Autogynephilia

"Men Trapped in Men's Bodies:"

An Introduction to the Concept of Autogynephilia

By Anne Lawrence, M.D.


Male-to-female transsexuals are popularly characterized as "women trapped in men's bodies." And undoubtedly there are some transsexuals for whom this is an accurate description. But there are also some of us male-to-female transsexuals to whom this popular description does not so obviously apply. Many of us transitioned in our 30's, 40's, or even later, after having lived outwardly successful lives as men. Often we were not especially feminine as children, and some of us are not especially feminine after transition, either. Many of us were, or occasionally still are, married to women; often we have fathered children. A sizable number of us identify as lesbian or bisexual after reassignment. Many of us have a past history of sexual arousal in association with cross-dressing. Yet there is no doubt that we can suffer from intense gender dysphoria, and no less so than our more outwardly feminine transsexual sisters. And we pursue sex reassignment surgery every bit as intensely, too.

Is there a more accurate way to characterize those of us who knew we were male anatomically, who were not outwardly feminine and sometimes had to work rather hard to appear feminine, yet who intensely wanted to be women? I have sometimes half-jokingly said that we were "men trapped in men's bodies." I do not use this expression disparagingly. Many of my closest friends come from the background I have described; and in most respects it is my background as well. (I also acknowledge that some persons fitting the above description would emphatically deny that they were ever "really" men, and I have no quarrel with their self-definition.) While it takes tremendous courage for anyone to undergo gender transition, this seems to be especially true for those of us whose presentation may not be "naturally" feminine, and whose years of male privilege have often resulted in our having a great deal to lose.

It is not difficult to understand why biologic males who have been extremely feminine ever since childhood, and who are sexually attracted to men, would seek sex reassignment surgery. It is more difficult to understand why males who are attracted to women, who have been fairly successful as men, and who do not appear remarkably feminine would do so. What force is powerful enough to make us give up our whole place in the world; to make us risk estrangement from our families, loss of our jobs, and rejection by our friends?

I know of only one force that powerful. To see that force in action -- and its ability to make otherwise prudent souls throw caution to the wind -- one need look no further than to the current American President. The force in question is one designed by nature to be terrifically powerful, because it is necessary to ensure the survival of our species. That force is, of course, sexual desire.

Naturally it flies in the face of conventional wisdom to assert that transsexuality has anything to do with sexual desire. Everyone knows that, although sexual orientation or "affectional preference" may be about sex, transsexuality is about gender. We transsexuals transition because we're transgendered, because we desperately want to live in the opposite gender role. In fact, it's not even politically correct to talk about "sex reassignment surgery" anymore; the politically correct term is "gender reassignment surgery" or even "gender confirmation surgery." This is to emphasize -- according to the theory -- that the quest for the sought-after gender role is primary; and that sex reassignment surgery is not an end in itself, but is merely a confirmation of our gender transition.

Unfortunately, there are a few troublesome people who are inclined to doubt the conventional wisdom. Some of them are clinicians who work with transsexual clients, and who find that the conventional wisdom fails to explain much of what they observe. And a few of these troublesome people are transsexuals themselves -- unusually candid transsexuals, who are not shy about saying that sexual desire was a significant motivation in their transitions. To understand what these people are getting at requires making the acquaintance of a seven-syllable word derived from Greek: "autogynephilia."

The term autogynephilia was coined in 1989 by Ray Blanchard, a clinical psychologist at the Clarke Institute of Psychiatry in Toronto. He defined autogynephilia as "the propensity to be sexually aroused by the thought or image of oneself as a woman." In a remarkable series of papers published between 1985 and 1993, (1) Blanchard explored the role of autogynephilia in the erotic lives of hundreds of male gender dysphoric patients.

Blanchard hypothesized that there are two fundamentally different types of gender dysphoric males: those who are exclusively or almost exclusively aroused by men, i.e., who are androphilic ; and all the rest, who, as it turns out, are primarily aroused by the idea of being women, i.e., who are autogynephilic.

Blanchard studied over 200 male subjects who presented for evaluation at the Clarke Institute, saying that they felt like (or wanted to be) women. He found that the gender dysphoric males who were primarily attracted to men -- those with what he called androphilic or homosexual gender dysphoria -- presented for initial evaluation at a relatively early age. (Note that the term "homosexual" here refers to attraction to someone of the same biologic sex. This is the conventional usage in the psychiatric literature. Also by convention, this usage does not reverse following sex reassignment surgery: a postoperative male-to-female transsexual who is attracted to men is still called "homosexual"). Blanchard's homosexual gender dysphoric males usually reported having been very feminine as children. Only about 15% of them gave any history of sexual arousal with cross-dressing. And they generally were not sexually aroused by fantasies of simply being female. What primarily aroused them were men -- especially men's bodies.

The other group of gender dysphoric males was more diverse, and included: those attracted primarily to women (heterosexual or gynephilic ); those attracted to both women and men (bisexual); and those with very little attraction to other persons of either sex (anallophilic, "not attracted to other people"). Collectively these persons were said to have a non-homosexual type of gender dysphoria. Blanchard found that the males in this group presented for initial evaluation at a somewhat later age. They reported less childhood femininity, and in fact they often appeared to have been unremarkably masculine as children. About 75% of them admitted to sexual arousal with cross-dressing. And, most significantly for Blanchard's theory, they were almost always intensely aroused sexually by autogynephilic fantasies -- simply by the idea of being women. Subsequent studies using penile plethysmography further demonstrated that many of those who had denied arousal to cross-dressing actually did become aroused while listening to spoken descriptions of cross-dressing scenarios. (2)

Autogynephilia can be seen as a type of paraphilia, although Blanchard has sometimes been reluctant to say this unequivocally, for reasons I will discuss below. Paraphilias are defined in DSM-IV as:

recurrent, sexually arousing fantasies, sexual urges or behaviors generally involving 1) non-human objects, 2) the suffering or humiliation of oneself or one's partner, or 3) children or other non- consenting persons. (3)

The unstated assumption here is that "normal," non-paraphilic sexuality necessarily involves arousal primarily toward other people. Therefore arousal which is primarily toward a fantasized or actual aspect of oneself, or of one's own behavior, in which other people may be present but are essentially superfluous, is in principle equivalent to arousal involving a "non-human object."

What makes the issue complicated is that autogynephilia does not necessarily preclude attraction to other people. That is why one can say that some transsexuals are autogynephilic, and simultaneously categorize them as heterosexual, bisexual, or anallophilic. (If autogynephilia completely precluded attraction to other people, all autogynephilic persons would be anallophilic.) But autogynephilic arousal often does seem to compete with arousal toward other people. For example, autogynephilic persons who are heterosexual or bisexual often report that when they first become involved with a new sexual partner, their autogynephilic fantasies tend to recede, and they become more focused on the partner. But as the relationship continues, and the novelty of the partner wears off, they more frequently return to autogynephilic fantasies for arousal. (Perhaps for biologic males, novelty is an important factor in determining which of several possible sources of arousal receives attention.)

Another common observation made by autogynephilic persons is that, while they like having partnered sex, there is sometimes a way in which their partner is almost superfluous, or merely acts as a kind of prop in an autogynephilic fantasy script. Blanchard has observed that this is especially characteristic of many autogynephilic fantasies involving male partners: often the male figure is faceless or is quite abstract, and seems to be present primarily to validate the femininity of the person having the fantasy, rather than as a desirable partner in his own right. In part because autogynephilia seems to compete with attraction toward other people, but without precluding it, Blanchard has sometimes preferred to call autogynephilia an "orientation," rather than a paraphilia. (4)

Blanchard distinguished four different types of autogynephilia in his subjects, although many individuals demonstrated more than one type. The first type is transvestic autogynephilia, in which the arousal is to the act or fantasy of wearing women's clothing. The second is behavioral autogynephilia, in which the arousal is to the act or fantasy of doing something regarded as feminine, e.g., knitting with other women, or going to the hairdresser's. The third is physiologic autogynephilia, in which the arousal is to fantasies such as being pregnant, menstruating, or breast-feeding. The final type is anatomic autogynephilia, in which the arousal is to the fantasy of having a woman's body, or aspects of one, such as breasts or a vulva.

Blanchard thought it was entirely predictable that biologic males who experienced sexual excitement at the idea of having a woman's body would in fact seek to acquire or inhabit such a body. And his research subsequently confirmed that his subjects with the anatomic type of autogynephilia were the ones most interested in physical transformation, i.e., in sex reassignment surgery. He summarized his theory this way:

"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." (5)
I consider this to be one of the most brilliant and insightful analyses in the entire clinical literature devoted to transsexuality.

It is worth emphasizing that Blanchard's theory refers to sexual desire in a fairly broad sense; it means more than just genital arousal. In fact, Blanchard was quite aware that his theory about non-homosexual transsexuality being a manifestation of sexual desire would have to explain why the transsexual impulse persists even when genital arousal is reduced or absent. For example, many of us with a history of sexual arousal to cross-dressing or to other autogynephilic imagery report that while our sexual excitement diminishes over time, our desire for sex reassignment surgery continues and even intensifies. Likewise, when we autogynephilic transsexuals take estrogen, our libido is often diminished or even eliminated, but our desire for sex reassignment usually is not. Blanchard hypothesized that after a period of time, stimuli which have been experienced as sexually exciting come to be regarded as rewarding and desirable in their own right, even when they no longer evoke intense genital arousal. Again using the analogy of heterosexual marriage, Blanchard pointed out that men often continue to experience intense emotional bonds to the objects of their sexual desire (i.e., their wives), even after their initial intense sexual attraction has diminished or completely disappeared.

Moreover, we do not have to deny that sex reassignment has other rewarding aspects in order to accept the idea that, for many of us, sexual desire is the origin and the kernel of our transsexual impulse. The qualities we need to cultivate to live successfully in female role can be very rewarding in their own right. Learning to embody such feminine traits as gentleness, empathy, nurturance, and grace improves the quality of our lives, and simply makes us better human beings. Many of us happily discover a number of genuine non-sexual reasons for wanting to undergo sex reassignment. Therefore it becomes easy -- and not necessarily inaccurate -- to tell ourselves and everyone else that we genuinely do want to transition for reasons which have nothing to do with sexual desire. Yet many if not most of us would probably have to admit, if we were honest, that sexual motivations were at least originally at the heart of our desire to transition -- and that they are probably still there, lurking not far beneath the surface.

It would be a mistake to conclude that if autogynephilic transsexuality is in large part about sexual desire, then it is somehow suspect, or is less legitimate than homosexual transsexuality. Although the focus of this essay is not on homosexual transsexuality per se, I do want to say enough about it to dispel any mistaken notions that homosexual transsexuals are the "real" transsexuals, or that their motivations are exclusively non-sexual. Neither is true. By definition, transsexuals are those who undergo sex reassignment as a treatment for gender dysphoria. The gender dysphoria of autogynephilic transsexuals is every bit as real as that of their homosexual counterparts. And it matters not a whit if that dysphoria stems in whole or in part from an inability to achieve sexual satisfaction in one's existing body or role. Autogynephilic transsexuals have just as much claim to being "real" transsexuals as their homosexual sisters.

And homosexual transsexuals are not exactly devoid of sexual motivations themselves. Colleagues who have spent a lot of time interviewing homosexual transsexuals tell me that they can best be thought of as very effeminate gay men who do not defeminize in adolescence. Nearly all go through a "gay boy" period; and their decisions about whether or not to transition are often based in large part on whether they expect to be sufficiently passable in female role to attract (straight) male partners. Those who conclude they will not pass usually do not transition, no matter how feminine their behavior may be. Instead they accept, perhaps grudgingly, a gay male identity, and remain within the gay male culture, where they can realistically expect to find interested partners. This self-selection process explains the intriguing observation that transitioning homosexual transsexuals tend to be physically smaller and lighter than their autogynephilic sisters. (6) The bottom line is that in homosexual transsexuality, too, a sexual calculus is often at work. Transsexualism is largely about sex -- no matter what kind of transsexual one is.

Although Blanchard's research was rigorously performed, it is also important to understand its limitations. First, it was conducted on a clinical sample: a group of males sufficiently distressed or symptomatic that they chose to be evaluated. Second, in order to partition his subjects into categories based on sexual attraction, Blanchard used a deliberate seeding technique to ensure that four clusters would result. While this may be useful and valid for statistical purposes, a look at the graphic data reveals that the clusters are not really that distinct. The bisexual and homosexual clusters are particularly arbitrary in their separation, which argues against any rigid typology, and suggests the hypothesis that at least some bisexual transsexuals might comprise an intermediate type. Third, at the risk of stating the obvious, Blanchard merely found statistical correlations, albeit highly significant ones, between several of the variables he examined. This does not imply that the patterns he discovered will necessarily hold true in any particular individual case. There will always be exceptions. Finally, none of Blanchard's subjects had actually undergone gender transition and sex reassignment surgery -- they were simply males who were gender dysphoric, and who said they felt like they were, or wanted to be, women. Blanchard has never tested his ideas in a group of postoperative male-to-female transsexuals.

I tried to confirm Blanchard's theories among a group of postoperative transsexual women at the 1996 and 1998 New Woman's Conferences, using an anonymous survey method. In 1996, ten out of thirteen of the women, fully three-quarters, said that " self-feminization was erotic" for them. And over half of the women said that "self-feminization had been their primary erotic fantasy prior to transition." (7) In 1998, somewhat better prepared, I asked a question specifically written by Blanchard. In answer to it, five of eleven women, nearly one half, agreed that before surgery, their "favorite erotic fantasy was that they had, or were acquiring, some features of a woman's body." (8) Additional evidence for the importance of autogynephilic fantasy in transsexuals who have actually undergone surgery comes from Maryann Schroder's unpublished Ph.D. thesis, "New Women." Five of her seventeen postoperative subjects described having been aroused by autogynephilic sexual fantasies prior to surgery. (9)

Why is it that autogynephilia, which is so readily reported in these small groups of postoperative women, has received so little attention? I think there are several reasons.

Among transsexuals, autogynephilia is not quite respectable as a topic for discussion. For one thing, many transsexuals have a passionate dislike for the Clarke Institute, and tend to dismiss out of hand any findings that have come from it. Therefore Blanchard's ideas are not often talked about; and when they are raised, they tend to get shouted down. Shame is undoubtedly another deterrent. It is probably just too threatening for many transsexuals to admit that they have had autogynephilic fantasies, and especially to admit that autogynephilic sexual desire may have been one of their motivations for seeking sex reassignment surgery. People are understandably reluctant to admit to having a paraphilia -- more popularly known as a perversion. Most transsexual women want to be seen as a "real women," and it is widely understood that paraphilic arousal is almost exclusively confined to men. Transsexuals who admit to autogynephilic arousal may not be seen as "real women" -- and may not even be seen as "real" transsexuals!

Therapists and surgeons undoubtedly have their own reasons for ignoring autogynephilia. Most therapists are accustomed to thinking about transsexuality using more traditional, gender-based formulations. The idea that there may be sexual motivations for transition may seem to them "untidy," and not consistent with their paradigm. Accordingly, they may think that autogynephilic sexual desire in transsexuals is rare and aberrant. And since their clients are often unwilling to talk about their autogynephilia, who can blame the therapists for thinking so? Moreover, most therapists and surgeons would probably find it difficult to acknowledge that when they give approval for sex reassignment surgery, or perform it, they are sometimes simply helping a transsexual woman act out her own paraphilic sexual script.

Personally, however, I do not find the idea that transsexual women sometimes seek SRS for sexual reasons to be especially problematic, even when that sexuality is essentially paraphilic. The real question is not what one's motivation might be, but whether sex reassignment surgery improves the quality of one's life. The overall level of satisfaction following SRS is extremely high. And the evidence thus far seems to demonstrate that those transsexual women whom one would expect to be autogynephilic -- late onset, sexually attracted to women, etc. -- tend to do about as well after surgery as those who present younger and who are sexually attracted to men.

Certainly no one should be shocked to learn that there are people who want to modify their bodies -- surgically and in other ways -- primarily to enhance their sexual attractiveness, to themselves or to others. This is a billion dollar industry in the United States alone, and most of it does not involve transsexuals. We routinely cut, color, tattoo, pierce, augment, reduce, lift, tuck, rearrange and contour parts of our bodies to express our sexuality and to enhance our sexual satisfaction. Nor is this unique to modern Western culture, as any anthropologist can tell you. I am not suggesting that we should be complacent about SRS, or regard it as a casual undertaking. I am suggesting that, to my mind, having sexual motivations for seeking SRS does not pose any kind of unique ethical problem. Sexual motivations underlie a vast range of medical and surgical procedures which are routinely performed on non-transsexuals, and which we more or less take for granted.

Recently some exceptionally brave transsexual women have been calling for more candor about the role of sexual motivations in our life paths. Jessica Xavier wrote this in her article "Reality Check," published in 1995:

"To become fully cognizant of our realities, we must first acknowledge our fantasies. The eroticism of crossdressing and transsexuality for many of us is based upon a powerful sexual fantasy of becoming someone else, either temporarily or permanently. Why must we view our own essential eroticism as less than a valid means of self-pleasure and self-discovery? Sex is a powerful but seldom-discussed influence in our transgendered lives.... It is both ironic and unfortunate that our own gender education efforts to date have obscured this essential eroticism." (10)

Margaret O'Hartigan put it more bluntly in her article "Surgical Roulette," published in 1994:

"It is necessary for transsexuals to stop pretending that changing sex is about gender and not about sex. 'Transgenderism' used as a euphemism for changing sex masks the reality that transsexuals seek to change their bodies in order to experience genital sexual pleasure without a prick getting in their way. The recent attempt by some to replace the term 'sex-reassignment surgery' with 'gender confirmation surgery' only further confuses the separate issues of sex and gender." (11)

I think that honest expressions such as these are not only healthy, but are extremely valuable. Such candor helps transsexual women whose experiences don't fit the traditional pattern to feel less isolated, less alone. It is unfortunate, in my opinion, that transsexual women have not written more extensively about their sexual feelings and fantasies, and about how these relate to their decisions to pursue transition and surgery. Carol Christ wrote the following about non-transsexual women, but it applies to transsexual women equally well:

"Women's stories have not been told. And without stories there is no articulation of experience. Without stories a woman is lost when she comes to make the important decisions of her life. Without stories she cannot understand herself." (12)

Transsexual women's stories need to be told, and heard. Elsewhere in these pages, I have encouraged readers who have experienced autogynephilic sexual fantasies or arousal to write to me, describing their feelings and discussing what role sexual desire has played in their decisions to transition and to have genital surgery. I hope to make such material more widely known, so that all those concerned with transsexuality, both consumers and clinicians, can better understand the complex relationship between transsexuality and sexual desire.

I'll close with a true story, about a friend I'll call Linda (not her real name). Linda transitioned in her late forties, following a very successful professional career. While living as a man she had been married to a woman, and had fathered a son. Linda took to female role like a duck to water, and was soon passing effortlessly. She has SRS with an excellent American surgeon, known for his skill at preserving sexual feeling. After surgery she began dating men, and met with some success. Only one problem continued to bother Linda: In the two years following her surgery, she had never been able to have an orgasm. One day I ran into Linda at a conference, and she pulled me aside with a conspiratorial grin:

"I finally had one! The Big O!"
"That's wonderful, Linda," I replied. "How did you do it?"
"It was simple, really. I finally found the right fantasy."
"And that was...?"
"Forced feminization."

*********************************************

If there is a moral here, I think it is that knowing and accepting our own truth is what sets us free.


REFERENCES:

1. The following is a bibliography of articles by Ray Blanchard concerning autogynephilia:

Typology of male-to-female transsexualism
Arch Sex Behav 14(3), 247-261 (1985)

Heterosexual and homosexual gender dysphoria.
Arch Sex Behav 16(2), 139-152 (1987)

Nonhomosexual gender dysphoria.
J Sex Res 24, 188-193 (1988)

The classification and labeling of nonhomosexual gender dysphorias.
Arch Sex Behav 18(4), 315-334 (1989)

The concept of autogynephilia and the typology of male gender dysphoria.
J Nerv Ment Dis 177(10), 616-623 (1989)

Clinical observations and systemic studies of autogynephilia.
J Sex Marital Ther 17(4), 235-251 (1991)

Nonmonotonic relation of autogynephilia and heterosexual attraction.
J Abn Psychol 101(2), 271-276 (1992)

The she-male phenomenon and the concept of partial autogynephilia.
J Sex Marital Ther 19(1), 69-76 (1993)

Partial versus complete autogynephilia and gender dysphoria.
J Sex Marital Ther 19(4), 301-307 (1993)

Varieties of autogynephilia and their relationship to gender dysphoria.
Arch Sex Behav 22(3), 241-251 (1993).

2. Blanchard R, Rachansky I, Steiner B. (1986) Phallometric detection of fetishistic arousal in heterosexual male cross-dressers. J Sex Res 22(4), 452-462.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC; American Psychiatric Association; 1994. pp. 522-523.

4. Blanchard R. (1993) Partial versus complete autogynephilia and gender dysphoria. J Sex Marital Ther 19(4) p. 306.

5. Blanchard R. (1991) Clinical observations and systemic studies of autogynephilia. J Sex Marital Ther 17(4) pp. 245-246.

6. Blanchard R, Dickey R, Jones CL. (1995) Comparison of height and weight in homosexual versus nonhomosexual male gender dysphorics. Arch Sex Behav 24(5), 543-554.

7. Lawrence A. Life after surgery: questions and answers from the 1996 new woman's conference. Paper presented at the Second International Congress on Sex and Gender Issues, Philadelphia, PA., June 20, 1997.

8. Lawrence A. Unpublished data.

9. Schroder M. New women: sexological outcomes of gender reassignment surgery. Unpublished Ph.D. thesis, Institute for Advanced Study of Human Sexuality, San Francisco, CA, 1995.

10. Xavier J. Reality check. Transsexual News Telegraph, #5, Summer/Autumn 1995, pp. 32-33.

11. O'Hartigan M. Surgical Roulette. TransSisters, #3, Winter 1994, p. 28.

12. Christ C. Diving Deep and Surfacing. Boston, Beacon Press, 1980, p. 1


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1998 Anne A. Lawrence, MD