The Little Case Study that Autogynephilia Forgot

(a discussion specific to Dr. Ray Blanchard's model of autogynephilia, and not so much to people who identify as autogynephile because they feel it's a close representation to their identity. This is a draft response to the proposed DSM5 changes, in this case specifically to the diagnosis of Transvestic Fetish / Disorder, which I see as the most urgent part to address from the trans spectrum -- Mercedes)

Everyone has a sexual identity, some mental image of themselves, to take their place in their fantasies. That sexual self-identity might be more buff or more sultry, might be more muscled or more busty… they never seem to conform to our physical reality. It’s just a diversion, after all. There’s no shame in it. Unless you have a male body and are picturing yourself as female – then, you’re considered mentally ill. The sexual arousal of a male who pictures himself as a woman is increasingly being labeled “Autogynephilia,” and as of 2010, is proposed to be written into the Diagnostic and Statistical Manual (DSM) as one of two subcategories of Transvestic Fetish (TF, to be renamed “Transvestic Disorder”).

There have been a large number of questions about whether non-damaging consensual sexual activity should be pathologized to begin with, and the revisions to the DSM proposed in 2010 attempt to make a distinction between “paraphilias” and “paraphilic disorders.” Thus the paraphilias sub-group (led this revision by Dr. Ray Blanchard) still gets the juicy job of defining what “normative” and “non-normative” sexual behaviours are, while still apparently limiting diagnosis-to-treatment paths to those times when the behaviours cause distress or impairment, or hurt others -- a paraphilic disorder. Distinctions can be important.

Starting in the mid 1950s, Dr. Evelyn Hooker started collecting data about homosexuals, having realized that there was a marked difference between those who’d reached self-acceptance and those who sought treatment – that homosexuality itself was not a mental health issue, only the distress wrought by societal stigma. In the late 1960s, this sentiment slowly grew among select therapists who’d realized that people coming to them to deal with their struggles with guilt were only a part of a larger, healthier picture. Although political pressure is often credited with the removal of homosexuality from the DSM in 1973, this slow realization also helped fuel the decision.

This is a distinction that Dr. Blanchard, the father of Autogynephilia, would do well to remember, as he is developing a theory about crossdressers while studying both transvestites and transsexuals, and hopelessly conflating the two because of the imbalance between those who he sees seeking treatment, versus those who don’t.

Transsexuals are currently catalogued in the DSM as having Gender Identity Disorder (GID, which is proposed to be renamed Gender Incongruence), which oversimplified is a sense of being a gender opposite their birth sex. More and more, we’re coming to realize that there is something very real to transsexual identities, whether or not we believe or are familiar with the accumulating medical studies that demonstrate a likelihood of a biological origin or biological component of transsexuality. ¹ I tend to believe that transsexuality and many other transgender identities have a similar cause, but are mostly separated by the degree that cross-gender identification is experienced – transsexuals have totally oppositive cross-gender identification, while someone who crossdresses or fits in more as bigendered or genderqueer might have a less intense or dual-gendered identification. Someone who is further away on the scale and is a non-tactile transvestite may have a cross-gender identification that is submerged to the point that it only surfaces in sexual fantasy (although I don’t know enough about transvestites to know if this is the case for all or some). But while a difference in degree, it is a difference nonetheless.

Dr. Blanchard conflates transsexuals with crossdressers because he refuses to accept transsexual identities as valid, referring to post-operative transwomen as men without penises.² But because transsexuals comprise the majority of patients seeking treatment (because GID provides a framework through which they can obtain hormones and surgery, while it’s mostly only crossdressers struggling with shame who will ever seek treatment) and because of a refusal to accept transwomen as women, it becomes easier to equate the two. Indeed, at times Blanchard seeks to annex transsexuals (particularly those who are not solely androphilic / attracted to men), including this recent footnote in his rationale for the proposed changes to TF / TD: “As a practical matter, the autogynephilic type seems to have a higher risk of developing gender dysphoria. This was confirmed in a secondary data analysis reported by Blanchard (2009c).”³

Because of the existence of the two diagnoses (TF and GID) and some lack of clarity in the concept of Autogynephilia as to where the division lies, it becomes necessary to provide some kind of differentiation, and Blanchard misplaces this by dividing patients by sexual orientation (“homosexual transsexuals” versus “autogynephiles,” to simplify) – in other words, you’re either gay and want to change your body so you can be straight, or you want to change your body because you get turned on by the thought of being a woman. In reality, transsexuals are often neither ashamed of their sexual orientation (whatever it may be), nor motivated by arousal (otherwise, male-to-female hormone therapy would be very self-defeating!), so this misconception could easily be dispelled just from listening to transsexual experiences. In the transsexual community, a clear understanding has developed that transsexuality is about who we are, not who we love, and consequently a transsexual might be attracted to a man, a woman, or both. In the transsexual community (by my observation over the years, anyway), the intensity in which trans identities are experienced does not appear to vary in any significant discernible way purely according to sexual orientation.

Transvestic Disorder (where Autogynephilia is proposed as a subcategory) also has the unique distinction of being the only paraphilia (possibly the only psychiatric disorder?) that is exclusive to one gender. In the proposed revisions, TF / TD is still defined as recurrent sexual fantasies by a male of having a female body.⁴ Besides overlooking possible male sexual identities in the female-bodied and/or women who crossdress, studies being done related to autogynephilia fail to include control groups of cisgender (non-transgender) women, making it impossible to know if the difference between a cisgender woman who occasionally dresses up and feels a bit of self-excitement mingled with anticipation and a transvestite who gets turned on by crossdressing (and not all crossdressers do) stems mostly from the different amounts of testosterone produced by the body. Ultimately, the cisgender woman becomes the little case study that autogynephilia forgot, and with this absence, it is impossible to see “autogynephilic” female sexual identity in context.⁵

When it comes to defining Autogynephilia, it becomes all about sex fantasies. Several years ago, I had been diagnosed with Gender Identity Disorder. I have transitioned and am accepted as female in my everyday life. Given the wrong therapist, I could have been diagnosed with TF / TD instead. After all, in my pre-transition sexual fantasies (upon which the diagnosis of TF / TD hinges), I’d always been female… just as in every other moment of self-identification in my life. After all, what else would I be? I could never make enough sense from forcing myself into a male identity (sexual or otherwise), so arousal was impossible without a female sexual identity. But the thought of being female was not of itself a cause of arousal. Distinctions are important. I would think it would be much the same for any cisgender woman. The framework of autogynephilia makes it possible or even likely that one can observe female self-identification in someone who is male-bodied, and assume causality when it's simply a reflection of a deeper problem.

The diagnosis of GID has traditionally taken into account a spectrum of people who experience gender variance, but the revision clarifies by indicating treatment only for those who feel distressed by their bodies enough to need to change them to reflect their identification as fully male or female.⁶ Distinctions are important. However, this puts Transvestic Fetish and Gender Incongruence in a position of competing to be applied to overlapping groups of people, creating a quandary for the therapist. This has the potential of being resolved entirely by the therapist’s own bias, hinging on whether he or she accepts transsexuals as being genuinely the gender to which they identify, or whether he or she considers this to be fantasy... or for those therapists in between, it will depend on what criteria they will settle upon to determine which identities are “real” and which are not. For any who doubt this, keep in mind that this has largely been the practice for years of the Centre for Addictions and Mental Health (CAMH), where Blanchard is the Head of Clinical Sexology Services. At CAMH, it appears that only transsexuals who are at risk of harming themselves and “autogynephiles” who are at risk to themselves because of the distress and anxiety caused by societal stigma are approved for surgery – and then, only after several years of therapy. The mere admission of a female sexual identity that I’d made above (combined with bisexuality) would have resulted in a diagnosis of autogynephilia in a CAMH framework, regardless of the context I’d given it.

Having two potentially overlapping and competing diagnoses is duplicitous, especially when one (GID / GI) has a long history of study and proven track record for positive outcomes, while the second (TF / TD) integrates a theory that is highly controversial, depends on studies often described as unrepeatable by other researchers,⁷ and rings so untrue with the communities most at risk of the diagnosis as to generate enormous vitriol that has been leveled at the proponents of the theory. When it comes right down to it, most people in the trans community do realize that Blanchard and his network of supporters sincerely want to help people, but react to the harm we feel being caused by their misguided attempts to do so.

Distinctions are important.

And returning to Transvestic Fetish / Transvestic Disorder, if we take transsexuals completely out of the equation, then we return to the question of whether mere crossdressing (along with consensual BDSM and a number of other things classified as paraphilia, except for when they affect minors or cause harm) really need to be categorized in the DSM, or (like homosexuality prior to 1973) if researchers are only seeing a part of the equation based on a circumstantial bias in the types of patients they typically see.

With the exception of behaviours that involve minors or cause harm, it's time to look at the depression, anxiety and distress caused by societal stigma as being depression, anxiety and distress caused by societal stigma, rather than giving causal status to and targeting treatment for a sexual or gender identity.

Of course, I don't speak for the whole transgender community (as nebulous as that concept can be). Trans encompasses an enormous set of diverse identities, and there are in fact even a few who do identify as autogynephile (although with the high-profile exception of Dr. Anne Lawrence, even many self-identified autogynephiles take issue with how autogynephilia is defined and treated clinically⁸). I speak as an individual who has been through treatment for GID and would be considered one of its many success stories. I also speak as someone who has been involved in trans communities for years, learned a great deal about varying perspectives (including crossdressers, who are an extremely varied crowd) and while I know I can't speak for all of them or claim for certain that my answers represent a majority opinion, I can say that I've heard a great deal of concerns made regarding the proposed subcategory of Autogynephilia and the diagnosis of Transvestic Fetish.

-- Crossposted on DentedBlueMercedes --

References:

1. Including (and covering a range of theories / phenomena):

Sexual differentiation of the human brain in relation to gender identity and sexual orientation D.Swaab & A.Garcia-Fulgaras Functional Neurology, Jan-Mar 2009

http://www.ncbi.nlm.nih.gov/pubmed/15724806,

http://www.nature.com/nature/journal/v378/n6552/abs/378068a0.html,

http://weblogs3.nrc.nl/swaab/2009/04/03/the-atypical-brain-development-of-transsexuals/,

http://www.ncbi.nlm.nih.gov/pubmed/15177706?ordinalpos=26&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum,

http://forum.mesomorphosis.com/mens-health-forum/prenatal-exposure-diethylstilbestrol-des-134253671.html

2.Armstrong J. The Body within, the body without. Globe and Mail, 12 June 2004, p. F1.

3. from the dsm5.org revision website, with a footnote referring to Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3.”

4. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=189#

5. Wyndzen MH. A personal and scientific look at a mental illness model of transgenderism. APA Division 44 Newsletter, Spring 2004, p. 3.

6. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=193

7. i.e. Wyndzen MH. A personal and scientific look at a mental illness model of transgenderism. APA Division 44 Newsletter, Spring 2004, p. 3., http://www.genderpsychology.org/autogynephilia/

8. http://autogynephiliac.blogspot.com/2010/01/blanchard-and-dsm-v-redefining.html

Petition to the International Olympic Committee

About a month ago the IOC (International Olympic Committee) came out with new 'policies' for addressing intersex women athletes. If you're not familiar with the new guidelines, this article is a good overview. There is a petition being circulated by the Organisation Intersex International requesting the IOC to abandon these guidelines. If you care to learn a bit more about the petition, here is the link.

The Dr. Oz Show and the Transgender Umbrella

For those of you who haven’t seen it, the Dr. Oz show recently did a story about transgender youth. (If you have not yet seen it, you can learn more here: http://glaadblog.org/2010/02/18/the-dr-oz-show-raises-the-bar-for-transgender-talk-show-coverage/). For the most part, I have heard many Trans people applauding the show and the parents/families featured. Although I fully support the parents, the show, and the language used therein, was, difficult for me to handle. For instance, in one “explanatory” segment, the narrator (presumably Dr. Oz), states that “EVERY transgender child” feels they are the wrong sex. The show largely conveyed that the term transgender means, “changing sex” (female to male or male to female). This seems to be a growing trend: when the Trans community gets the chance to be visible in a large medium (TV shows, movies, etc), the term transgender is characterized as synonymous with changing sexes.

Although I fully support the visibility for the Trans community, and the amazingly compassionate parents featured on the show, I am disheartened by the misuse of language and the continued misconceptions about the wide spectrum of identities under the “transgender umbrella.” Where is the visibility for GenderQueer, Third Gender, Poly-Gender, Bi-Gender, Androgyne, Crossdressers, and all the other diverse Trans identities?! Why do these dialogues fail to mention other Trans identities? Why are these identities ignored? I can’t help but find this situation analogous to the GLB (gay, lesbian, and bisexual) community’s choices to ignore the Trans community in the past. Because gender-variant identities are harder for the public at large to understand, the majority chooses to ignore these identities; we are swept under the rug, if you will.

I’m not angry, so please don’t think that. Honestly, I am simply hurt and heart-broken. I have dedicated my life to Trans rights: and yet, as a GenderQueer, I am continuously treated as invisible in these extremely important dialogues. Where is the representation, information or even acknowledgment of other Trans identities outside the FtM and MtF spectrum?

My goal in writing this is two-fold. First, I hope that people who are outside the Trans community learn a little something: consider the possibilities of gender diversity and realize that not all Trans people are transmen or transwomen. This, of course, is nothing against my brothers and sisters who identify as such, but please remember the other identities within the Trans-family. This leads us to my second goal: please, to those within the Trans community, don’t forget about other identities represented by the “T” in the GLBT. You may not understand our experiences in gender; but we are not looking for you to understand us, just acknowledge and accept us as a part of this community. Don’t leave members of the Trans family out in the rain, just because our experiences differ from your own. In the end, we are all one family: let us start acting like it.

From the Guardian: Julie Bindel's Dangerous Transphobia

This essay originally appeared on the Guardian's Comment is Free website on Monday, February 1st 2010. The comments thread was, shall we say, lively, and included both a reply from Ms. Bindel herself and my own reply to her reply.

I don't much care for Julie Bindel, unlike Beatrix Campbell, who defended her on this site yesterday. That does not mean I don't admire her. As a feminist whose radicalism would probably surprise her, I appreciate Ms Bindel's advocacy and the genuine good that has come for her work against violence directed at women. Yet in her long, lonely crusade against transsexuals she contradicts three of her own three feminist principles:

1) Gender is a social construct and malleable – unless you try to change yours.
2) Biology is not destiny – except men are always men and women are always women.
3) Bodily autonomy is something all women struggle for – but not something trans women are competent enough for.
4) Misogyny is evil – unless it is directed at a trans woman, even if, as is often the case, no one knows she is trans.

Indeed, what is astonishing about Bindel's writing on transsexuals, which has been published in the Guardian, is how often it resembles the diatribes of anti-gay bigots: the disregard of our own voices, the disbelief that transness is anything but a degeneracy, and the general air of condescension and paternalism.

Gays and lesbians have long known that such diatribes are not merely "offensive," but dangerous – as is transphobic writing like Bindel's, and for the same reason: they support social attitudes that have often proven deadly for trans people. According to the Transgender Day of Remembrance web site, 130 people were murdered in 2009 simply because they were transgendered – and those were only the deaths that were reported. Like gay and lesbian people, trans people face the very real threat of violence every day simply for being themselves. Very often, even in places where legal protection exists for gays and lesbians, no similar protection exists for trans people.

That Stonewall, an organisation named for riots that were led in part by a trans woman, Sylvia Rivera, should honour a writer with such disdain for the transgendered was a profound insult. Its action deserved protest, but protest is not censorship, as Campbell argued. Neither is the NUS applying its "no-platform" policy to Bindel nor other groups who no longer want her to appear at their functions. This is more a sign of an evolution of the modern feminist movement away from its historic transphobia towards an inclusive model; one that, as Laurie Penny puts it, "...holds that gender identity, rather than being written in our genes, is an emotional, personal and sexual state of being that can be expressed in myriad different ways that encompass and extend beyond the binary categories of 'man' and 'woman'".

Like any woman, a trans woman experiences having her anatomy scrutinised, commodified, and criticised; her appearance criticised for being either too masculine or too feminine; and is told repeatedly how her gender disqualifies her from many positions – all before she transitions. Afterwards, she is subject to both the misogyny that all women face plus the added prejudice faced by trans people, sometimes from the very organisations who exist to help women in need. We are neither dupes nor Jake Sully-like avatars of the patriarchy: we are just ordinary women and men facing the same problems of other women and men.

It is my guess that neither Campbell nor Bindel would have a problem with the NUS refusing someone a platform who had frequently published homophobic writings, even if they had done other good works. Both, I suspect, would happily write about and protest against such a person. Their surprise that the same thing should happen to a person with a long record of public transphobia must thus seem a bit disingenuous – unless you don't think trans people are worthy of human dignity. Which is neither good activism, feminism – or politics.

I'll be doing some follow-ups to this piece and some of the issues Ms. Bindel and other commentators brought up over at The Second Awakening.