightful and compassionate therapists are already bending the rules, to help selected patients undergo hormone therapy and sex reassignment surgery without a full-time Real-Life Experience. It is time the Standards of Care gave this humane treatment the legitimacy it deserves. Here is what one of my respondents wrote:

"To protect people from unwise decisions, I truly hope that there will always be a waiting period with intense therapy before SRS. But I hope the fact that someone does not choose to live as the opposite sex is not held against him or her. If I were 5'7", 135 lbs., and a size 12, things might have been different for me -- but I am not. I would never be accepted as female, regardless of what I did. Rational thought should prevail. People should not have to destroy their entire lives, families, friends, jobs and the like, to have what is between their legs changed to fit their self- image."
I couldn't agree more - and I hope many of you will agree as well.

To summarize briefly: When offered anonymity, some male-to-female transsexuals will confirm what astute clinicians like Blanchard have known for years. They will freely admit that their desire to change sex is an outgrowth of their paraphilic sexuality. The lesson we can learn from autogynephiles is that transsexuality is often a sexual problem -- with or without an associated gender problem. Hormones and genital surgery are an effective treatment for autogynephilic transsexualism, because they allow paraphilic sexual desires to be simultaneously expressed and controlled. If we recognize that transsexualism is sometimes the expression of a paraphilia, we can reframe our therapeutic efforts, so that perhaps one day soon we can offer sex therapy with hormones and genital surgery to persons unable to undertake a full-time Real-Life Experience. This will help us end unnecessary suffering.

I'll close with a quotation from one of my respondents, which expresses my views succinctly:

"When we let go of the dogma of a 'core gender identity' that inevitably needs to be lived, and look at things like autogynephilia, we get a more differentiated picture of transsexuality -- one that offers many starting points for therapy, and alternative solutions."
Thank you.

© 1999 by Anne A. Lawrence, M.D., Ph.D. All rights reserved.