The Gender Gulag: Voices of the Asylum

 

Kelley Winters, Ph.D.

GID Reform Advocates

www.gidreform.org

 

 

In 1860, abolitionist and suffrage leader Susan B. Anthony risked arrest to help a battered wife, who had been committed by her husband to an insane asylum for over a year.  Mrs. Phoebe Phelps, a school principal and accomplished author, was imprisoned and allowed no contact with her children, friends or family for nonconformity to the submissive role expected of women. It was remarkably easy to incarcerate women of that time with a diagnosis of “delusions” or in later years “hysteria.”  After her release by writ of habeas corpus, she asked Ms. Anthony to help her flee the grasp of her abusive husband, a Massachusetts Senator. On Christmas night, Anthony took Mrs. Phelps and her daughter by train to New York City and a chance for freedom.

 

“aware of how often her friends of the Underground Railroad had defied the Fugitive Slave Law and hidden and transported fugitive slaves, Susan decided she would do the same for this cultured intelligent woman, a slave to her husband under the law.” [1]

 

A century and a half later, so much and yet so little have changed. Our country has abolished the atrocity of slavery, enacted civil liberties for people of color and just this month elected our first African American President of the United States. Yet, gender variant Americans are still incarcerated in mental institutions and physically and emotionally assaulted with drugs and “aversion therapies” for failing to comport to the roles of their assigned birth-sex.

 

In 1995, Dr. Deidre McCloskey, a renowned professor of economics at the University of Illinois, Chicago, was taken from her home by sheriff’s deputies with “a warrant for arrest for mental examination.” Dr. McCloskey was a transsexual woman who had come out of the closet to her family prior to social transition,  Deidre’s sister, a psychologist, held intolerant views of gender diversity and, like Mrs. Phelps’ nineteenth-century husband, was easily able to procure a civil commitment to a psychiatric ward.

 

Dr. McCloskey was incarcerated not once but twice at her sister’s insistence. In Crossing, a Memoir, [2] McCloskey described the “treatment protocols” for those seized for gender transgression:

 

“the victim has no civil rights, especially if poor and unable to hire a vigorous lawyer; nothing he says is to be credited; no penalty of perjury or civil liability or even court costs attaches to the people initiating the seizure if their testimony proves to be false; and the psychiatrists to everything to avoid the liability from letting the victim free, are cowardly about taking the responsibility to do so and in effect are exempted from liability for the consequences of a false seizure and an unreasonable detention.”

 

Deidre was interrogated by psychiatrists who displayed utter ignorance about gender dysphoria and the transition process.  She was labeled as “manic,” resulting from “latent homosexuality,” decades after the American Psychiatric Association had removed same-sex orientation from the classification of mental illnesses.  One psychiatrist demanded, “Are you a homosexual?” “Do you wish to become one?”  When Deidre responded “no,” that she was attracted to women, the doctor was incredulous. Reflecting old stereotypes confusing sexual orientation with gender identity, he responded, “Well, then, why are you doing this?”

 

To regain her freedom, Dr. McCloskey was forced to pay $8000 in legal fees and, astonishingly, was billed $3000 by the hospitals that falsely imprisoned her. She wondered, “What if I were poor?”  

 

Susan Anthony would be disappointed at how little we have progressed.

 

The extraordinary narrative of Ms. April Ashley, a British transwoman and fashion model, illustrates the cruelty inflicted on gender variant individuals in mental institutions in the 1950s and beyond.  Attempting suicide at eighteen years old, Ashley was rescued by her long hair from the Mersey river and delivered to the Ormskirk Mental Hospital near Liverpool. She agreed to a regimen of gender-reparative therapy at nearby Walton Hospital, intending to change her feminine identity. April’s “treatments” included drugging her with ether while doctors exacted, “Why do you want to be a woman?” Later, the interrogations were punctuated with sodium pentathol injections.  Ashley was given massive doses of male hormones. Finally, she was placed in a public ward and administered electroconvulsive therapy:

 

“These blitzed souls returned from the convulsion chamber like zombies, their eyes blinking and heavily bloodshot, with an attendant supporting them on each side. A few hours later they awoke in their beds with murderous headaches in comparison to which an aspirin overdose is like a day at the seaside. When it comes to medical matters I’m usually very brave but on these occasions was not.”

 

Ashley’s treatment illustrated a recurring theme in gender incarceration: obsessed with attempts to change her gender identity, they neglected the depression and despair that led to her original hospitalization. In spite of her abuse, Ms. Ashley persevered to live her truth.

 

“’No matter what you do, you’ll never be able to change my mind. I said with a knowledge I didn’t know I had.” [3]

 

Ashley prevailed as a remarkable pioneer in the transcommunity. She was one of the first patients for corrective genital surgery with Dr. Georges Burou in Morocco, and she appeared in Vogue and the movie, The Road to Hong Kong, starring Bing Crosby and Bob Hope.

 

Phyllis Burke, author of Gender Shock: Exploding the Myths of Male and Female, [4] told the heartbreaking story of Jamie, a transsexual woman who survived fifteen years of hospitalization from age six.  “Jamie did not do boy things, and would not lie about it,” Burke explains. Admitted in the late 1950s, Jamie was drugged and given numerous electroconvulsive shock treatments over the span of her imprisonment:

 

“The treatments never became less painful, and there was nothing more painful than the shock, not even the rapes by the male patients, not even Mother and Father never returning.”

 

At twenty years old, following an extremely painful ECT treatment, Jamie escaped the institution and made her way to San Francisco and transition to an affirmed life.  Jamie asked Ms. Burke to find as many children like her as she could and write about their stories,

 

“No one is talking about them, … but there are still kids in the hospitals.”

 

Burke noted that attitudes about childhood gender nonconformity within American psychiatry were influenced by Dr. Martha MacDonald and her 1938 study of eight birth-assigned males at Michael Reese Hospital on the South Side of Chicago. [5]  In a paper entitled “Criminally Aggressive Behavior in Passive-Effeminate Boys,” [6] MacDonald associated feminine expression with violent aggression. Contrary to this stereotype, she observed that these youth were “model playmates” in the company of girls, and she did not clearly distinguish them as perpetrators of violence in the presence of boys or as victims.  Nevertheless, MacDonald advocated psychiatric hospitalization of gender variant youth — a role that her own institution would play, decades later, in one of the best known and most tragic stories of the gender gulag.

 

In his seminal autobiography, The Last Time I Wore a Dress: A Memoir, [7] Dylan Scholinski recalls high school years incarcerated in a series of mental institutions with a diagnosis of Gender Identity Disorder. [8]   The first of these was Michael Reese Hospital, where the fifteen year-old was termed by doctors “an inappropriate female.”   

 

“Can you tell me,” Scholinski’s father had asked at a prior clinic, “why she won’t wear a dress?”

 

At Michael Reese, the award-winning author describes being pressed to the floor under the boot of a guard who ordered, “Shut up, you f***ing crazy-ass queer”  – a phrase apparently synonymous with a diagnosis of Gender Identity Disorder; being injected with thorazine; being locked in seclusion; being tied to a bed while touched, assaulted, by a male patient on the ward.  The attending psychiatrist would ask, “Why don’t you put on a dress instead of those crummy jeans?”

 

At Forest Hospital in Des Plaines, Illinois, Scholinski was told that, “if I appeared more feminine I would be better adjusted.”   This was followed by daily humiliation with “girly lessons,” and make-up sessions:

 

“If I didn’t emerge from my room with foundation, lip gloss, blush, mascara, eyeliner, eye shadow and feathered hair, I lost points. Without points, I couldn’t go to the dining room. I couldn’t go anywhere. …

 

Ever lied to save yourself?  … Ever been so false your own skin is your enemy?”

 

After three years of incarceration in three institutions at a cost of one million dollars, Scholinski was finally released when insurance benefits ran out.  Today, Dylan is an accomplished artist, author and community advocate in Denver, Colorado.  He recently founded the Sent(a)Mental Project, A Memorial to GLBTIQ Suicides. [9]

 

Trey Polesky, a counselor and GID reform advocate [10] received very similar mistreatment at Forest Hospital in 1990.  He tells how a psychiatrist diagnosed him with Gender Identity Disorder at age 9 and recommended incarceration to “help me become more in touch with my feminine side.”  In a program of gender-reparative therapy, he was forced to wear pink and purple dresses and skirts, grow out his hair and read teen fashion magazines to learn to behave “like a girl.” Trey recalls,

 

“I finally learned to fake my way out in order to be released, though the reparative therapy did nothing but shatter my sense of self confidence in who I was. Essentially, they taught me to hate who I was.”

 

Harsh punishment of gender variant youth occurs in outpatient as well as residential settings. Dr. Arianna Davis today is an advocate for trans and intersex communities and GID reform. Though born with an intersex condition and expressing a strong female identity at a very early age, she was assigned male and later diagnosed as mentally ill for not comporting to that assignment. Arianna was subjected to a gender-reparative therapy regimen at UCLA in the 1980s:

 

“I was subjected to forced testosterone injections and used as a study subject against my wishes. These things happened (under the physical beatings and punishment -recomended by a therapist of a reparative mindset- the urging of my father and the all too eager compliance of UCLA doctors and researchers).” [11]

 

Dr. Davis’ story raises the point, a painful memory to so many of us, of how physical violence from parents of gender variant children is encouraged by intolerance from the mental health professions – what has been called, “the sissy-whupping method.” [12]   I have often remarked in my own diversity lectures that if it were possible to beat, shame or coerce the gender identity out of a child, I would not exist and my audience would not be having this conversation with me. Playwright Eve Ensler termed this violence toward young transwomen, “They Beat the Girl Out of My Boy… Or So They Tried,” in a 2004 Los Angeles production of The Vagina Monologues. [13]

 

In Aldous Huxley’s, Brave New World, psychiatric aversion therapies were used to condition the lower classes to hate books [14].  In our real world, aversion therapies have long been the cornerstone of reparative therapies intended to “cure” both gender variance and same-sex orientation.  However, the American Psychiatric Association issued position statements in 1998 and 2000 opposing these “conversion” treatments that attempt to change sexual orientation: [15]

 

“APA recommends that ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the medical dictum to First, do no harm.”

 

Sadly, the APA never discouraged analogous gender-reparative therapies attempting to change gender identity or suppress gender expression.  Indeed, the dictum of “First, do no harm,” does not seem to apply to the treatment of gender variant people within American psychiatry. Nor do the bounds of  human compassion and decency, when it comes to enforcing conformity to assigned birth sex. For example, Dr. Ron Langevin of the University of Toronto Clarke Institute of Psychiatry (today known as the Centre for Addiction and Mental Health) promoted inhumane aversion treatment of cross-dressing individuals assigned male at birth in his 1983 book, Sexual Strands: Understanding and Treating Sexual Anomalies in Men. [16] 

 

Reminiscent of a scene from Anthony Burgess’ A Clockwork Orange, [17] Langevin described chemical aversion therapy to “cure” cross-dressing,

 

“In chemical aversion therapy, the patient is first administered nausea inducing drugs. When he indicates that he feels sick, his favorite female clothes used for crossdressing are presented. He should touch them and look at them as best he can. Then he is overwhelmed by the need to vomit. The clothes are withdrawn and the procedure repeated several hours later.”

 

Next, he noted the advantages of “electrical aversion” in offering greater “control” over timing.  He described the treatment of a patient:

 

“The conditioning stimuli were pictures of women wearing panties which were followed by the unconditioned stimulus, electric shock. The shock level was set so the patient found it so uncomfortable, he wanted it stopped. In addition to seeing pictures, he was instructed to handle panties and to imagine himself wearing them. After 41 sessions, he said he was no longer troubled by the “fetish” but a month later, it spontaneously recovered.” 

 

Finally, Dr. Langevin introduced a newer form of “shame aversion therapy” used on a “transvestite:”

 

“the patient was required to crossdress before a disinterested group of men and women who watched him without reaction or comment. … In this case, shame replaces electric shock … the patient was evidently experiencing shame. He was in tears as he crossdressed and had a look of anguish on his face. He attempted suicide the following day according to the investigator.”  [18]

 

This unconscionable treatment brings to mind a quote by Nurse Ratched of Ken Kesey’s One Flew Over the Cuckoo’s Nest. “Aren’t you ashamed?” she demanded. [19]  

 

Ashamed of what, though? Where exactly is the shame in being different? Author Dylan Scholinski perhaps said it best:

 

            “But I’ve proven the doctors wrong. I don’t feel disgust in myself or in love.

 

They are the ones who should be ashamed” [20]

 

Psychiatric incarceration and abuse of gender variant youth and adults has for generations been facilitated by diagnostic nomenclature that equates difference with disease: nonconformity to assigned birth-sex with mental disorder and sexual deviance. It is time for the American Psychiatric Association and other mental health organizations to repudiate the practice of gender-reparative therapies, as they have renounced reparative therapies for sexual orientation.  It is time for the APA and the mental health professions to extend an apology to all who have been imprisoned or traumatized in the course of these treatments.  In drafting the fifth edition of the Diagnostic and Statistical Manual of Mental Disorder, it is time for the APA to remove the classification of Transvestic Fetishism and revise that of Gender Identity Disorder to serve constructive rather than destructive purposes.  It is time for new diagnostic nomenclature consistent with the medical principle of “First, do no harm.”

 

 

 

 

[1] A. Lutz, Susan B. Anthony: Rebel, Crusader, Humanitarian, Zenger, 1959, p90.

 

[2] D. McCloskey, Crossing, a Memoir, University of Chicago Pres, 2000, pp. 98, 107, 117.

 

[3] D. Fallowell  and A. Ashley, April Ashley’s Odyssey, Jonathan Cape, London, 1982. http://www.antijen.org/Aprilv1/

 

[4] P. Burke, Gender Shock: Exploding the Myths of Male and Female, Anchor, 1996, pp. 75-84.

 

[5] Burke 1996, pp. 71-74.

 

[6] M. MacDonald, “Criminally Aggressive Behavior in Passive-Effeminate Boys,” American Journal of Orthopsychiatry, v.8, 1938,  pp. 70-78.

 

[7] D. Scholinski and J. Adams, The Last Time I Wore a Dress: A Memoir, Riverhead, 1997, pp. x, 6, 7, 33, 56, 57, 80, 117.  Dylan Scholinski’s name was Daphne at the time of publication.

 

[8] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000, pp. 576-582.

 

[9] D. Scholinski, “Sent(a)Mental Project, A Memorial to GLBTIQ Suicides,” http://www.myspace.com/dylanscholinski

 

[10] T. Polesky, http://www.gidreform.org/advocate.html#trey

 

[11] Personal correspondence, A. Davis.  See also http://www.gidreform.org/advocate.html

 

[12] Holly, “The Sissy-Whupping Method,” Feministe,  http://www.feministe.us/blog/archives/2008/05/13/7399/

 

[13] E. Ensler, “They Beat the Girl Out of My Boy… Or So They Tried,” performed by Calpernia Addams, The Vagina Monologues, V-Day Los Angeles, February 2, 2004, http://www.deepstealth.com/vday/

 

[14] A. Huxley, Brave New World, Harper, 1932, p. 22.

 

[15] American Psychiatric Association, “Position Statement: Therapies Focused on Attempts to Change Sexual Orientation (Reparative or Conversion Therapies),” 2000, http://archive.psych.org/edu/other_res/lib_archives/archives/200001.pdf

 

[16] R. Langevin, Sexual Strands: Understanding and Treating Sexual Anomalies in Men, Lawrence Erlbaum Assoc., 1983.

 

[17] A. Burgess, A Clockwork Orange, William Heinemann (UK)  1962.

 

[18] Langevin 1983, pp. 222, 224, 254.

 

[19] K. Kesey, One Flew Over the Cuckoo’s Nest, Signet, 1963, p. 242.

 

[20] Scholinski 1997, p. 195.

 

 

 

Copyright © 2008 Kelley Winters, GID Reform Advocates 

 

Autogynephilia: The Infallible Derogatory Hypothesis, Part 2

 

Kelley Winters, Ph.D.

GID Reform Advocates

http://www.gidreform.org

 

Dr. Blanchard’s taxonomy of “autogynephilia” and “homosexual transsexualism” follows a long tradition of dividing transsexual women into categorical buckets based on sexual orientation. A premise in American psychiatry/psychology has traditionally held that male-to-female transsexualism is a phenomenon of effeminate male homosexuality, while the label of “transvestism” is associated with heterosexual men. Hence, diagnostic nomenclature and research literature have for decades favored candidates for surgical transition care who would have heterosexual outcomes (i.e., transwomen attracted to men). [1]

 

In the 1960s, Dr. Harry Benjamin’s defined two types of so-called “true transsexuals” as distinct from “transvestites” and “non-surgical transsexuals,” based on Kinsey’s scale of sexual orientation. Those attracted to men were labeled “high intensity,” resembling Blanchard’s “homosexual” label. Benjamin described asexual, “auto-erotic” and some bisexual individuals as “low intensity” or “nonsurgical transsexual.”  He labeled transsexual women attracted to women mostly as “transvestites,” [2] and the belief that those termed “transvestites” were not gender dysphoric or attracted to men held until the 1980s.

 

While Benjamin emphasized that his six types of MTF transsexualism “are not and never can be sharply separated,” psychiatrist. Robert Stoller insisted on exclusive division of transsexualism from “transvestism.”  Stoller considered a single episode of cross-dressing associated with sexual arousal sufficient to exclude a diagnosis of transsexualism [3] and therefore denial of access to transition medical care. (Like Blanchard today, Stoller conflated “association” with erotic causation in his literature.) This view was reflected in the DSM-III-R, [4] where concurrent diagnosis of Transvestic Fetishism and GID of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) or Transsexualism were not allowed [5].

 

In the real world, however, large numbers of transsexual women, who were attracted to women and applied for corrective transition surgeries, refuted the theory that assumed transsexual women to be gay men. They were called such uncomplimentary names as “transvestic transsexuals,” [6], “aging transvestites” [7] and “non-transsexual men applying for SRS” [8]  Where researchers in other scientific discliplines might have questioned the premise in view of contrary data, psychiatric researchers leapt to an incredible assumption: that there must be an additional independent “etiology” or cause for MTF transsexualism. Early on, this second “etiology” was described as a “regression” of transvestism into transsexualism, inexplicably “provoked” by stress. [9] In the late 1970s, Person and Ovesey offered a Hitchcockian psychoanalytic explanation of this process:

 

At times of stress, … transvestites frantically step up the pace of acting out. Should such reparative measures fail, they regressively fall back on the more primitive fantasy of symbiotic fusion with the mother. It is at this point that transsexual impulses break out and may go on to full-blown transsexual syndrome (secondary transsexualism).” [10]

 

Blanchard’s theory of “autogynephilia,” later emerged to fill this role.  But is this science, or is this a defensive response to contradicting evidence?

 

Deogracias, et al., recently proposed that the similarity of transwomen, regardless of sexual orientation, supports a “concept of equifinality,” meaning that the same effect or end state can result from completely different causes. [11]  I am very skeptical of this opinion. Data that contradict a hypothesis most likely call the validity of the hypothesis into question. We in the physical sciences and engineering often use the principle of Occam’s Razor to discern credible from unlikely theories. Contrary to the notion of equifinality, it asserts that simpler parsimonious theories are more likely to be true than twisted complex theories, if all other considerations are equal. Are we to believe that the same effect, gender dysphoria, comes from not one but two unrelated causes depending upon the sexual orientation of the person? Perhaps Occam’s Razor would be a good R_x for the behavioral sciences as well. [12]

 

 Moreover, a corner-stone of scientific methodology is the falsifiability of hypotheses — the possibility that a hypothesis may be refuted by evidence or experiment. Theories are widely considered to be scientific only if they are falsifiable. By capriciously spawning a new independent theory of “autogynephilia” to explain the existence of transwomen who were not exclusively attracted to men, these researchers rendered the original hypothesis of “homosexual male” transsexualism to be unfalsifiable. In my view, this does not suggest equifinality. Rather, it is evidence of a dubious hypothesis that conveniently metastasizes in the face of contradicting data. It is evidence that the development of gender identity in all people, trans and cisgender alike, is not yet understood.

 

In recent years, Dr. Blanchard has attempted to draw a distinction between “autogynephilia” as a sexual phenomenon from the other meanings associated with the term, including his own controversial theories. [13]  However, the word “autogynephilia” has evolved far beyond sexual taxonomy and theoretical speculation to carry a negative context of its own. It has become an offensive epithet to many transwomen. For example, Blanchard and collaborators have grouped “autogynephilia” (lesbian, bisexual and asexual transwomen) with pedophilia, fetishism and even apotemnophilia (desire for limb amputation). [14, 15]  This reinforces some of the most stigmatizing and dehumanizing false stereotypes that transsexual women bear in society.

 

In addition, the terms “autogynephilia” and “homosexual transsexual” have become associated with extremely offensive remarks and stereotypes about transsexual and other transgender women.  Here are but a few examples from a very controversial book by Dr. J. Michael Bailey of Northwestern University, entitled The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. [16]

 

• “The Man Who Would be Queen”  –this maligning description of transsexual women in the book title is accompanied by a cover photo that offensively caricatures them.
• “men who want to be women are not naturally feminine. There is no sense in which they have women’s souls.”
• “The autogynephile’s main romantic target is herself.” – in reference to transsexual women not exclusively attracted to men.
• “Men Trapped in Men’s Bodies” – in reference to transsexual women labeled as “autogynephiles,” this chapter title is a quote from Dr. Anne Lawrence. [17]
• ‘but they don’t have the wrong body, they are mentally ill’. – in reference to transsexual women labeled as “autogynephiles,” Bailey quotes his undergraduate students.
• “homosexual transsexuals are a type of gay man.” –in reference to straight transsexual women.
• “homosexual transsexuals are used to living on the margins of society”
• “homosexual transsexuals might be especially well-suited to prostitution.”

 

Published in 2003, this book promoted inflamed a firestorm of outrage among the transgender community and supportive allies. [18-21] Bailey’s remarks about transsexual women are worse than offensive; they are gratuitously cruel.

 

Finally, “autogynephilia” has been used in a punitive context to discredit critics of  these theories and negative stereotypes. For example, Bailey and Triea associated disagreement with the theory of “autogynephilic” motivation as symptomatic of “autogynephilia:”

 

“although most public transsexual activists appear by their histories and presentations to be nonhomosexual MtF transsexuals, they have generally been hostile toward the idea that nonhomosexual transsexualism is associated with, and motivated by, autogynephilia.” [22]

 

The authors went on to name individuals they termed “transsexual activists” and publicly speculated about their private sexualities. Hence, “autogynephilia” has morphed from a term of taxonomy to a political tool to suppress criticism.

 

To summarize, the term “autogynephilia” means far more than a description of erotic phenomenon. “Autogynephilia,” and its corollary “homosexual transsexualism,” have come to represent an over-arching body of derogatory stereotypes that are promoted as science but remain dogmatically resilient to contrary evidence:

 

• “Homosexual transsexual” maligns all straight transwomen attracted only to men as “homosexual men.”
• “Homosexual transsexual” implies that  all straight transwomen were motivated to transition by their so-called “homosexuality” or denial of it.
• “Autogynephilia” maligns all lesbian and bi transwomen, who are not exclusively attracted to men, as pathologically narcissistic “men.”  
• “Autogynephilia” implies that all lesbian and bi transwomen are attracted to themselves instead of other women, which demeans and undermines these relationships and families.
•  “Autogynephilia” implies that all lesbian and bi transwomen are motivated to transition primarily by sexual paraphilia or deviance, undermining their legitimacy and dignity as women.
• “Autogynephilia” denies that transwomen who live happy and full lives as women, regardless of sexual orientation, possess an inner feminine gender identity or “essence.”
• “Autogynephilia” is a politically punitive epithet for transwomen who criticize psychiatric policies and stereotypes.
• “Autogynephilia” is indelibly associated with cruel dehumanizing epithets of transwomen, such as “man who would be queen,” and “men trapped in men’s bodies.”

 

The term “autogynephilia” has grown to represent an affront to the human legitimacy and dignity of many transitioned women. It serves no constructive purpose in an evidence-based diagnostic nosology.  I strongly urge the American Psychiatric Association to remove this offensive term from the supporting text of the GID diagnosis and refrain from adding it to the nomenclature of paraphilias in the DSM-V.

 

 

 

[1] K. Winters (published under pen-name Katherine Wilson) and B. Hammond, “Myth, Stereotype, and Cross-Gender Identity in the DSM-IV,” Association for Women in Psychology 21st Annual Feminist Psychology Conference, Portland OR, 1996,  http://www.gidreform.org/kwawp96.html.

 

[2] H. Benjamin, The transsexual phenomenon, Julian Press, pp. 23-24.

 

[3] K. Freund, B. Steiner, S. Chan, “Two Types of Cross-Gender Identity,” Archives of Sexual Behavior, v. 11, n. 1, 1982, p. 55.

 

[4] American Psychiatric Associatio, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, 1987, pp.76-77,289.

 

[5] The diagnostic criteria for Transvestic Fetishism excluded diagnosis of Transsexualism or GIDAANT, and the criteria for GIDAANT excluded erotically motivated cross-dressing and Transvestic Fetishism.  The criteria for Transsexualism did not explicitly exclude TF, but were assumed to do so. See Bradley, S., et al. (1991). “Interim Report of the DSM-IV Subcommittee on Gender Identity Disorders,” Archives of Sexual Behavior, Vol. 20, 1991, No. 4, p.338.

 

[6] E. Person and L. Ovesey, “The Transsexual Syndrome in Males. II. Secondary Transsexualism,” Am. J. Psychotherapy, v. 28, pp. 174-193.

 

[7] T. Wise and J. Meyer, “The Border Area Between Transvestism and Gender Dysphoria: Transvestic Applicants for Sex Reassignment,” Archives of Sexual Behavior, v. 9 n. 4, 1980, p. 329.

 

[8] R. Stoller “Gender Identity,” in A. Freedman, H. Kaplan, & B. Sadock (eds.), Comprehensive Textbook of Psychiatry, 2^nd ed., vol II, Williams and Wilkins, pp. 1400-1408.

 

[9] Wise & Meyer, 1980, p. 340.

 

[10] E. Person and L. Ovesey, “Transvestism: New Perspectives,” 1978, in E. Person, The Sexual Century, Yale University Press, 1999, p. 167.

 

[11] J. Deogracias, L. Johnson, H.  Meyer-Bahlburg, S. Kessler, J. Schober, K. Zucker, “The gender identity/gender dysphoria questionnaire for adolescents and adults,” Journal of Sex Research, v. 44 n. 4, November 2007, pp. 370-379, http://findarticles.com/p/articles/mi_m2372/is_4_44/ai_n27467813***

 

[12] K. Wilson (former pen-name for Kelley Winters), “Autogynephilia: New Medical Thinking or Old Stereotype?” Transgender Forum Magazine, April 16, 2000. http://www.gidreform.org/kwauto00.html

 

[13] R. Blanchard, “Early History of the Concept of Autogynephilia,” Archives of Sexual Behavior, Vol. 34, No. 4, August 2005, p. 445.

 

[14] K. Freund, & R. Blanchard, R., “Erotic target location errors in male gender dysphorics, paedophiles, and fetishists,”  British Journal of Psychiatry, 162, 558–563p. 1993, 558.

 

[15] A. Lawrence, “Clinical and theoretical parallels between desire for limb amputation and gender identity disorder,” Archives of Sexual Behavior,  v. 35, 2006, 263.

 

[16] J. Bailey, The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, Joseph Henry Press, 2003, pp. xii, 172, 178, 183-185, 206.

 

[17]  A. Lawrence, “Men Trapped in Men’s Bodies: Autogynephilic Eroticism as a Motive for Seeking Sex Reassignment,” 16th Harry Benjamin International Gender Dysphoria Association (HBIGDA) Symposium, London, August 1999.

 

[18] H. Cassell, “Controversy Dogs Sexuality Researcher,” Bay Area Reporter, October 4 2007, http://ebar.com/news/article.php?sec=news&article=2274

 

[19] A. Dreger, “The Controversy Surrounding The Man Who Would Be Queen: A Case History of the Politics of Science, Identity, and Sex in the Internet Age,” Archives of Sexual Behavior, vol. 37, no. 3, June 2008, pp. 366-421. http://www.bioethics.northwestern.edu/faculty/work/dreger/controversy_tmwwbq.pdf

 

[20] L. Conway, “An investigation into the publication of J. Michael Bailey’s The Man Who Would Be Queen,” 2004,  http://ai.eecs.umich.edu/people/conway/TS/LynnsReviewOfBaileysBook.html

 

[21] A. James, “’Autogynephilia’: A disputed diagnosis,” Transsexual Road Map, 2004, http://www.tsroadmap.com/info/autogynephilia.html

 

[22] J. Bailey, K. Triea, “What Many Transgender Activists Don’t Want You to Know and Why You Should Know It Anyway,” Perspectives in Biology and Medicine, v. 50, 4,  autumn 2007, pp. 527.

 

 

Copyright © 2008 Kelley Winters, GID Reform Advocates 

Autogynephilia: The Infallible Derogatory Hypothesis, Part 1

 

Kelley Winters, Ph.D.

GID Reform Advocates

http://www.gidreform.org

 

 

In the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, the American Psychiatric Association explained the reasons for removing the diagnostic category of homosexuality: [1]

 

“The crucial issue in determining whether or not homosexuality per se should be regarded as a mental disorder is not the etiology of the condition, but its consequences and the definition of mental disorder.”  [2]

 

This marked a significant shift in diagnostic policy toward the consequence of a condition rather than speculation of its cause. Two decades later, the APA discarded this principle by emphasizing the controversial and inflammatory theory of “autogynephilia” in the supporting text of Gender Identity Disorder diagnosis of the DSM-IV-TR:

 

“Adult males who are sexually attracted to females, to both males and females, or to neither sex usually report a history of erotic arousal associated with the thought or image of oneself as a woman (termed autogynephilia).” [3]

 

This statement and its supporting literature, that hypothesize sexual deviance as a cause of transsexualism, have sparked dissent among clinicians and researchers and outrage within the transgender and transsexual community [4-8]  While theories around “autogynephilia” seem exceptionally impervious to contrary evidence, the controversy has raised questions about tolerance and bias in American Psychiatry– at what point do bad stereotypes preclude good science?

 

The term “autogynephilia,” meaning “love of oneself as a woman,” was first introduced by Dr. Raymond Blanchard of the Clarke Institute of Psychiatry, now known as the Centre for Addiction and Mental Health in Toronto. He is currently chairman of the Paraphilias Subcommittee for the upcoming DSM-V.  Blanchard stated that,

 

“All gender dysphoric males who are not sexually oriented toward men are instead sexually oriented toward the thought or image of themselves as women.” [9]

 

The absolutism in this statement, in the words “all and “instead,” seems astonishing. [10] It reduces a broad continuum of sexuality among transwomen to two narrow maligning stereotypes: either “homosexual males” in denial of a “homosexual” identity or pathological narcissistic “males” sexually attracted to themselves This strict dichotomy stands in contrast to the words of Dr. Alfred Kinsey, the father of modern sexology:

 

“The world is not divided into sheeps and goats. Not all things are black nor all things white. It is a fundamental of taxonomy that nature rarely deals with discrete categories. Only the human mind invents categories and tries to force facts into separated pigeon-holes. The living world is a continuum in each and every one of its aspects. The sooner we learn this concerning sexual behavior the sooner we shall reach a sound understanding of the realities of sex.” [11]

 

Although the phenomenon described by “autogynephilia,” arousal to thoughts of being women, has been reported in personal narratives by some transwomen, [12] there is no apparent basis for projecting this stereotype upon all lesbian, bisexual and asexual transwomen. Dr. Blanchard conflates association with causation by using the phrase “erotic arousal in association with the thought or image of themselves as women” interchangeably with “erotically aroused by the thought or image…” [13]  However, “association with” is not the same as “aroused by.”

 

What role do birth-assigned women play in their own sexual fantasies? We would not consider it odd or “fetishistic” for non-trans women to be themselves on the stage of their sex lives. Nor would we assume that they are aroused by their self-image as women rather than by their partners. Why are lesbian and bisexual transwomen treated so differently by American psychiatry and psychology? For transwomen born without female anatomy, incongruence of our bodies with our self-identities pose understandable barriers to sexual expression. The desire to surmount these barriers is more accurately described as an adaptive accommodation to a physiological deficiency. Does the image of a female body “interfere” with normal attractions as Blanchard suggests [14] or does it enable them?

 

Dr. Blanchard’s studies of clinical patients reporting “erotic arousal in association with cross-dressing” were presented as “fetishistic cases.” [15-16]  His findings have been criticized by psychologist and community advocate Dr. Madeline Wyndzen as having never been replicated, excluding control groups of birth-assigned women, and for confounding causation with observational data. [17]  For gender dysphoric youth with no access to medical transition procedures, is cross-dressing a “fetishistic” pathology, or is it an adaptive coping strategy to an incongruent body?  It seems more plausible that cross-dressing represents an accommodation to conceal or disguise anatomy which poses barriers to lesbian or bisexual expression or fantasy.

 

Dr. Blanchard’s studies omitted control groups of birth-assigned women and the roles that fashion, clothing and lingerie play in their sexual expression and fantasy.  For birth-assigned women, sexual expression is accompanied by a $300 billion fashion industry in the U.S. [18] but without diagnosis of fetishistism or pathology. Dr. Sigmund Freud, however, noted how fashion accompanies sexuality with a metaphorical remark:

 

“In the world of everyday experience, we can observe that half of humanity must be classed among the clothes fetishists. All women, that is, are clothes fetishists. …  For them clothes take the place of parts of the body, and to wear the same clothes means only to be able to show what the others can show, means only that one can find in her everything that one can expect from women, an assurance which the woman can give only in this form.” [19]

 

Freud’s observations on the role of clothing in the expression of womanhood seem relevant to Blanchard’s presumption of  “autogynephilic” pathology in transwomen for whom “clothes take the place of parts of the body”  — parts that nature did not provide.

 

What of transwomen who attest attraction to women and frequently are in very long term relationships, partnerships and marriages with women?  Blanchard’s theory of “autogynephilia,” like Dr. Magnus Hirschfeld’s “automonosexualism,” [20]  implies that all transwomen not exclusively attracted to men are incapable of genuine attraction to other women. [21]  However, clinical literature has long reported 20 to 30 percent of transsexual women attracted primarily or exclusively to other women [22-23].  These early figures were likely understated, as attraction to women posed barriers to access to hormonal and surgical transition care. Nonclinical surveys report higher rates of same-sex orientation (with regard to affirmed identity, not assigned birth-sex) [24-25]  It seems paradoxical that these women are labeled as “autogynephiles” on the basis of their attraction to women, while that very label contradicts the validity of their attraction to women.

 

How does the “autogynephilia” hypothesis, that “all” transwomen are attracted to men or “instead” to themselves, explain the existence of long-term relationships with other women?  Here in Colorado, writer Laurie Cicotello related the story of her remarkable family. In 1997, Ms. Cicotello testified before the Colorado legislature with her father, Dana, a transwoman, educator and advocate respected throughout the transgender community. They spoke in opposition to an anti-gay and lesbian marriage bill that would have threatened her parents’ legal same-sex marriage of forty years at the time of  this writing. Laurie described how she stood with her parents later that year, hands clasped together over their heads, before fifty-five thousand people at the Denver PrideFest Rally. In a state known in the 90s for religious intolerance of GLBT diversity, Dana proclaimed to the crowd, “I’ve got your family values, right here!”[26]

 

Theories of “autogynephilia” not only associate hurtful stereotypes of sexual deviance with transwomen, they presume “erotic anomalies” or self-focused deviance to be the cause of gender dysphoria and the motivation for transition, with both nature and nurture playing secondary roles. Speaking of lesbian, bisexual and asexual transwomen not primarily attracted to men, Dr. Blanchard states:

 

“This hypothesis asserts that the various discriminable syndromes of non-homosexual gender dysphoria are the results of autogynephilia interacting with additional constitutional or experiential factors.” [27]

 

Bailey and Triea recently supported this view that “nonhomosexual transsexuals experience erotic arousal at the idea of becoming a woman, and this arousal motivates them to become women.” [28] However, they nor Blanchard offer evidence of a causal relationship between a sexual affinity for one’s-self and gender dysphoria (intense distress with one’s assigned birth-sex or natal anatomy.)  This body of theory seems to proffer the circular reasoning that:

 

If “autogynephilia” is associated with all lesbian and bisexual transsexual women, then it must be the cause of gender dysphoria for them.

 

And—

 

If  “autogynephilia” is the cause of  gender dysphoria in lesbian and bisexual transsexual women, then all of them must be “autogynephilic.”

 

Proponents of these stereotypes of sexual deviance have not asked the fundamental questions about how gender identity forms in all human beings, transgender and cisgender. They neglect to include control groups of birth-assigned women with their limited, clinical samples of transwomen. They most often neglect to include nonclinical samples of transitioned women living full lives in the real world.  They fail to consider the similarities between birth-assigned women and transitioned women of all sexual orientations, similarities so profound that the existence of large numbers of transitioned women remains unacknowledged by psychiatric researchers. [29] Moreover, the proven efficacy of social and medical transition in relieving the distress of gender dysphoria and improving quality of lives [30-31] remains unexplained by “autogynephilic” theories of etiology.

 

The corollary of  “autogynephilia” theory postulates that straight transwomen attracted to men do not possess female gender identities but are merely gay men in denial. They are branded by Blanchard with a maligning label of “homosexual male transsexuals.” [32] He asserts that straight and lesbian/bisexual/asexual transwomen are so fundamentally different that they represent two entirely distinct “disorders,”

 

“The feminine gender identity that develops in homosexual males is different from the feminine gender identity that develops in heterosexual males. In other words, homosexual and heterosexual men cannot ‘‘catch’’ the same gender identity disorder in the way that homosexual and heterosexual men can both ‘‘catch’’ the identical strain of influenza virus. Each class of men is susceptible to its own type of gender identity disorder and only its own type of gender identity disorder.” [33]

 

Dr. Blanchard’s certainty of mutually exclusive transsexual types based on sexual orientation seems peculiar within sexology, where both gender identity [34] and sexual orientation [11] have long been viewed as continuous rather than dichotomous. He based this assumption on differences in “a history of erotic arousal in association with cross-dressing,” in ages of presentation for “professional help,” and in “degrees of childhood femininity”  within clinical populations. Correlating these attributes to the lack or presence of attraction to males, Blanchard concluded that “the main varieties of nonhomosexual gender dysphoria are more similar to each other than any of them is to the homosexual type.” [35]  However, a recent study of gender-dysphoric MTF subjects reported no significant difference in scores on a gender identity/gender dysphoria questionnaire with regard to sexual orientation. [36] This result is not explained by Blanchard’s assumption of fundamentally different gender identities.

 

Blanchard’s analogy of gender variant identities to communicable disease is offensive and perhaps demonstrative of bias.  His research does not consider the shame and guilt that force gender dysphoric youth and adults into the closet, often for decades. For example, “degrees of childhood femininity” may indicate degrees of closeted self-expression far more than innate femininity. The doctrine of “autogynephilic” dichotomy neglects different social pressures faced by gender dysphoric youth and adults, based on their sexual orientations. These differences in social oppression would certainly impact their ability to emerge from the closet and express their inner identities.

 

Inferring gender identity based on age of clinical presentation is especially troubling, given Zucker and Bradley’s observation that gender variant youth are “invariably” referred by adults and not by themselves. [37]  Admission to clinics that practice gender-reparative therapy (attempting to change one’s gender identity or espression) may well indicate parental intolerance rather than gender identity per se.  For MTF youth, dates of clinical presentation may likely signify the dates they were caught by their parents in their sisters’ clothes and little more.  For any closeted population, it is wrong to confuse “onset” with presentation to a mental institution or clinic.

 

For straight transwomen attracted to men, Dr. Blanchard states that all “homosexual gender dysphorics are sufficiently similar to be treated as one diagnostic group.” [38] The statement makes clear the intent of “homosexual gender dysphorics” as a term of mental disorder. However the theory that attraction to men is the sole motivation for transition does not explain why the vast majority of gay males do not transition. It does not explain very low rates of surgical regrets for transwomen, with and without partners or spouses. Nor does it explain very young children who are painfully distressed with their assigned birth-sex or why some transition years before adolescence. What then would differentiate straight transwomen and girls from gay males, if gender dysphoria is hypothesized to exclude any innate sense of gender identity?

 

Perhaps the model of “homosexual gender dysphoria” assumes that living as transsexual women is somehow socially advantageous to living as gay men. To the contrary, gay men possess greater social status, economic privilege and civil rights protection than transwomen in the U.S. and much of the world. For example, 20 states currently prohibit workplace discrimination based on sexual orientation, while only 12 include protection based on gender identity. 88 percent of U.S. Fortune 500 employers prohibit discrimination based on sexual orientation versus 25 percent that include gender identity. [39]  It seems farfetched that “all” straight transwomen who forfeit social status to transition would be driven only by attraction to men.

 

 

To Be Continued—

Autogynephilia: The Infallible Derogatory Hypothesis, Part 2

 

 

 

 

 

[1] Diagnostic nomenclature of homosexuality was actually removed from the DSM in intermediate stages over a fourteen year span.  Homosexuality per se was replaced by Sexual Orientation Disturbance in the seventh printing of the DSM-I in 1973 and by Ego-Dystonic Homosexuality in the DSM-III in 1980. This was removed from the DSM-III-R in 1987. While APA policy now affirms that same sex orientation is no longer regarded as mental disorder, two diagnostic categories remain in the current DSM-IV-TR that may be used to diagnose homosexuality as mental illness: Sexual Disorder Not Otherwise Specified and Gender Identity Disorder of Children.

 

[2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, 1980 p. 380.

 

[3] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000, p. 578.

 

[4] H. Cassell, “Controversy Dogs Sexuality Researcher,” Bay Area Reporter, October 4 2007, http://ebar.com/news/article.php?sec=news&article=2274

 

[5] M. Wyndzen, “Everything You Never Wanted to Know About Autogynephilia (But Were Afraid You Had To Ask),” Psychology of Gender Identity & Transgenderism, 2004, http://www.genderpsychology.org/autogynephilia/

 

[6] A. Dreger, “The Controversy Surrounding The Man Who Would Be Queen: A Case History of the Politics of Science, Identity, and Sex in the Internet Age,” Archives of Sexual Behavior, vol. 37, no. 3, June 2008, pp. 366-421. http://www.bioethics.northwestern.edu/faculty/work/dreger/controversy_tmwwbq.pdf

 

[7] L. Conway, “An investigation into the publication of J. Michael Bailey’s The Man Who Would Be Queen,” 2004,  http://ai.eecs.umich.edu/people/conway/TS/LynnsReviewOfBaileysBook.html

 

[8] A. James, “’Autogynephilia’: A disputed diagnosis,” Transsexual Road Map, 2004, http://www.tsroadmap.com/info/autogynephilia.html

 

[9] R. Blanchard, “The Classification and Labeling of Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 18 n. 4, 1989, p. 322-323.

 

[10] K. Wilson (former pen-name for Kelley Winters), “Autogynephilia: New Medical Thinking or Old Stereotype?” Transgender Forum Magazine, April 16, 2000. http://www.gidreform.org/kwauto00.html

 

[11] A. Kinsey, W. Pomeroy, and C.Martin. Sexual Behavior in the Human Male, W.B. Saunders:

1948, p. 639.

 

[12] A. Lawrence, “28 narratives about autogynephilia,”  2004, http://www.annelawrence.com/agnarratives.html.

 

[13] R. Blanchard, “Early History of the Concept of Autogynephilia,” Archives of Sexual Behavior, Vol. 34, No. 4, August 2005, p. 439.

 

[14]  Blanchard 1989, p. 323.

 

[15] R. Blanchard, “Typology of male-to-female transsexualism,” Archives of Sexual Behavior, v. 14, 1985, pp.  247-261.

 

[16] R. Blanchard, “Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 24, 1988, pp.  188-193.

 

[17] Wyndzen M.H. (2004).  “A Personal and Scientific look at a Mental Illness Model of Transgenderism,” Division 33 Newsletter, Society for the Psychological Study of Lesbian, Gay, and Bisexual Issues, Vol. 20, No. 1, Spring. P.3.  http://www.genderpsychology.org/autogynephilia/apa_div_44.html

 

[18] C. Horyn, “Fashion Industry Rallies to Aid Designer in Trouble, New York Times, May 7, 2007.

 

[18] A. Hamlyn, “Freud, Fabric, Fetish,”  Textile: The Journal of Cloth and Culture, Volume 1, Number 1, 1 March 2003 , pp. 8-26.

 

[20] Blanchard 1989, p. 317.

 

[21] Wilson 2000.

 

[22] J. Wålinder, Transsexualism: A Study of Forty-Three Cases, Scandinavian University Books, 1967.

 

[23] K. Freund, B. Steiner, & S. Chan, “Two Types of Cross-Gender Identity,” Arch. Sex Beh 11: 49-63.

 

[24] J. Xavier, “The Washington Transgender Needs Assessment Survey,” US Helping Us – People Into Living, Inc., Washington D.C., 2000, http://www.glaa.org/archive/2000/tgneedsassessment1112.shtml

 

[25] P. De Sutter, K. Kira, A. Verschoor and A. Hotimsky, “The Desire to have Children and the Preservation of Fertility in Transsexual Women: A Survey,” International Journal of Transgenderism, v. 6 n. 3, 2002, http://www.symposion.com/ijt/ijtvo06no03_02.htm

 

[26] L. Cicotello, “She’ll Always be my Daddy,” in N. Howey and E. Samuels, Out of the Ordinary: Essays on Growing Up with Gay, Lesbian, and Transgender Parents, Macmillan 2000, pp. 131-142.

 

[27] Blanchard 1989, p. 232.

 

[28] J. Bailey, K. Triea, “What Many Transgender Activists Don’t Want You to Know and Why You Should Know It Anyway,” Perspectives in Biology and Medicine, v. 50, 4,  autumn 2007, pp. 527-529, 531.

 

[29] F.  Olyslager and L.Conway, “On the Calculation of the Prevalence of Transsexualism,” WPATH 20th International Symposium, Chicago, Illinois, 2007. http://ai.eecs.umich.edu/people/conway/TS/Prevalence/Reports/Prevalence%20of%20Transsexualism.pdf , Submitted for publication, International Journal of Transgenderism (IJT).

 

[30] F. Pfäfflin, A. Junge , Sex Reassignment: Thirty Years of International Follow-Up Studies after SRS — A Comprehensive Review, 1961-1991. 1992, English translation 1998. http://209.143.139.183/ijtbooks/pfaefflin/1000.asp

 

[31] A. Lawrence, “Factors associated with satisfaction or regret following male-to-female sex reassignment surgery,” Archives of Sexual Behavior, v. 32 n. 4, August 2003, pp. 299-315, http://www.accessmylibrary.com/coms2/summary_0286-23760688_ITM

 

[32] Blanchard 1985, p. 247.

 

[33] Blanchard 2005, p. 443.

 

[34] Benjamin, H. (1966). The transsexual phenomenon. New York: The Julian Press, page 22-23.

 

[35] Blanchard 1989, pp. 315, 324-325.

 

[36] J. Deogracias, L. Johnson, H.  Meyer-Bahlburg, S. Kessler, J. Schober, K. Zucker, “The gender identity/gender dysphoria questionnaire for adolescents and adults,” Journal of Sex Research, v. 44 n. 4, November 2007, pp. 370-379, http://findarticles.com/p/articles/mi_m2372/is_4_44/ai_n27467813***

 

[37] K. Zucker and S. Bradley, “Gender Identity Disorder and Transvestic Fetishism,” in S. Netherton, D. Holmes and C. Walker, eds, Child and Adolescent Psychological Disorders: A Comprehensive Textbook, Oxford Univ Press, 1999, p. 386.

 

[38] Blanchard 1989, p. 331.

 

[39] Human Rights Campaign, Inc., The State of the Work Place 2006-2007, http://www.hrc.org/documents/State_of_the_Workplace.pdf

 

 

 

Copyright © 2008 Kelley Winters, GID Reform Advocates 

 

 

Disordered Identities: The Ambiguously Sexual Fetish

 

Kelley Winters, Ph.D.
GID Reform Advocates
www.gidreform.org

 

In January 2000, Peter Oiler, a married Louisiana truck driver for the Winn-Dixie grocery chain, was fired from his job after he came out of the closet to his boss,

“I told him  … I’m not gay, I’m transgendered.”
“I told him I have a tendency to dress as a lady.” [1]

A Winn-Dixie manager explained why Peter, an exemplary employee of more than 20 years, was terminated:

“[Oiler] was doing something that was abnormal in most people’s opinion about what was accepted for a person who is a man.” [2]

Unfortunately, such derogatory public perceptions about cross-dressing and “abnormality” are promoted by the American Psychiatric Association in the current Diagnostic and Statistical Manual of Mental Disorders (DSM), edition IV-TR. [3] The diagnostic category of Transvestic Fetishism casts gender nonconformity in clothing as mental disorder and sexual deviance. Its inclusion in the DSM begs the question, should a clothing disorder merit medical nomenclature?  Is cross-dressing by born-males a psychosexual wardrobe malfunction or is it simply a facet of human diversity “ubiquitous throughout human history?”[4]

The term, transvestite, was coined by Magnus Hirschfeld in 1910 from Latin roots meaning to cross-dress. Transvestism in the DSM-III was renamed “Transvestic Fetishism” (TF) in the DSM-III-R [5]. The very title equates cross-dressing with sexual fetishism and social stereotypes of perversion. It sexualizes a diagnosis that does not clearly require a sexual context. In fact, Hirschfeld rejected fetishism as a diagnostic label for cross-dressing that represents self-expression, erotic or not, rather than erotic focus on clothing itself. [6]

Cross-dressing very often represents social expression and social identity. People who identify as cross-dressers make up a large portion of the emerging transgender movement.  The oldest U.S. national support organization for heterosexual cross-dressers, the Foundation for Personality Expression, was founded by Virginia Prince in the 1960s and is now known as The Society for the Second Self or Tri-Ess. [7]  Tri-Ess describes cross-dressers as “ordinary heterosexual men with an additional feminine dimension.” Their vision emphasizes “Full personality expression, in a blending of both our masculine and feminine characteristics, in order to be all we can be.” [8]  However, the diagnostic criteria for Transvestic Fetishism ambiguously reduces this social expression of femininity by cross-dressing males to sexual deviance.

 

Criterion A for Transvestic Fetishism:

Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. [9]

 

Criterion A is grammatically ambiguous. [10]  The phrase, “sexually arousing,” could be interpreted to apply to only “fantasies” or to all three of “fantasies, sexual urges, or behaviors” with very different meaning. The first interpretation would implicate all recurrent cross-dressing behavior as sexual deviance. This interpretation is promoted in the DSM-IV Casebook, [11] which recommends a TF diagnosis for a male whose cross-dressing is not necessarily sexually motivated. The second would limit the diagnosis to sexually motivated cross-dressing, as did the DSM-III-R, [12] and imply the ackward phrase, “sexually arousing sexual urges.” Although labeled a “fetishism,” it is not clearly stated whether or not cross-dressing must be sexual in nature to qualify for diagnosis.

Moreover, coincidence is conflated with causality in the phrase “behaviors involving cross-dressing,” which requires no actual erotic motivation. This can imply that all cross-dressing by born-males is sexually motivated, whether it is or not.  The resulting stereotype of sexual deviance is not limited to cross-dressers but disparages transsexual women as well. Full-time transition to a female social role could be interpreted as “behaviors involving cross-dressing” and therefore “fetishistic” under Criterion A.

 In fact, transsexual and gender dysphoric individuals were specifically excluded from Tranvestic Fetishism diagnosis in the DSM-III-R [13] and this exclusion was removed in the DSM-IV.  A major focus of the DSM-IV Subcommittee of Gender Identity Disorders was to allow concurrent diagnosis of GID and TF which was prohibited in previous editions. [14]  A positive consequence of this change removed barriers to medical transition care for transsexual women who had been diagnosed as “transvestites.” However, it also broadened the stigma of sexual paraphilia and deviance to include many transsexual women.

Diagnosis of Transvestic Fetishism is limited to heterosexual males in Criterion A. Curiously, women and gay men are free to wear whatever clothing they chose without a label of mental illness. This criterion serves to enforce a stricter standard of conformity for straight males than women or gay men. Its double-standard not only reflects the social privilege of heterosexual males in American culture, but enforces it. [15]  One implication is that biological males who emulate women, with their lower social status, are presumed irrational and mentally disordered, while biological females who emulate males are not. A second implication stereotypically associates femininity and cross-dressing with male homosexuality and serves to punish straight males who transgress this stereotype.  Author Arlene Lev noted that the TF diagnosis is “more about sexist values and conflicts between individuals and society than they are about sexual disorders and human distress.” [16]  This violates the definition of mental disorder given in the DSM, which specifically exclude “conflicts between the individual and society” without  clinically significant dysfunction. [17]

Criterion B for Transvestic Fetishism:

The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Distress and impairment became central to the definition of mental disorder in the DSM-IV, [18] where a generic clinical significance criterion was added to all Sexual and Gender Identity disorders, including Criterion B of Transvestic Fetishism. It was an attempt to prevent false-positive diagnosis of people who do not meet the definition of mental disorder.

Unfortunately, Criterion B does not specifically define distress or impairment for the TF diagnosis. It does not allow for the existence of healthy, well-adjusted male-identified heterosexual cross-dressers. Moreover, Criterion B makes no distinction between internal clinical distress and that caused by external prejudice and discrimination. Tolerant clinicians may infer that transgender identity or expression is not inherently impairing, but that societal intolerance and prejudice are to blame for the distress and internalized shame that transpeople often suffer. [19] However, clinicians intolerant of gender diversity will infer the opposite: that cross-gender identity or expression by definition constitutes impairment, regardless of the individual’s happiness or well-being.

Dr. Kenneth Zucker, chair of the present DSM-V Sexual and Gender Identity Disorders work group and Dr. Raymond Blanchard, chair of the DSM-V paraphilias subcommittee, were critical of including the clinical significance criterion for Transvestic Fetishism and dismissed it as “muddled” and having “little import.”  They reasoned that “individuals with TF who consult mental health professionals are presumably, in some respect, distressed or impaired by their condition.” [20]  This circular logic is even more concerning, because “… adolescents with TF rarely self-refer. The initiative is invariably on the part of an adult.” [21]. This implies that cross-dressing youth who are subjected to intolerance by parents or authorities are classed a priori as mentally disordered.

Ironically, the clinical significance critera for five other paraphilia diagnoses in the DSM-IV-TR, Exhibitionism Froteurism, Pedophilia, Sexual Sadism and Voyeurism, were revised with more precise wording to limit inappropriate diagnosis. [22] The APA apparently had no such concern for false-positive diagnosis of gender nonconforming males who meet no definition of mental disorder.

In the supporting text of the TransvesticFetishism diagnosis, behaviors that would be considered ordinary or exemplary for genetic women are presented as symptomatic of mental disorder on the basis of born genitalia and sexual orientation. These include collecting and wearing female clothes or undergarments, dressing entirely as females, wearing makeup, expressing feminine mannerisms and “body habitus,” and appearing publicly in a feminine role. [23] It is not clear how these same behaviors can be pathological for one group of people and not for another.

More disturbing, the supporting text lists “involvement in a transvestic subculture” among symptomatic “transvestic phenomena.” Psychiatric diagnosis on the basis of social, cultural or political affiliation evokes the darkest memories of medical abuse in American history. For example, women suffragettes who demanded the right to vote in the early 1900s were diagnosed and institutionalized with a label of “hysteria.” [24]  Immigrants, Bolsheviks and labor organizers of the same era were labeled as socially deviant and mentally defective by psychiatric eugenicists. [25] In truth, transgender support organizations worldwide are a primary source of support, education and civil rights advocacy for gender variant people, families, friends and allies. Their necessity is a consequence of social intolerance, not of mental deficiency.

The Transvestic Fetishism diagnosis is currently classified as a sexual paraphilia, defined in the DSM-IV-TR as

“recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation or oneself or one’s partner, or 3) children or other nonconsenting persons” [26]

Sexual paraphilias in the DSM include such terribly stigmatizing disorders as Pedophilia, Exhibitionism, Fetishism, Frotteurism, Sexual Masochism, Sexual Sadism, and Voyeurism. This placement of the TF diagnosis serves to legitimize false stereotypes that unfairly associate cross-gender expression with criminal or harmful conduct.

Lacking a clear justification for the Transvestic Fetishism diagnosis according to the definition of mental disorder in the current DSM, its authors resorted to the heteronormative presumption:

“If the phylogenetic function of sexuality or eroticism is reproduction, and if its ontogenetic function is to enhance pair-bond formation and intimacy, then TF clearly is problematic at both levels of analysis.” [27] 

This is essentially the argument used to justify the classification of homosexuality in prior editions of the Diagnostic and Statistical Manual [28-30]. In proclaiming gender role nonconformity as mental illness, the authors of Transvestic Fetishism fail to mention the role of intolerance, prejudice and sex stereotyping as barriers to intimacy and pair-bonding in a species as diverse as ours.

Speaking at the 2003 Annual Meeting of the American Psychiatric Association, Dr. Charles Moser noted, “Diagnoses should be removed if they cannot be shown to meet the definition of a mental disorder unambiguously and be substantiated by appropriate research.”  [31]  Arlene Lev concurred for the case of Transvestic Fetishism:

“transvestic fetishism is a normal human behavior transformed into a mental illness. … it should not be listed in a manual of mental disorders.” [32]

Perhaps Peter Oiler said it best,

 “I’m tired of the closet. It’s dark and musty and I want out! I want to settle some issues I have with myself. I want to tell everyone in my situation, “you are not alone.” It doesn’t make you a weirdo to put on a dress or pants.” [33]

With publication of the DSM-V, it is time for the American Psychiatric Association to remove the anachronistic and sexist diagnosis of Transvestic Fetishism. Nonconformity to gender stereotypes is not mental illness; difference is not disease.

 

 

[1] GenderPAC, “GenderPAC National News Interviews Peter Oiler,” Feb 2001, http://www.gpac.org/archive/news/notitle.html?cmd=view&msgnum=0275

[2] K. Choe, American Civil Liberties Union, “Why We’re Asking Courts and Legislatures for Transgender Equality, ”  Where We Are 2003: The Annual Report of the ACLU Lesbian & Gay Rights Project, Jan 2003, http://www.aclu.org/lgbt/transgender/12077pub20030101.html

[3] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.

[4] V. Bullough and B. Bullough, Cross Dressing, Sex and Gender, Univ. of Pennsylvania Press, 1993, p. 18.

[5] American Psychiatric Associatio, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, 1987, p. 288.

[6] M. Hirschfeld, The Transvestites: An Investigation of the Erotic Drive to Cross Dress [Die Tranvestiten], Leipzig: Sporh, 1910;  trans. M. Lombardi-Nash, Promethius Books, 1991, p. 161.

[7] V. Prince, R. Ekins, and D. King, Virginia Prince: Pioneer of Transgendering, Haworth Press, 2005, pp. 7-8.

[8] The Society for the Second Self, Inc. , http://www.tri-ess.org/ 

[9] DSM-IV-TR, 2000, p. 575.

[10] K. Winters (published under pen-name Katherine Wilson) and B. Hammond, “Myth, Stereotype, and Cross-Gender Identity in the DSM-IV,” Association for Women in Psychology 21st Annual Feminist Psychology Conference, Portland OR, 1996,  http://www.gidreform.org/kwawp96.html.

[11] Spitzer, R., editor,  DSM-IV Casebook, A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition), American Psychiatric Press, 1994, pp. 257-259.

[12-13] DSM-III-R, 1987, p. 289.

[14] Bradley, S., et al. (1991). “Interim Report of the DSM-IV Subcommittee on Gender Identity Disorders,” Archives of Sexual Behavior, Vol. 20, 1991, No. 4, p. 338.

[15] K. Wilson (former pen-name for Kelley Winters), “Gender as Illness: Issues of Psychiatric Classification,” 6th Annual ICTLEP Transgender Law and Employment Policy Conference, Houston, Texas, July 1997. Reprinted in Taking Sides – Clashing Views on Controversial Issues in Sex and Gender, E. Paul, Ed., Dushkin McGraw-Hill, Guilford CN, 2000, pp. 31-38.  http://www.gidreform.org/kwictl97.html

[16] A. Lev, Transgender Emergence, Therapeutic Guidelines for Working with Gender-Variant People and Their Families, Haworth Press, 2004, p. 171.

[17] DSM-IV-TR, 2000, p. xxxi.

[18] DSM-IV, 1994, p. xxi.

[19] G. Brown, “Cross-Dressing Men Often Lead Double Lives,” The Menninger Letter, April, 1995, pp. 4-5.

[20] K. Zucker and R. Blanchard, “Transvestic Fetishism: Psychopathology and Theory,” Handbook of Sexual Deviance: Theory and Application, Guilford Press, 1997, p. 258.

[21] K. Zucker and S. Bradley, “Gender Identity Disorder and Tranvestic Fetishism,” eds. S. Netherton, et al., Child and Adolescent Psychological Disorders, A Comprehensive Textbook, Oxford Press, 1999, p. 386.

[22-23] DSM-IV-TR, 2000, p. 574.

[24] M. Mayor, “Fears and Fantasies of the anti Suffragists,” Connecticut Review 7, no. 2, April 1974, pp. 64-74.

[25] I. Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940. Sage House, 1997, pp. 133-177.

[26] DSM-IV-TR, 2000, p. 566.

[27] Zucker and Blanchard, 1997, p. 262.

[28] S. Rado, Psychoanalysis of Behavior II, Grune and Stratton, 1962.

 [29] C. Socarides, The Overt Homosexual, Basic Books, 1962.

 [30] R. Stoller, J. Marmor, I. Beiber, et al.,”A Symposium: Should Homosexuality be in the APA Nomenclature?” American Journal of Psychiatry, vol. 130, 1973, pp. 1208-1215,

[31] C. Moser and P. Kleinplatz, “DSM-IV-TR and the paraphilias: An argument for removal.” Journal of Psychology and Human Sexuality 17(3/4), also published in Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Eds.  D. Karasic, and J. Drescher, Haworth Press, 2005, p. 106.

[32] Lev, 2004, p. 171.

[33] GenderPAC, 2001.

 

Copyright © 2008 Kelley Winters, GID Reform Advocates