Presented at the 16th HBIGDA Symposium, London, UK, August 20, 1999.
Those of you who attended the TS Professional Panel on Wednesday will already know some of the background to this talk. Like several other presenters this week, I have been interested in studying personal narratives as a means to understanding. I have been collecting the personal narratives of male-to-female transsexuals who by their own reports do not conform to traditional ideas about transsexuality. On Wednesday, I shared a few highlights from these narratives, along with my personal reflections on their implications for the Standards of Care. Today I will present the contents of these narratives in greater detail.
My respondents are persons who feel that "classic" transsexual narratives do not accurately describe their experiences and motivations. Typically they do not see themselves as having been "women trapped in men's bodies." Rather, they are -- or were -- men who desperately wanted to be women. That is why I refer to them, somewhat tongue in cheek, as "men trapped in men's bodies."
I should again make clear that I use the term "transsexual" today 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" nowhere appears in my definition. I am interested in the experiences of persons who want to change their anatomy, or sex; and I think it best to make no assumptions about how much that desire relates to gender identity, or gender role.
I will be reporting what transsexuals themselves have to say about the theory, put forth by Ray Blanchard and others, that transsexualism sometimes represents a kind of paraphilia, and that some transsexuals' desire for sex reassignment arises from their need to accommodate their paraphilic wish for feminization.
Please note that I use the term "paraphilia" in a purely descriptive sense. If any of you find its implications too pejorative, I invite you to substitute the phrase "sexual orientation" in its place -- because that is all a paraphilia really is.
Clinicians have long been aware that males who seek sex reassignment constitute a diverse group. Over twenty-five years ago, Laub and Fisk recognized that diversity in their formulation of the so-called "gender dysphoria syndrome" -- which they might more accurately have called the "sex dysphoria syndrome." They noted that applicants for sex reassignment frequently included persons who did not conform to that era's definition of the "classic" transsexual -- for example, persons with a history of transvestic fetishism.
However, over the years, the professional community gradually became comfortable with the idea that males with a history of sexual arousal to crossdressing or cross-gender fantasy could be "legitimate" transsexuals. This was based on the belief that such transsexuals often "outgrow" their paraphilic sexuality, and develop or discover a true feminine gender identity. The paraphilic arousal once displayed by these individuals could be overlooked because a) it was all in the past, and b) these persons now displayed a genuine, non-paraphilic desire to live in the gender role of the opposite sex.
One clinician who challenged this explanation was Ray Blanchard, a clinical psychologist at the Clarke Institute of Psychiatry in Toronto. He conducted research with hundreds of biologic males seeking sex reassignment, and was particularly interested in their sexual orientation and eroticism. He discovered that roughly half his subjects, who typically resembled "classic" transsexuals, were primarily sexually attracted to men. The other half, who were usually older, and less consistently feminine, might give histories of either heterosexuality or bisexuality -- but they were primarily aroused sexually by the idea of themselves as women, or as feminized persons. Blanchard believed that these later individuals essentially had a paraphilia.
Blanchard coined the term "autogynephilia" to describe their pattern of sexual arousal. The term "autogynephilia" literally means "love of oneself as a woman." He defined it formally as "the propensity to be sexually aroused by the thought or image of oneself as a woman."
Blanchard's observations contradicted the idea that these applicants for sex reassignment had "outgrown" their paraphilia -- in his subjects, paraphilic arousal was still very much alive. But Blanchard went further still. He proposed that autogynephilia was not an incidental finding, but was in fact the primary motivation for his subjects seeking sex reassignment. Here again is what he wrote:
"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."Last year I wrote an article summarizing Blanchard's theory of autogynephilia. I published 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 wanted to see whether transsexuals from a non-clinical sample would report feelings and experiences consistent with Blanchard's ideas.
I have thus far received over 100 narratives. I have analyzed about 60 of these from persons who seemed to be genuinely transsexual. I have no illusions that my respondents are representative of transsexuals generally, or that their reports can be objectively verified. In fact, I suspect that complete anonymity is probably a prerequisite for obtaining such candid narratives. I do suggest that many of the accounts show remarkable psychological insight, and that they provide a fascinating window into some little-discussed aspects of the transsexual journey.
Virtually all of my respondents freely acknowledged that they were sexually aroused by feminization, and thought that Blanchard's concept of autogynephilia accurately described them. Here are some representative comments:
"The definition of autogynephilia describes me perfectly. Feminizing my body has always been sexually exciting for me -- even after SRS."Many of my respondents confirmed that autogynephilic sexual feelings had played a significant part in their decisions to seek sex reassignment. Here are some typical comments:
"The description of anatomic autogynephilia comes closer to my own personal experience than anything I have ever read on the subject of transsexuality."
"I have often expressed to others that this is the 'dirty little secret' of transsexuals. Yes, I had fantasies of 'acquiring' a feminine body, and, yes, they were erotic."
"I find [my] own transsexualism to be the continuing culmination of many erotic fantasies. I want to thank you for expressing the importance of the 'sexual' in transsexual."Some of my respondents had, at one time, doubted that they were "really" transsexual, because of their feelings. Here is a representative comment:
"[The] erotic impulse created by the desire to be and live as a woman has probably been an important factor in my transition."
"I think the increasing pervasiveness of [my] sexual fantasies has contributed to my decision to transition."
"I think that autogynephilia is why a lot of MtF's initially feel (as I did) that they are not really TS. You shouldn't enjoy these thoughts, and if you do, then you're not really TS."Sometimes my respondents had imagined they were unique in experiencing autogynephilic arousal. These are two typical comments:
"I thought I was the only person who felt this way."My respondents were often unwilling to disclose their autogynephilic feelings to their caregivers, because they believed they would not be seen as "real " transsexuals, and might not be approved for SRS. Here are two examples of what they said:
"Until I started reading the comments of others, I thought I was alone or crazy."
"To date I have not told anyone else about this. I have a strong desire for SRS and do not want to jeopardize my chances by appearing in any way skewed from the 'classic' TS profile."Several of my respondents volunteered that autogynephilic imagery was obligatory for sexual performance. This suggests that their autogynephilia was not an incidental finding, but was a fundamental aspect of their sexuality. Here are some representative comments:
"I didn't bring it up because I wanted SRS. I figured out early on that I had to present what they wanted to see, not what I really was. I had no belief at all that I could get approval without lying, so I lied."
"From my very earliest masturbatory experiences, I have exclusively used this type of 'becoming female' fantasy for arousal. I was married for approximately 5 years, [and] I would always use feminization fantasies to achieve orgasm."My respondents often reported that their autogynephilic eroticism continued after SRS. Again, this suggests that autogynephilia was not just an incidental consequence of their desire for reassignment, but was a more enduring aspect of their sexuality. Here are three representative comments:
"Arousal, whether in intercourse or masturbation, was only possible when I imagined I was female."
"The only way I could have an orgasm was the thought of forced feminization, and the visualization that I was a woman."
"I am seven months post-operative. My fantasies were of my feminization, which still continue, despite not having testosterone."There was one way in which some of my respondents' stories were less consistent with Blanchard's ideas about autogynephilia. If the desire for sex reassignment is indeed an outgrowth of these persons' autogynephilia, then we would expect autogynephilia to appear first, with cross-gender wishes appearing only later. But some of my respondents who freely acknowledged autogynephilic arousal reported that they had experienced cross-gender wishes long before their autogynephilia became evident. Here are two typical comments from this group:
"Wearing women's clothing and feminizing my body has always been sexually exciting for me -- even after SRS. I am still sexually excited knowing that my urination process is just like a woman's."
"I am six months post-op now, and still get sexually aroused when I think of the transformation that I just completed."
"I am almost 100% sure that my desire to be a woman is more established than [my] autogynephilia. The former has been rather stable since the age of six, whereas I don't recall any remotely autogynephilic fantasies before the age of 20."It is hard to know whether accounts like these are accurate, or are simply retrospective re-writings of early memories to agree with accepted notions about transsexualism. I believe that we must at least consider the possibility that autogynephilia can, in different individuals, be either the cause or the effect of a desire for sex reassignment.
"I don't think that autogynephilic sexuality is the reason I am transsexual. I think it is a symptom of my transsexualism. I had my first feelings of wanting to be female around the age of 3-1/2. It was only after puberty that autogynephilia began to display itself."
There was one other way in which some of my respondents' stories did not completely agree with Blanchard's theory. Autogynephilia was not confined solely to those with a history of heterosexual or bisexual arousal. One or two persons who were apparently exclusively androphilic - - attracted only to men -- also reported autogynephilic eroticism. Perhaps this should not surprise us, since in non-transsexuals, too, paraphilias can coexist with both homosexuality and heterosexuality.
Overall, my respondents' narratives provide substantial support for Blanchard's theory of autogynephilia. What are the implications of these narratives for the clinical care of transsexual clients?
First of all, they should make us aware that paraphilic eroticism is widespread in male-to-female transsexuals. Furthermore, in many individuals, autogynephilic eroticism is not just an incidental finding, but is rather the central motivation for the transsexual journey. However, our clients are not likely to reveal their autogynephilic desires unless we convey our understanding, and our acceptance. If we make it clear that we regard paraphilic arousal to feminization as consistent with genuine transsexualism, then our clients will probably tell us the truth. But if we cling to the outmoded idea that transsexualism is simply about gender, and that it has nothing to do with sex, then our clients will simply tell us precisely what we want to hear -- just as they have done for decades.
We must let our clients know that we understand that sex reassignment can be a logical and effective treatment for autogynephilic transsexuality. Sex reassignment can help autogynephilic transsexuals simultaneously express and control their paraphilia, by creating desired feminization, and by moderating ego-dystonic paraphilic arousal. If we can look at sex reassignment as a form of sex therapy for the sexual problem posed by autogynephilic eroticism, then we can treat our clients with greater empathy, and with greater effectiveness.
© 1999 by Anne A. Lawrence, M.D., Ph.D. All rights reserved.