Saturday, 20 April 2013

Emasculation Trauma (an anonymous article from


Perhaps including Jasper Gregory's insights, this is the most elucidating article on autogynephilia that seems to be on the internet. To get straight to the most relevant stuff I recommend skipping to chapter 4.

This analysis covers areas considered controversial in the trans-community, primarily human diversity and autogynephilia. While not an academic text as such, this analysis attempts to formulate some cohesive thoughts on these issues where coherent thought and jumping to sensationalist conclusions are rife. After all, reasoned analysis can be complicated and "unsexy".
While the focus is on male-to-female transsexuals (M2Fs) some of the material is applicable to F2Ms. Possible causes of autogynephilic desires - and their immutability - are explored here, something that appears to be left curiously unexamined by even experienced doctors and academics. While it is more exciting to announce an unusual sexual orientation, it seems to be rather less enthralling for pundits to look behind the actions at the underlying psychodynamics.
In a nutshell, this analysis methodically examines the most likely cause of autogynephilic tendencies and, in doing so, makes it clear that such inclinations are often not the reason why transsexuals change their outward gender but is actually caused by transsexuals' innately cross-gender characteristics and the frisson between those traits and society's norms.
As a result of this realization, a redefinition of Ray Blanchard's hypotheses is proposed, marrying his concepts with other factors involved in transsexualism, demonstrating that transsexualism is not a issue that lends itself to simple black-and-white analysis; ergo, there are not just two types of transsexuals, and there is a good deal of overlap between groups that have been currently defined.
The menu above indicates of the issues explored and an overview and summary are provided in the In Summary page for those without the time or inclination to go into detail.

Why should anyone bother analyzing transsexualism?

It is easy to sympathize with those who argue that there is no good reason to analyse to causes and roots of transsexualism and that we should simply accept the phenomenon as exactly that, a phenomenon, or more colloquially. take the approach that "stuff happens".
However, there are now a number of forces aligning against transsexuals. Apart from the usual suspects - conservatives and rednecks - transsexuals now also must contend with attacks from anti-trans groups run by ex-transsexuals, a burgeoning religious fundamentalism movement, along with the continuing skepticism of radical feminists and non-empathetic gay men - all willing to attack transsexuals with fanatical zeal.
If transsexuals are to survive this seemingly never-ending assault upon their credibility it needs to be made clearer what transsexualism is and what it means. The fact is that, to many, the "woman trapped in a male body" is neither satisfactory nor credible; such a claim is unscientific and is only true for practical means and purposes, and even then only in some cases.
In the political sphere, candidates from both sides of the political fence are becoming increasingly conservative, reflecting an electorate fearful of change in a dynamic and globalized world. Some of the anti-trans lobby groups are red-hot in their beliefs and may yet find sympathetic ears in our conservative Governments.
Further, as if transsexuals didn't have enough to cope with, there is considerable infighting within their own ranks in regard to the different means of identifying different types of transsexuals. Aggressive internal conflict only plays into the hands of those who wish to undermine what are among the most (unfairly) downtrodden people in society.
All of the above means that the need to be more precise in clearly describing transsexualism becomes ever more essential if transsexuals are to experience anything approaching normal human rights.
Before ideas or hypotheses are announced or denounced, we need to revisit some basic facts - what we already know about cross-gendered human behavior.

1. Nature vs nurture: humans are diverse

Throughout history, and prehistory for that matter, there have been people who have taken on opposite sex roles in their societies /tribes / groups. Clearly a Bell Curveof sorts applies to the level of masculinity and femininity found within each gender. In this context we are talking about psychological and social aspects and androgynous characteristics, not intersex conditions.
In the past, people with cross-gender leanings and identification were unable to access the kind of technology which helped create the concept of transsexualism as it is known today. In the absence of technology, such people changed their social role and conducted and presented themselves as the opposite sex. There is little doubt that had they been able to avail themselves of today's treatments they would have done so.
The existence of human diversity is the most compelling reason for cross-gender behaviour and identification to be properly accepted by governments and the public at large. That is, transgender behaviour is a natural human variation, and there is no valid reason for discriminating against "non normal" individuals simply because they are uncommon.
Whilst only affecting a small percentage of people, the fact that cross-genderedness is not common does not make it "unnatural", a frequent charge made against cross-gendered individuals (just as it was, and occasionally still is, made about homosexual people).
Not surprisingly, human beings are not the only species to engage in these behaviours  as graphically evidenced in Joan Roughgarden's Evolution's Rainbow : Diversity, Gender, and Sexuality in Nature and People, which details varying gender roles (eg. a number of fish change sex during their lifetimes) and sexuality (eg. many mammals engage in homosexual relations). As with every other part of nature, humans are diverse.
In regard to human diversity, some females are extremely feminine - princess types - who tend to be hyper-sensitive, dependent and sedentary by nature. There are also some highly masculine women - warrior women if you like - who are athletic, independent and aggressive. Between those extremes are the vast majority of women, graduating from very feminine to very masculine in varying ways.
Not surprisingly, this principle applies equally to males - from the girly boys to gladiators, drag queens to footballers, with most men fitting somewhere inbetween.
This is standard diversity, and it can be found in all aspects of nature aside from gender and sexuality - from the height and weight of animals and plants to the weather. Our school marks, IQs, our earnings, our musicality, intelligence and even levels of compassion in some way can fall into a Bell - or some equivalent - curve.
In short, in any area of life you will find a small number of extremes at either end with the majority occupying the middle ground.

Biological factors and culture

What causes gender diversity within a particular sex? What exactly is "female" about M2Fs and what is "male" about F2Ms?
Studies have shown that there are elements of intersex conditions - such as Klinefelter Syndrome (XXY males) and Partial Androgen Insensitivity Syndrome (PAIS) - in only a tiny minority of transsexual cases. There has been some research into transsexuals' levels of HY antigens but at this stage it is inconclusive and is not considered relevant in the majority of cases.
One obvious factor is genetics. Genetics clearly plays a role, even though there is no evidence that transsexualism per se is passed on genetically (bearing in mind that a "transsexual gene" would be expected to be an evolutionary dead end).
To explain genetic factors further, a male who is 190cms tall with a broad skeletal structure, with thick beard growth and body hair, and strongly masculine facial features will logically be less likely to seek a sex change than a person of similar mentality but who is under 175cms tall, slender, relatively hairless, and possesses a "pretty" face. Some people are so lacking in the expected characteristics of their sex that life can be very difficult for them in a society with simplistic notions of sex and gender.
Brain sex is another important issue. One (limited) study of transsexuals showed that a nucleus in the hypothalamus of transwomen was identical to that of genetic women, and differing from those of both gay and straight men. However, because of the limited number of subjects - mainly because such experiments can only be performed post-mortem - the results cannot be deemed conclusive. In addition, it is not known whether the brain structure actually caused the transsexualism or is a result of it.
Nonetheless, this result tentatively suggests that post-operative transsexuals may have a greater claim to legitimacy in their quest for recognition as women than some protagonists may claim.
Pre-natal hormonal conditions
Another area that has been studied is the action of hormonal conditions within the womb on a developing foetus. There is obviously a range of possible hormonal conditions that can occur in-utero, from a high level of hormones matching the foetus' chromosomes to high levels of opposing hormonal conditions.
These conditions not only may vary from gestation to gestation, but they may also fluctuate during a single gestation. To further complicate issues, the way hormonal variations affect a developing foetus depend on when they occur during a gestation, and to what extent they are experienced (ie. how receptive a fetus is to the hormones it encounters).
Especially important in this context is the first half of the first trimester, when the foetus' brain is undergoing pivotal developments. A high level of oestrogen during this period can result in an XY foetus' brain remaining mostly in the female state, bearing in mind that all XY fetuses start as female and are shaped into the male form by the action of hormones in-utero.
In this context experiments where pregnant laboratory rats were given estrogen during the period where their fetuses' brains were developing are enlightening. The male rats born from these hormonally-altered pregnancies assumed the female mating position when placed with normal male rats. That is, their brains were "wired female", at least in regard to their sexuality.
Barring interventions in a laboratory, factors such as stress, diet and drugs can make a profound difference to in-utero hormonal states.
This begs the question, why would high-level stress create such an effect? Could there be an evolutionary advantage in a stressed mother bearing "sissies"? In the wild, the main causes of stress-related problems would most likely be conflict and famine. Perhaps less combative male offspring with reduced inclination to breed could be an advantage in times or war and famine?
Of course, this idea is just speculation, although it may yet prove an interesting line of inquiry for scientists at some stage.

Nature and nurture

Whatever, it is fair to assume that there can be biological factors at play behind people's cross-gender inclinations. However, it is the interplay between the biological and social that decides how a cross-gendered (as opposed to intersexed) person deals with his or her situation.
Culture clearly must play a role. If a naturally cross-gendered person lived with his or her family on a desert island, it is hard to imagine that s/he would seek to change his/her gender role or body. Transsexualism, along with gender roles in general, is necessarily contextual.
Cultural influence, however, does not necessarily render transsexualism invalid. After all, if any of us lived in isolation from society on a desert island our interest in art, relationships, politics, career, hobbies and our gender role, amongst other things - areas that most of us consider paramount to our fulfilment - would be markedly altered. What would modern people who harbour passions for modern art, jazz, movies, knitting, the law, interior design, cars, human rights, computers or religion be interested in if they lived on a remote desert island?
The point here is that, as social animals, virtually every activity humans undertaken is contextual in relation to the social group.
Social aspects of transsexualism will be discussed in greater detail later in this analysis. As mentioned earlier, the challenge for transsexuals is to explain their situations to others in a more credible manner, that is, in a manner which can help lawmakers and other power-brokers better understand that they are as deserving of full human rights as anyone else.
General acceptance and credibility is more likely to become more widespread if some of the confusion and incongruity is drawn from the issue.
For instance, many people cannot understand why some masculine males - both physically and mentally - undergo gender reassignment, yet some highly feminine males happily retain an identity as gay (and sometimes heterosexual) men.
Until the conundrums such as these are better explained than has been the case so far, the validity of transsexualism will continue to be questioned by those with an instinctive phobic reaction to it.

2. Diversity in society

As discussed in Part 1, the way human diversity plays out is affected by the societal setting in which it exists.
It is easy to see how a highly feminine male in prehistoric times could find himself being excluded from hunting and warfare and being given "women's work". The tribe would see him as a liability in classically masculine pursuits, needing to be carried by his peers. It would be fair to say that feminine males may well have tended to die prematurely on the hunt or during warfare due to their lesser competence in these endeavours.
In some tribal societies, notably those of the American Indians and Pacific Islanders, feminine males took on female roles. They assisted with child-minding, arts and crafts, and took on ceremonial duties. This indicates that so-called "primitive" societies, by observing human diversity within their midst over time, realized that it was to everyone's advantage to be flexible in how they utilized their "human resources".
By the same token, it would also be to the advantage of tribal societies to utilize the skills of any women within their ranks who had weak maternal instincts and a natural aptitude for active, typically-masculine pursuits.
Life in pre-"civilized" times was tenuous, often close to the edge of survival. Few people lived beyond 40 years of age. Tribal groups and small communities could scarcely afford the luxury of underutilizing any community member; they needed to make the best possible use of their people after expending so much time, energy and scarce resources towards their upbringing. It hardly made sense to let them flounder and die prematurely performing roles in which they were unsuitable. It was only logical for them to let them use their natural aptitudes to best advantage.

In modern society, by contrast, our affluence and technology virtually assures our survival, and it could be said that we fell we can afford to let some people, like gender-transgressors, fall by the wayside. That is, we complacently ignore the potentials of some of our human resources. It is ironic that our so-called advanced societies still struggle with what is a very basic fact - we are not all the same.

People have taken on opposite sex roles from pre-history right up to the present. It is not difficult to imagine the kinds of people today who would have taken on those ancient gender-bending roles had they been born a few thousand years earlier - transsexuals and gender-transgressive gays.

The effect of culture - taboos

Modern Western society (along with some older societies) adds an extra layer of complexity to the situation - probably mostly due to residual religious fundamentalism from Elizabethan times. As a result, much of our awareness (and efficient use of) human diversity has been lost in a sea of dogma; unbending "shoulds" and "oughts" often hinder our ability to simply accept "what is".

In societies dominated by Christianity, Judaism and Islam, crossing gender boundaries has generally been considered "sinful" and "unnatural", based on selective use of religious texts to justify discriminatory attitudes. For example, it is unclear to the author why we (thankfully) do not stone women to death for adultery today, even though the Bible exhorts us to do this.
This begs the question, how did those "conservative" attitudes come about in the first place?
Initially, hostility towards queer people was no doubt due to their lesser ability to breed prolifically than their "normal" peers. Certainly, in some tribal / traditional societies (such as Aborigines living in outback Australia in pre-settlement days) it was impossible for queer people to do anything but take on the standard heterosexual role as best they could.
Instinctually, this approach is based on the "populate or perish" principle. Its manifestation today now appears under the banner of "family values", but in essence it is the same thing.
Once the taboo was established, another layer of complexity was added to "queer phobia". A number of indigenous cultures condone same-sex relations in youth as preparation for opposite-sex relations in adulthood. More recently, the Greek Empire famously took this approach (and took it beyond youth as well). In modern times homosexual activity between individuals who identify as heterosexual is commonplace in single sex boarding schools, jails, and other arenas where opposite-sex opportunities are artificially limited.
The above indicates that people generally have a greater capacity to respond sexually to the attentions of either gender than they care to admit, but refuse to act on those feelings or desires to avoid stigmatization.

Sexuality and identity politics

In terms of sexual identity, modern people tend to polarize into two major camps - straights and gays. Visible bisexuals are but a very small sub-group. So the two main camps consist of those who fear the culturally-transmitted taboos and those who see themselves as outsiders, a least in a sexual sense.
Therefore our sexuality tends not to be (although it can be) not just what we do but who we are. That is, our sexuality becomes our identity, at least in part, and is not necessarily related to our true activities or desires.
This is the reason why so many gay people are as vehement in denying the possibility of bisexuality in themselves as heterosexuals. If we were truly honest, or if our sexual responses were scientifically measured, those with either an absolute sexual preference or no preference whatsoever would be the minority. Most of us would be found to be capable - in varying degrees, of course - of responding to the attentions of either sex.
As a result, there is a tendency for those with an especially deep fear of sexuality taboos (that is, phobic) to attack those who manifest what they fear within themselves to project their own self-loathing onto others.
This projection is most likely a major factor behind avid homophobia, with a study conducted at the University of Georgia showing that a far higher percentage of the males who declared themselves homophobic displayed measurable arousal when viewing homo erotica than non-homophobic males. While those who conducted the test did not claim it to be conclusive proof, the results are not only compelling, but they also conform to intuitive and anecdotal observation.
Commonsense would indicate that those who are strongly heterosexually-inclined will "prove" their normality by simply acting out on their desires -enjoying opposite sex relations - and will have little or no interest in the activities of those who transgress sexuality norms. By contrast, people who are insecure in their sexuality are more likely to have a strong interest in attacking queer people so as to shore up their heterosexual credibility.
This vague awareness of our innate bisexuality is also most likely at the core of the homophobic fear that "our children may be corrupted" if they were to be provided with sexual diversity concepts in sex education classes. The fact is that children (or adults for that matter) are only likely to be drawn to things which they find attractive. If our sexuality is so clear-cut, why would raising awareness of sexual and gender diversity in sex education classes considered to be so threatening?
Homosexuality is discussed in this context, not because transsexuality and homosexuality are the same (although they are related in some ways), but to illustrate how "queerness" per se can be influenced by cultural taboos, causing some people to shape themselves in ways contrary to their own natures for the sake of an outwardly peaceful life.
There is little doubt that fear of stigma - with associated denial - causes many individuals to come out as gay or transsexual later in life. Stigma fear also explains why so many M2F transsexuals who had formerly identified as heterosexual form relationships with men during and after transition.

Gender identity

John Money, a psychologist at the John Hopkins Medical Center, attempted to prove that gender identity was simply a matter of upbringing. However, his attempt to prove this hypthesis on a male infant (of the infamous John/Joan) case, whose penis had been damaged by a botched circumcision proved disastrous. During his teens the boy was extremely disturbed and reverted to the male role - the role which aligned with his gender identity. On the surface this boy's experience was analogous to those of transsexuals.
Of course, this case (and those of other infants who have been reassigned) was an extreme one, since the boy had a mostly male physiology to contend with as well as a male psychology. But what is gender identity?
Generally speaking, gender identity is simply a psychological response to a person's physicality and psychology. It is the sense of identifying with those with similar characteristics and seeing those of the opposite sex as "other".
With transsexuals, the matter is less simple because they find that they share certain characteristics with either gender. For example, M2Fs will share a penis and upbringing with other boys, and often some interests, but will find that they share some physical characteristics such as petiteness, prettiness and softness (and later, sexuality in many cases) with girls, perhaps along with some interests and preferred communication style. This can lead to feelings of "otherness" with almost everyone else.
In addition, denial and internalized homophobia can also play a part in this dynamic, resulting in them spending some time experimenting with roles before deciding for certain on their gender identification.

Patriarchy and the devaluation of femininity

History is littered with examples of innocent people being executed, beaten, incarcerated, exiled and ostracised  their only "crime" being their intrinsic difference to the norm. The burning of witches is perhaps the best-known example of this persecution.
Sadly, gender transgressors have often paid for their natural variation from the norm with their lives. Highly masculine women have long been forced to suppress their natures or to masquerade as men, for example, Hatshepsut, an ancient Egyptian queen needed to dress as a man and wear a false beard in order to establish her right to rule. Others probably ended up as outcasts and criminals, or living in subterfuge.
Feminine males too were considered to be freaks and cast from the mainstream, often falling into prostitution to survive. Early death was a common fate for gender transgressors. In parts of the Middle East, Asia and Africa the official persecution, and even execution, of queer people continues unabated.

Even in modern Western society this abuse still occurs, albeit more subtly. The continued dominance of patriarchy in contemporary gender politics means that feminine traits are still widely considered to be inferior to masculine attributes. Teachers' and nurses' wage scales (and those of other caring professions) and the huge disparity between the sexes in politics and boardrooms are clear indications that we remain patriarchal in thought and deed to this day in modern western society.
The women's liberation movement cannot be seen as having succeeded in achieving true equality until there are as many female senior figures as there are males. In such an egalitarian environment, the human lessons learnt in child-bearing and rearing would be seen as sufficient life lessons to offset the time lost from work while concentrating on parenting. Needless to say, such a non-materialistic age appears so far off that it sounds like a pipe dream.

This devaluation of, and hostility towards, "the feminine" is clearly a major factor in the continued violence perpetrated against both women and gay men, especially those who are effeminate.

It also means that women who are masculine by nature - while still experiencing marginalization and devaluation - tend to fare a little better in regard to societal attitudes than do feminine males.

This dynamic plays out most dramatically in our schools, where feminine males are often abused fearfully. Common sense suggests that this is the reason why there are more male-to-female sex changes than female-to-male.

3. A woman trapped within a man's body or autogynephilia - or both? 

This commentary focuses on male-to-female transsexualism, although in some areas the circumstances may be conversely true for female-to-males.
For some decades controversy has existed in regard to the manner in which extremely feminine males and masculine females decide to live their lives, that is, how they deal with the situation of being different.
In this context, the obvious questions to ask would be:
  • Why do some quite masculine males who are clearly not at that extreme end of the feminine scale - tall, strong, aggressive and excelling in fields like engineering or the military - seek to undergo genital surgery and change their sex roles?

  • Why do some extremely feminine men and masculine women not seek to make the change?
Until now, the trans community has tended to rely on time-tested clichés to explain itself, such as "I'm a woman trapped in a man's body" or "I'm a woman inside" (for M2Fs). Many people, including transsexuals themselves, do not see this explanation as credible, or at least so impossibly subjective that it inspires distrust.

By definition, females are organisms with large sex cells (ovaries) and males are those with small ones (sperm). Therefore, barring intersex situations, it is not possible for a female to be trapped in a male body, nor vice versa. By the same token, it is impossible for a male to actually become a female, to be shaped by the imperatives of those who carry large sex cells (or vice versa).

Technology can only create a "cultural" woman who is a facsimile of a biological woman. Of course, this may be a moot point given that, except in matters of procreation, we do not relate to each other on a chromosomal or skeletal level, nor in relation to our internal organs.
Therefore the concept of being "a woman in a man's body" simply refers to a male possessing unusual levels of stereotypically feminine mental, emotional and/or physical characteristics.
However, these innate qualities will necessarily differ from that of natural females due to the dynamics of mating, as discussed below (and also in regard to upbringing, which is discussed later).

Biology and the sexes

Richard Dawkins' bestseller, The Selfish Gene, examines the way the size of our sex cells shapes our behaviour  primarily due to the level of "parental investment" in our offspring. Biologically, there is a never-ending to-and-fro battle between the sexes.

Depending on the species, males and females tend towards two strategies, which Dr Dawkin's colloquially terms "He-man" and "Domestic Bliss".

In the "He-man" scenario, the males of the species are large and powerful. The dominant male in the group mates with all of the females, jealously guarding his harem from other males in the group. The females are attracted to the most dominant male, knowing instinctively that he will have the best possible genes to pass onto her offspring, thus maximizing their chances of survival. This behaviour is reinforced through generations via natural selection, that is, the genes of females who are not attracted to the "he-men" of such species tend not to survive.

On the other hand, Dr Dawkins' "Domestic bliss" strategy is seen when females withhold sexual privileges to males - unless they can demonstrate that they will help with child rearing. In this case, male strength is less desired than male commitment.

Females in this scenario will avoid males that appear to be the type who would "do the deed" and then quickly leave in order to mate with other females, leaving the female stranded to rear the offspring single-handedly. A female would prefer not to spend a gestation period unable to spread her genes, while the father is still free to spread his genes with any gullible female that he finds - to his genetic advantage.

However, a female can refuse to mate unless the male builds her a nest or goes through an elaborate courtship ritual. In this way she can force the male to make a major investment in the offspring, making him less likely to run off impregnating others. After all, he needs to make sure that his considerable "investment" will come to fruition, ie. his offspring survive and perpetuate his genes.
"Loose" females of a domestic bliss type species are at an evolutionary disadvantage since, without coercing males to help out, their offspring stand a lesser chance of survival than those of her more discerning peers since she must rear her young without any assistance.

While Dr Dawkins declined to make comparisons between human behaviour and that of other animals, it is easy to think of examples of where the above dynamics play out in the human world.

By the same token, in terms of evolutionary dynamics, it is difficult to see how a genetic male can sensibly claim that s/he is a woman trapped in a man's body or vice versa. The fact is that, in nature, the basic agendas of males and females are markedly different. It is only in cultural terms that this basic tenet does not apply, and this is the domain od transsexualism.

How the usual differences between males and females play out

The major differences between male and females can be broken into physical and psychological & emotional.

Physical gender differences are fairly straightforward, the main feature being differing gonads and breasts. There are also a number of complementary secondary sexual characteristics such as body size and shape, skin texture, hair distribution and density, facial features, voice, voice intonation and manner of movement.

Stereotypical psychological gender-specific traits are a collection of gender-marked behaviours that will tend to naturally follow, depending on whether a person has large (female) or small (male) sex cells.

This affects how we relate with each others. Examples might be our desire for closeness and approval as opposed to independence, our emotional expression, our sensitivity, empathy, forcefulness, competitiveness, the way we use language, our manner of speaking, our body language, how decisive we are, and so on.

Discounting hermaphrodites and genitals, there is clearly room for overlap in all of the above characteristics between the genders.
Nonetheless, it is as rare for any individual male to be oriented towards the feminine in all of the above psychological stereotypes as it is for a single female to have a mentality that's typically masculine in all areas. Even discounting cultural shaping, the effect of our genitals and sex hormones alone makes this unlikely.

So when a transsexual states that she is "a woman trapped in a male body" or that she's "a woman inside", it is easy to understand why so many people are instinctively sceptical. This is especially so if the transsexual is large, heavy-boned, muscular, deep-voiced, forceful, dryly analytical and unemotional, and quite simply doesn't "vibe" like a woman.


In recent years Dr Ray Blanchard and others have raised the ire of the trans community with alternative explanations to explain male-to-female transsexualism, especially his "autogynephilia" concept.

In brief, Dr Blanchard's ideas go like this:

Transsexuals can usually be grouped into two categories - homosexual and autogynephilic. The homosexual type is at that extreme feminine end of the male spectrum. They were the "girly boys" who simply found the male role too at odds with their basic natures to lead happy and productive lives in that role. They tend to seek gender reassignment at an early age, report an active and enthusiastic desire for men,, little or no fetishistic history (although this is very likely under-reported), and perform stereotypically feminine jobs such as hairdressing, secretarial/office and sex work.

The group he terms "autogynephiles" are transsexuals who apparently behaved in a gender-congruent manner in youth with relatively uneventful schooling years, and had a history of transvestic fetishism. They form heterosexual relationships and marry in their former lives, and can be found in any manner of occupations, including hyper-masculine ones such as the military and engineering. Quite a few identify as lesbian after making the change.

Dr Blanchard asserts that autogynephiles are sexually aroused by feminization. The sense of wellbeing (created by arousal) with which feminization provides them becomes indispensable to their happiness. Many transsexuals vehemently deny any sexual arousal at their feminized state, and it would be fair to say that if they wereperennially aroused by being feminized they would be thoroughly exhausted!

To explain this apparent dichotomy, let's take the example of an elderly, long-married couple. While no longer enjoying a sexual relationship, they may still find that the comfort of each other's presence and company to be a crucial part of their lives, and they become co-dependent. In much the same way, according to Dr Blanchard's speculations, autogynephilic transsexuals may find their "relationship" with their cross-presented self or opposite sex transformation fantasies may become more platonic in nature but they deepen with age and take on increasing importance. It would be fair to expect that this occurs with many crossdressers as well as autogynephilic transsexuals, but Dr Blanchard's focus is on male-to-female TSs.

At the risk of offending transpeople, it is clear that his theory, while flawed, does help to clarify some aspects of transsexuality, at least as it pertains to some individuals.

Flaws in the autogynephilia model

The issue is not black and white: Dr Blanchard's theory's main flaw is the black-and-whiteness of his definitions, so much so that the unstated "shades of gray"must be applied to the theory for it to be applicable in most cases. Again, diversity necessarily applies, with only a minority of transsexuals being either extremely autogynephilic or not autogynephilic at all. The majority most probably have experienced some degree of autogynephilia during at least at some stage during their lives, even though this is rarely openly admitted by either of Dr Blanchard's sub-groups. The reason for this will be further explained later.

It is likely that it is this black-and-white approach that generates so much hostility in transpeople to his theories. Nobody wants to be squeezed into (uncomplimentary) rigid boxes which fail to take their individual circumstances into account.

By way of analogy, imagine if it was claimed that that males can be placed into two groups - beanpoles and shrimps. If you are over 5'8" (173cm) you are a beanpole and, if not, you are a shrimp.
A statement like this would hardly inspire faith in those in the 5'6" (168cm) to 5'10" (178cm) range. Logic tells us that most males will in fact fall into this middling range, as per a Bell Curve. As such, focusing on the extremes will tend to exclude a majority of cases, and any hypothesis that is wrong in the majority of cases clearly needs refinement.
The problem with black-and-white viewpoints

Seeing things as they are, the detail explains the reality.

A black-and-white viewpoint sacrifices the essence and meaning.

Dr Blanchard's reason for taking an absolutist approach may be caused by his apparent lack of consideration of the causes of autogynephilia - nor those of its relative, fetishistic transvestism (or "crossdressing" to use the more socially considerate term). This will be discussed later.
It must be also said that there are a number of rather more significant, motivators / rationales behind transsexuals' decisions to change other than sexuality. Usually such decisions are based on discomfort with biological gender roles and physiology and the feeling that they "have to play a role" in order to be accepted.
While Dr Blanchard acknowledges that transsexuals do have other reasons for transitioning, he tends to de-emphasize them, which may be useful for promotional purposes but ultimately reduces the credibility of his approach.
Confusing of cause and effect: While it is convenent to divide transsexuals into two simple categories, the reality, is more complex. As discussed later in this analysis, it is not only possible but probably quite common for high levels of childhood femininity to be the reason for autogynephilia.
In this context, a boy may have strong feminine leanings but suppresses them to avoid rejection by parents and peers, a fact that is not acknowledged by Dr Blanchard and advocates of his hypotheses.

Not all feminine people are stereotypical: Another aspect of Dr Blanchard's theory that fails to ring true is the sexism of his definitions. His autogynephilia tests include questions regarding occupation. The tests imply that homosexual-type transsexuals tend towards hairdressing, entertainment (ie. drag shows) secretarial/office and sex work.
If this is the case, then one would assume that all homosexual transsexuals are uniformly either uneducated, lack interests outside of intimacy with men, or lack intellectuality (just like normal woman?[sic]). In fact, Dr Blanchard has been quoted as saying that high level ability in the use of computers in a transsexual is a near-guarantee that she is autogynephilic. The implication is that ability with computers is unfeminine which, while holding true for many, is a assertion which could be argued against by the many thousands of females working in IT.
The joy of feminization is not an exclusively male domain: Another aspect of Dr Blanchard's autogynephilia theory which requires correction is his assertion that autogynephilia - a sexual/emotional response to feminization - is an exclusively male phenomenon. Numerous normal women "feel sexy" when they dressed up for a special event or when they wear certain items of clothing /jewellery / makeup. That is, when they take on a form of personal presentation they may feel especially potent in their receptiveness. They may even be somewhat aroused at the thought of the effect they will have on their beau. It is not the same thing, but it can look the same at times.
At times similar feelings reported by some transsexuals could conceivably be mistaken for autogynephilia. This could also be seen as a matter of degree, the level of intensity of such feelings being determined by novelty value and taboo.
It will be proposed in future chapters that autogynephilic urges and male hyper-femininity (in physicality, mentality or both) are far from necessarily mutually exclusive, as is maintained by Dr Blanchard. More credibly, it is all simply a matter of degree.
Invalidating use of language: Another problem with the autogynephilia theory, and that of its proponents, is the language used to describe the two supposed categories of transsexuals.
Classing transsexuals as "homosexual type" is confusing. While the term "homosexual" in this context refers to a transsexual's former life, its use as a classifier (perhaps inadvertently) implies to the layperson that no matter how many changes such transsexuals undergo, they remain homosexual men rather than heterosexual constructed women.
While this point may be considered debatable in some civic and psychiatric communities, it rarely is for the transsexuals involved. M2Fs go to extraordinary lengths, often traversing the most extreme physical, mental and emotional challenges to become what they believe is, at the very least, a certain kind of woman - to basically feel more at home within themselves and the world. In this context, "androphilic" is a far more appropriate descriptor for this category of transsexual.
The issue at hand here is not that any connection with homosexuality is wrong per se, but the possible implications if the theory is distributed in the community at large, and especially within legal settings.
Further, the black-and-whiteness of Dr Blanchard's model leaves those with autogynephilic orientation in an invidious position, leaving the way open for proponents of this ideas to follow up with witty, but invalidating, titles for their treatises such as Anne Lawrence's Man in a man's body and Dr Bailey's The man who would be queen, where Dr Bailey consistently uses male pronouns when describing transsexuals.
Most individuals who have spent their lives struggling with gender issues will not thank the writers for their preference of wit over sensitivity. Even if such titles are simply attention-grabbers, the inevitable implication is "no matter what you do, you will always really be a man".
Such a fundamentalist, scientific-deterministic position ignores feminist theory, which has long maintained that while "male" and "female" are biological realities, "man" and "woman" are social constructs, the former being immutable and the latter subject to variations, depending on the individual and the prevailing culture.
Certainly, some transsexuals are more successful than others in being recognized in the world as their target gender. Nonetheless, politeness and consideration require that the (very considerable) attempts to make the change be recognized, regardless of the apparent authenticity of the person's final resultant form.
Again, this harks back to issues of stigma and taboo, where those "at the bottom of the pile" are considered fair game when it comes to cruel humour  If the comments - including jibes and silkily-veiled attacks - made of queer people (in both gender identity and sexuality) in the media were made about colored people, those of certain religious faiths, people with disabilities and so forth, there would be an outcry. For example, some years ago a senior politician earnestly pronounced that he was "conservatively tolerant towards homosexuals". Had he stated that he was conservatively tolerant towards black people he would have been in deep trouble, but this implicitly homophobic comment went mostly unremarked.
Proponents of Dr Blanchard's ideas (generally inadvertently) simply play into the hands of homophobic/transphobic politicians and lawyers in undermining transsexuals' human rights.
While it may be tempting for some analysts to attempt to jolt the trans-community out of their simplistic "woman trapped in a man's body" mantra, the use of the blunt instruments of invalidating language and cynical implications are unlikely to be helpful.

Why language is important

At present there are debates regarding discrimination and marriage and adoption rights of gays and transsexuals. If queer people are to be eventually permitted to marry and adopt, the rights may well be first afforded to transsexuals within a heterosexual (post operative) relationship.
If expert witnesses are called to give evidence in court cases and start referring to the woman in the marital union as "homosexual type" (not to mention autogynephilic), this could prove detrimental to her and her partner's case; magistrates and judges lack the knowledge of the issues to be able to properly contextualize the terminology.
The stakes here are high. Continuing discrimination in the legal arena not only affects the lives of transsexuals and their families, but also those of their partners and, especially, of children waiting for adoption to save them from institutionalization (studies indicate that children raised in institutions are over 150 times more likely to be institutionalized as adults).
Therefore, definitions should not be decided upon in an insular, trans-oriented manner, but with regard to their implications within the broader community.

The missing link

The only patterns found in transsexualism thus far has resulted in transsexuals being divided into two groups - primary types (or homosexual types in Dr Blanchard's terminology) and secondary (autogynephilic) types.
However, this classification system does not address questions as to why, in regard to homosexual transsexuals, some extremely feminine males take a transsexual path while others became feminine gay men (occasionally straight or bisexual). Nor does it explain why some fetishistic boys later become transsexual while others remained transvestite.
There is little doubt that while the degree of effeminacy or intensity of autogynephilic attachment almost certainly play a role in the two types' responses to their situations, it does not fully explain the situation. Psychiatrists are yet to find any real consistency in the backgrounds of M2F gender transgressors, regardless of the proposed classification types.
Therefore, at this stage analysts are yet to find any absolute clue as to what created this need for transsexuals to change roles; their backgrounds vary greatly:
  • The age range of transition ranges from early teens to over 60 years of age.
  • Transsexuals range from the extremely feminine to clearly masculine, both physically and mentally.
  • Some transsexuals report having strong feminine interests as young children (eg. playing with dolls, playing house) while others engage in either boys' or gender neutral play.
  • Some transsexuals report high levels of harassment and marginalization at school while others were popular or enjoyed relatively uneventful school years.
  • Prior to transition, their sexuality can be heterosexual (gynephilic), homosexual (androphilic), bisexual or asexual.
  • Some transsexuals were forced to dress or live as girls in childhood, or had parents who wished for an other-sex child. Others were, and did, not.
  • Some were abused in other ways - be it emotionally, verbally, physically or sexually, or any combination of these. Others had normal, even idyllic, childhoods.
  • Some are talkative and social while others are loners; some are creative and erratic, others are practical and solid; some are technically adept, others are not; some are sporty, some are bookish ...
The list goes on. There is almost no consistency - at least not in absolute terms and no attempt at classifying transsexuals to date has been successful in explaining all anomalies.
It is more likely then, that the consistency exists in relative terms. The consistency can be expected to lie in what went on in those children's minds at the time, not necessarily in what happened to them. To summarize further:
Transsexualism is not about what transsexuals' personal characteristics or events that occurred during children's formative years but how they felt about themselves as a result of those characteristics and/or events.
This point will be revisited later in Chapter 5, but to put this idea in context we need to look at the causes of displaced sexual desire - that is, the sexual desire some people feel for activities other than healthy, loving relationships with others.

4. Trauma can shape us

It is generally believed that some kind of childhood trauma is the usual cause of displaced sexual desire, or to use the pejorative and uncharitable term, "perversion".
One common thread between the most profound childhood traumas experienced - such as assault, rape and sexual abuse - is a lack of control, leading to a sense of disempowerment and/or humiliation. In the case of humiliation  the child feels that s/he is stuck in, forced or coerced into, a situation that could lead to severe disapproval from, and rejection by, his/her peers and elders.
Humiliation is an intense hurt, too often underestimated in a materialistic society that places greater importance on physical conditions than psychological ones. Wars are fought over perceived national humiliations, where hostility is fuelled by feelings of disempowerment. Many suicides have occurred as a result of people feeling that some disgrace they have experienced is irretrievable; a phenomenon that cuts across all cultures and time periods.
Human beings are social animals and our ability to relate satisfactorily with others is vitally important to our wellbeing. So humiliation can be an exceedingly powerful force.
On an individual level, intense humiliation or other traumatic events in our early years can shape us dramatically. For example, highly masochistic people often have a history of childhood violence or abuse. Yet in later life they are not hurt (at least not psychologically in an overt fashion) by such abuse and actually seek it out for sexual arousal. So what happened?

Trauma and coping mechanisms

High intensity fear, pain or humiliation can all be utterly devastating and traumatic. If the intensity reaches a level that is beyond a person's ability to cope, then trauma occurs. Especially important in this context is the fact that trauma, especially childhood trauma, permanently changes the physiology of the brain.
These permanent changes manifest in permanent hair-trigger responses to events or scenarios that are perceived to have caused the trauma. For instance, a woman who has been raped when left alone in her house may later experience panic attacks when left alone in her house. Shell-shocked war veterans often react badly to sudden noises, often never fully desensitizing.
Scientifically, this startle reflex is caused by a "short circuit" from the amygdala (the "emotional" part of our brain) to the cortex, without processing by the neocortex (the "reasoning" part of the brain). In practical terms this means that the startle response activates automatically in relation to what is perceived as the traumatising event. While in milder cases some assistance can be gained via cognitive therapy, allowing patients to lead relatively normal lives, this response is a permanent disability.

At this point our coping mechanisms come into play. It is not unusual, for example, for a masochist who had suffered abuse in early life to repeat those traumas in adulthood - but this time she or he is in control.
Every time a masochist goes through the ritual, s/he becomes just a little less sensitized to those painful memories, a little less disturbed, and eventually takes ownership of that pain. S/he is in control now, not the trauma.
It is known that trauma is associated with a lack of control, not necessarily with experiences per se. In one experiment, mice exposed to electric shocks in the laboratory were found to be noticeably less traumatized if they were provided with access to a device allowing them to turn the current off. Conversely, the mice with no way of stopping (controlling) the shock were far more traumatized

If a person lacks an understanding of the feelings that lie beneath his or her desires - through denial or lack of self awareness - then there is a good chance that their needs will escalate. The secret to gaining true control is achieving an understanding of those desires before they become habitual. That is, such desensitization exercises are most therapeutic if performed with the conscious aim of desensitizing.
However, if underlying causes of desensitizing behaviours remain unexamined, trauma victims undertaking an instinctive, desensitizing "cure" will find that that cure becomes increasingly less powerful through familiarity. There is a direct analogy here with drug abuse, where the addict acclimatizes to the narcotic and therefore always requires more and more to "get a buzz".
This leads trauma victims with little self-awareness to seek increasingly extreme remedies so as to regain the intensity required to repeat the trauma with the desired effects, the desired affect ultimately being a greater sense of control.

Autogynephilia and emasculation trauma

In this context, autogynephilic tendencies would seem to most likely stem from a sense of emasculation trauma, and this will be discussed further in Part 5.
To this end, autogynephiles (and crossdressers) often escalate their cross-gender activities with age, at times to the ultimate degree. This is simply an observation, not a value judgement on decisions to change gender roles. If the level of trauma experienced makes the male role unsustainable in the longer term for affected individuals, then that is as fair a reason as any to make the change, given the permanence of the affliction.
This is the reason why it is so essential for the psychiatric community to better understand these dynamics. Young people who have experienced emasculation trauma/autogynephilia should be properly treated so that they can undertake any coping activities with a clear aim of desensitizating. If left to their own devices, their self-feminization activities and fantasies will probably become habitual, taking on a life of their own, ultimately reinforcing feelings of emasculation rather than alleviating them. The purpose here is not to prevent people from transitioning, but reduction of post-traumatic stress.
Gender reassignment in individuals with high level emasculation trauma with highly established patterns of feminizing behaviour can still result in greater levels of happiness and adjustment - even if the person is quite masculine - because they may then achieve a sense of resolution in their lives which would be otherwise impossible.
Given the sensitivities involved, it should be pointed out that the above does not mean that trauma-facilitated transsexualism is not a pathological condition and the author does not believe that transsexualism should be considered a disorder is the DSM-IIIR. While intense emasculation trauma experienced by many transsexuals can be considered a disorder while they remain in the male role, in many cases once they have changed roles they are effectively "cured" and perfectly capable of leading productive and "normal" lives.

5. Emasculation trauma and autogynephilia

Upfront, it must be stressed that autogynephilic proclivity is not necessarily present in all people seeking gender reassignment, and when it is present it presents in widely varying degrees; there are a number of different rationales and motivations behind a decision to change sex, as discussed later.
Harking back to the effect of trauma on individuals, again taking the example of masochists, you will generally see elements of pain, fear and humiliation in their desired mix of "therapy". For autogynephiles the focus is on humiliation.

The crucial point to understand here is that the trauma of humiliation does not need to come from abuse (although it may do), but from a person's sense of self.
Therefore, both highly feminine and fairly masculine transsexuals can experience similar levels of emasculation trauma as children.
A number of factors may cause this feeling of emasculation. Again, it must be stressed that it is not the young person's reality but the perception of their reality that matters in this context.

There is no doubt that young males can be traumatized when their sense of emasculation is intense enough; when they feel they are irrevocably unable to measure up as males. This depends as much on "where the line is drawn" in what constitutes acceptable masculine behavior in their environment as their actual levels of actual masculinity or femininity.
Due to continuing patriarchal attitudes it is still a serious social "crime" in many modern societies for a male to fail to "measure up" as such, with punishments consisting of ridicule, abuse, exclusion, rejection, assault and, in extreme cases, murder.

So what causes these feelings of emasculation?

Hyper-feminine boys and emasculation trauma

Emasculation trauma can, of course, be the result of as the boy being, in fact, hyper-feminine - but in denial, or feeling negatively, about the way he is. One could say that such a boy feels emasculated for good reason - he really does not measure up to the typical male standards he encounters.
"Hyper-feminine" in this context refers to boys whose feminine qualities are obvious enough to be noticed by others, generally in a negative manner. Those feminine qualities may include androgynous appearance, girlish voice and manner of speaking, feminine mannerisms, typically feminine interests, crossdressing, dislike of rough behaviour  preference for girls' company, high levels of sensitivity / emotionality, romantic interest in boys, and so on. These attributes may be present in varying degrees in individuals. By the same token, many boys who are targeted as overly feminine by parents and/or their peers may only possess some, or just one, of those attributes.
Not that hyper-feminine boys will necessarily feel traumatized by their lack of masculinity. Several factors may insulate them, such as support from understanding parents, relatives or peers (ie. a non-phobic and/or cosmopolitan environment), strong self-belief or confidence, insulating philosophical belief systems and advanced social skills.
Nor will the nature of the trauma necessarily be emasculatory. For example, a hyper-feminine boy who is bolstered by some of the above insulating factors, may still be traumatized by violence, rejection and/or bullying he experiences. In this case, the trauma may lead to other disorders, such as PTSD, anxiety/depression and disorders related to poor self-esteem such as hysterical, narcissistic and borderline personality disorders.
Emasculation trauma will generally occur if the boy is in denial about his femininity; he will be especially be susceptible to such denial if his parents suffer from denial, that is, see him "though rose colored glasses". Without the benefit of an accurate "mirror", the child may develop a distorted self-image.
Certain personality types may also hope (realistically or otherwise) that they can change themselves (to "fool them all"), and will attempt to change themselves in order to better fit in. Such individuals may well experience mid-life crises, as is common with many non-transsexual people who profoundly shape themselves in youth to societal or other expectations at the expense of genuine self-expression.
A number of pertinent articles in this regard written by Dr Daniel Wegner examine the effects of denial and thought suppression (but in a general sense, not related to transsexualism), in particular, note his treatise on "The hidden costs of hidden stigma".

Non-feminine boys and emasculation trauma

Boys whose characteristics and behaviour lie within the normal range of masculinity may also experience intense feelings of emasculation. How could this happen? Some possibilities are:
  • He is surrounded by homophobia and macho worship, where the idealized image of masculinity around him is so strong that he feels he can never live up to it. He may feel unable to safely and honestly express himself in any aspect of his life.

  • Teasing and bullying at school or in the home. In regard to school bullying, this will be exacerbated if he has undeveloped social skills.

  • Slow physical development. If a boy remains small and soft and late in passing developmental milestones such as growing male body hair voice breaking, he may be perceived as "feminine" and adopt that self image. Even as an adult, this sense of self may persist even if he grows up to be stall, strong, hirsute and deep-voiced.

  • A direct sexual or gender-based humiliation, such as sexual molestation, being crossdressed by a mother who wished for a girl, or the use of crossdressing as punishment.

  • Any combination of the above.

Other factors

The more sensitive the boy, the less negative stimuli is needed to evoke intense feelings of emasculation. Further, other traumas may sensitize a child whose sensitivity would otherwise be in the normal range. Family conflict, deaths in the family, separation of parents, abuse and so on may lead to anxiety and a hair-trigger reaction to stress. In these cases, emasculating experiences which would be seen as relatively mild may be experienced as traumatic.
It should be noted that, logically, there is no definite line to be drawn between feminine and non-feminine boys; there are no objective measures in relation to masculinity and femininity.
For example, which boy is more feminine? A small, slender, pretty, high voiced boy with feminine mannerisms who is athletic, has a forceful nature, and prefers playing with other boys - or a larger, physically masculine boy who is soft, bookish, emotional, relationship-oriented and who eschews the rough and tumble of typical boys' games? Clearly this is a rhetorical question with no clear-cut answer.

Coping with emasculation trauma

Many boys feel inadequate as males at some stage during their formative years, experiencing embarrassment when they fail to live up to some exaggerated standard of masculinity they may encounter. It is all a matter of degree - how intense the feelings are and how long they persist.

So how does a boy cope with feeling emasculated to the point of trauma - be it due to a traumatic event or because of regular experiences occurring over an extended period? Importantly, in many cases he will feel this not something he can talk about - with anyone at any time - so he is on his own. This is especially the case for those who were children before the advent of the Internet.

Lacking in life experience, he may wonder if everyone feels as he does, so he may overcompensate, trying to be as rough and tough as he can be - just like his peers. Many transsexuals report that, in earlier years, they deliberately embarked on hyper-masculine careers like the military in order to normalize themselves.
Whether the boy feels it is possible or feasible to attempt to be masculine and "fit in" not only depends on his actual level of masculinity or femininity, but also on how realistically he perceives himself, how fearful he is of stigma, and his resilience and hopefulness. Parents play an important part in this equation, for if they are uninvolved, neurotic/psychotic or in denial, they may hinder their child's ability to realistically understand himself.
One means of relieving trauma is to repeat it, to embrace it, to own it, to control it - just like the masochist who seeks out abuse or the molested girl who becomes promiscuous.
A boy suffering emasculation trauma may give up the masculine ideal as a lost cause. Some may behave in an exaggeratedly camp manner as a form of rebellion. Ironically, while this approach may create more problems socially in the short term, the act of relinquishing any attempt at masculinity will ease a child's internal pressure, reducing the incidence of ironic effects caused by denial and suppression.

On the other hand, the boy may believe he can "fool" others in personal interactions. This will be the case if he is, in fact, capable of "passing" as a normal boy, or if he is denial about his levels of femininity. If he is in denial, he may "gloss over" repeated "hints" from others as to his true nature.
However, it is then likely that he will still be driven to embrace his perceived femininity (control his trauma) in private. This approach may involve crossdressing, thoughts of physical feminization or homo-erotic fantasy.
Dynamics such as these are the most likely roots of autogynephilia or, as it was known before the "A-word" became trendy, transvestic fetishism.
In short, whether a boy experiences emasculation trauma publicly or privately may well decide his level of fetishism.
This explains why the most extreme hyper-feminine boys tend to be less autogynephilic than other boys who experience emasculation trauma, because - if they are realistic - they realize that there is little chance of them being able to appear "normal" as males in the public arena.

6. Trauma and sexuality

By now it should be clear that Dr Blanchard's heavy emphasis on autogynephilia as an attribute of late-onset transsexuals misses the point - that emasculation trauma is at the root of most transsexualism and that autogynephila is merely the sexual response to that trauma.

It stands to reason that individuals need to experience extreme problems - be they external or internal - in regard to their gender to choose to undergo gender reassignment, with the attendant stigma, personal upheaval and medically invasive surgery. So it is safe to assume that at least some events (or self perceptions) leading up to transition were traumatic to those individuals. The only issue open to debate is the nature of that trauma.
However, a question yet to be addressed in this analysis is how a repeated trauma can become a sexual turn on. Extreme events capable of causing trauma (and the accompanying fear) and sex are things that arguably trigger more intense feelings within us than anything else.

Somehow they get mixed up. Both trauma and sex get our hearts beating, our blood rushing. Each can stimulate and sensitize us, awaken and arouse us, and remind us that we are alive; they are enervating. The link between trauma and sexuality is a well-discussed topic in academic and psychiatric circles. A Google search for educational institutions with the keywords "trauma" and "sexuality" yields over 15,000 pages in the search results.

As discussed earlier, it is likely that the translation of trauma to sexual stimulant is a natural desensitizer to aid in our survival. That is, our survival instincts may follow this form of logic:
If an event occurs that is highly disturbing, then it's a good idea to prepare (desensitize) just in case it happens again. That way, the blow will be less extreme.
So sexual and/or emotional arousal and attachment is the "bait" which coerces us to behave in ways that, on the face of it, would otherwise appear to be abhorrent, or at least undesirable, wasteful or senseless. Nature's use of sexual and emotional arousal to induce us to pursue inconvenient or seemingly pointless activities which facilitate our survival is an hardly a new concept [sic].
Excitement generally is a common thread between the two, in other words, a strong ailment requires strong medicine because the stakes are high. There is a sense of danger in breaking taboos, which only serves to make it all the more exciting. The more intensely a taboo is felt, the more exciting it is. "Look at me!", an autogynephile may say (internally). "I really am a girly freak and a part of me enjoys being that way (even if another part of me may hate it). So there!"
It could be said that what the autogynephile is really saying is, "I have a vulnerability that greatly disturbs me so I am desensitizing myself as a protection from possible future hurt".
There are some well-known, less dramatic, examples of this dynamic of desensitizing - in the way the gay community took ownership of the word "queer", and how American negroes now often affectionately call each other "nigger". As a result these words have lost much of their power to hurt. What was once traumatizing becomes less hurtful through repetition and re-enactment - as long as it remains within the affected people's control.

Problems with "self-medication"

However, the desensitizer - the insulation - carries its own problems. If behaviour patterns are reinforced though repetition often enough they can become habitual. While gays and negroes now commonly take public ownership of their traumas, this is less often the case for those with autogynephilic orientation; self-feminization is often a furtive activity. Therefore an autogynephile's feelings remain unexpressed publicly, festering unhealthily within over long periods of time, without the benefit of the "sunlight and oxygen of openness", and ultimately becoming psychically poisonous.
Therefore autogynephilic (and transvestic) people frequently endure intense periods of guilt and self-loathing. Yet they cannot push the desires out of their minds because of the way it cushions their feelings of gender inadequacy. Dr Wegner's insightful articles on suppression clearly spell out these dynamics.
Repeated emotional and/or sexual experiences reinforce our relationships, so in time transvestites and autogynephiles can develop a form of "relationship" with the "other", cross-gendered self - be it actualized or in fantasy.

Denial of this arousal in the trans-community is rife, and with good reason. Why would anyone want to admit that they are, or have been, sexually and/or emotionally aroused by something as seemingly ridiculous and childish as cross-gender presentation while almost everyone else appears to be exclusively aroused by healthy intimacy with others?
It is far more respectable and mature-sounding to say "I am expressing my femininity", even if that femininity is not apparent to others (although this may or may not be due to suppression). As mentioned earlier, such femininity may or may not be real, or may only exist in the person's past, but who can question what a person thinks and feels in private without extensive (and expensive) individual psychoanalysis?
Therefore, with a lack of any objective means of uncovering the truth, gender transgressors can easily fall into denial because they so often take on board the unsympathetic scorn they believe would be poured on them by most people if they discovered the truth.
This response is quite understandable within a phobic environment. Self-loathing is as common in the trans and crossdressing populations as is denial; the two go hand-in-hand. Fetishists of all stripes often report that they feel guilty about the self-centeredness of it all, believing that regularly indulging their sexual fantasies is pointless, selfish and unproductive. Such people are often torn between their realities and what they believe should be.
However, if the habituated behavior successfully acts as a pressure valve, then it could be argued that those behaviours do in fact have a productive aspect in allowing such individuals to function better in society.
On the other hand, a self-feminization habit may also lead to a further sense of emasculation. An example of this could be where boy who is considered unmasculine due to late development, and experiences emasculation trauma. Even if he grows up to be an apparently normal man, his furtive self-feminization activities may prevent him from being able to adjust his self image. In this sense his sense of emasculation becomes a self-fulfilling prophesy.

Sexual experiences need not be physically expressed

In this context it is important to draw a distinction between the term "sexual experiences" and sexual arousal. Sexual arousal is only one type of sexual experience. Again, our materialistic society's emphasis on the physical over the psychological creates confusion in analysis.

"Sexual experience" in this context refers to an experience that serves to arouse or enliven or stimulate but at the every least contains some sexual undertones. This can be felt mentally and emotionally. It does not necessarily include genital arousal, stimulation or orgasm, although it often does.

There are a number of reasons why a person may not take their arousal into the physical realm.
  • A strong sense of taboo regarding masturbation and self-oriented sexual behavior in general, perhaps for religious or value-based reasons, and generally due to upbringing.

  • Some transsexuals have an aversion to their genitals and prefer not to touch them. In many such cases the genitals have been blamed for "forcing" the person into which they feel unable to cope.

  • Lack of opportunity. Low libido.
Private vs public

An autogynephilic person who does not seek physical relief will experience repressed sexuality and/or emotional tension. All this person knows is that cross-gender activities give him comfort and relaxation, just like a partner in an established marriage. You may not be excited every time you are with your partner, but if your partner is away for an extended period you will feel a sense of loss.

The point here is that youths and teenagers who engage in of emasculating / feminizing behaviours in private (crossdressing, penis-hiding, use of prosthetics, sex change fantasy, etc) will necessarily gain some level of satisfaction from it - a payoff. It may be physical or it may be emotional. Often it is both, at least at first, but in time the emotional aspect often takes greater prominence, as as the case in most relationships.

Obviously, if it was not satisfying in some way, they would not do it. Nonetheless, it is not a cut-and-dried situation because there may also at times be elements of genuine feminine self-expression mixed in with the trauma-based undertones. 

The emphasis on the word "private" is important. If a young person (in adulthood, the dynamics are generally somewhat different) is willing to engage in cross-gender behaviour in public, then s/he clearly does not feel highly oppressed by a sense of emasculation. Lacking a critical level of crushing fear or traumatic stress in relation to his/her gender identity, s/he would be expected to be less autogynephilic than a more stressed peer.

This is often the case with transsexuals who are classically termed the primary type but can also the case with less feminine boys who feel the quest for being accepted as a "proper male" is a lost cause due to their social environment. So both feminine and masculine males may decide that they are really girls trapped in male bodies. Some of the more feminine types may find that they receive less rejection from others when cross-presented than in the male role (ie. "better to be a desired 'girl' than a weak guy").
This relative lack of fear in regard to cross-gender activities is essentially a lack of fear of authority. Perhaps their parents were relatively tolerant of gender-transgressive behaviour  or they may be so neglectful or abusive (perhaps as a result of their male child being too feminine for their liking) that their opinion ceases to matter and approval becomes impossible to achieve. In this context, parental upset may be seen as a bonus (as in aggravating their protagonists), or even a raison d'tere.
The parents could also be lassez faire and/or democratic in their approach, and the young person knows that any disapproval will be expressed safely, if at all, allowing them to just be themselves.
In the case of transsexuals who display strong overt feminine psychology and physiology, this fear, or lack of fear, of (parental) authority may well mark the difference between the so-called "homosexual type" transsexual and the "autogynephilic type" transsexual.
In fact, it is possible that having a close relationship with dominant and/or sexually conservative parents is a common thread amongst those with autogynephilic desires, although this idea is only based on anecdotal observation and has not been tested.
As mentioned earlier, there will inevitably be a grey area between "homosexual types" and "autogynephilic types", and this zone is populated with autogynephilic types with feminine/androgynous physical and mental traits or, conversely, androphilic (homosexual) types with autogynephilic tendencies.

7. Perversion, lifestyle choice or survival necessity?

The pain of separation

We have established that there tends to be some kind of actual or sublimated sexual arousal involved in private cross-gender activities. These activities often become increasingly overt in time due to increasing desensitization and gradual liberalization of societal attitudes. The satisfaction gained is based on alleviating the pain of intensely humiliating emasculation.
Cross-gender thoughts and/or activities can start very early in life, and their commencement before school age is not uncommon. Our sexuality normally starts to develop in earnest around age 11 or so, with variations between individuals.
Therefore, by adulthood those with autogynephilic feelings have already been involved in their "self-relationships" for some years by the time they start acting on those feelings in a serious way. It is no accident that wives of autogynephiles and transvestites report that they feel as though their husband is somehow cheating on them with "that other woman", that is, the cross-presented husband.

As mentioned previously, when we are in harmonious long term relationships the sexual arousal we experience during the early stages is variably replaced by a sense of comfort and wellbeing. If the relationship ceases, for whatever reason, then crippling grief and pain may be experienced after so many years "together".
This provides some indication of how high the stakes can be in the aforementioned "self-relationships".

The pain for an adult autogynephile who has been in a "self-relationship" since an early age can be almost as catastrophic to the person as the loss of a long-term, much-loved partner if s/he starts to feel that the "relationship" is no longer viable, perhaps due to ageing or life circumstances. Remember, this cross-gender "other person" has been with an autogynephile for all of his/her adult life, and generally through much of childhood too. This "other person" has helped cushion him/her from perhaps the most traumatic feelings he has ever experienced.

So cross-gender identity/fantasy can be extremely important to autogynephiles. It is rare that marriage partners form bonds that commence during early childhood, so it would be fair to say that many marriages lack the intensity and longevity of these "self-relationships".
This may explain the extremely high suicide rate of gender transgressors, caught between the rock of their desires and the hard place of taboo. Such people may try for decades to "cure" themselves through suppression, denial, distraction, oppositionalism (eg. engaging in hyper-masculine activities), meditation, prayer/religion, cognitive therapy, electroshock therapy, etc, and when it comes to no avail, their options appear to be narrow.


The scorn and abuse heaped upon people "married to" their cross-gender self (often from within the trans-community) is based on a misunderstanding of these people's motives. In the case of the trans-community, disgust with trans-fetishism can often be encapsulated in the adage: "we hate most in others what we hate about ourselves". Simple projection.
The fact is that trans-fetishists are rarely perverts of dubious intention. They hurt nobody except, arguably, themselves. The only pain they generally inflict on others is the breaking of relationships when they finally "come out", a pain that would not have occurred in a more mature and tolerant society. They are simply people who have become dependent on a psychological and emotional support mechanism.
It is therefore important that autogynephilic desire be destigmatized within trans-community (and elsewhere). It is nothing more than a trait which, since it stems from childhood emasculation trauma, says nothing definite about a person's worth, innate femininity or masculinity, nor his/her claims of validity as a sex change candidate.There are many other criteria, as discussed later, which are more important.
How can it reasonably be argued that an autogynephilic transsexual should not change roles if it results in her being a happier and more productive and engaged citizen?

The options - crossgender lifestyle choices

Ultimately, the best space for a person with trauma-induced autogynephilia to occupy in life depends on how incongruent their mentality/emotions are to their physical self, the intensity of trauma, and the level and nature of their other-centered sexuality.
It should be said that a person with autogynephilic desires will also have a "normal" sexual orientation, be it straight (many autogynephiles take on a heterosexual role in the male lives), bisexual or gay, although this other-centered sexuality will most likely be weakened because it is shared with self-oriented needs.
So there are a number of lifestyle choices available to gender transgressors in these comparatively liberated times, the choice being dependent on both the above-mentioned factors and fear of taboo:
  • Covert crossdressing
  • Overt crossdressing
  • Transgenderism (part-time cross-living)
  • Androgyny / "genderfuck"
  • Non-surgical transsexualism
  • Surgical transsexualism
Each of the above options may include gay, bisexual or hetero sexuality, regardless of what one terms "gay" or "straight" in this context.
Taking into account various sexualities, this means there are at least, broadly speaking, 18 options available to gender-transgressing individuals. If one adds additional options such as the taking of hormones, electrolysis, grooming (eg. hair styles, treatment of body hair, use of makeup, piercings) and cosmetic surgery, then the number of possible identity options can run into hundreds.
It is little wonder that gender-incongruent people frequently complain of feelings of confusion!

Issues with the various cross-gender options

Full heterosexuality, homosexuality or bisexuality are not listed above because they are rarely possible when autogynephilia is present, unless the cross-gender needs are very weak and/or the person has strong will and determined to be "normal". Usually autogynephiles have a heterosexual background, regardless of their actual preference, because their "desires" are born of stigma.
Even when pure other-centered sexuality is embarked upon, some aspects of the person's sexuality and/or psyche will be sublimated and relationships may not be stable over the long-term, although there are many examples to suggest otherwise. Nonetheless, it is unrealistic to expect that people are capable of entirely and permanently breaking intense bonds that were formed during childhood.
So autogynephiles (and crossdressers) with strong cross-gender impulses are generally not capable of sustained normal sexual relationships without bolstering them to some degree with cross-gender behavior or fantasy.
In such cases, even though a relationship may appear typically heterosexual to others - even to their partners - the private world of the crossgender-fixated person is almost certainly not a purely other-centered one (they often require fantasy during sex to be fully aroused). This may well be to the detriment of the relationship, especially when "the medicine wears off" in middle age with a resultant escalation of cross-gender behavior. This dynamic (as discussed in Part 4) often results in broken marriages.

In the case of "heterosexual" crossdressers and autogynephiles, some women come to accept their partner's needs, but often they feel cheated because those needs cut across their own. If a crossdresser's or autogynephile's needs are fairly mild, then it is far easier for a compromise to be reached that works for both partners.
This pseudo-straight lifestyle option is not the only one fraught with complications.

Gay autogynephiles (and they do exist, although they are less common than their heterosexual peers) also may face similar problems in that a gay partner (as with heterosexual women) usually desires his partner's masculinity, not his femininity - so a gay autogynephile can run at cross-purposes with his partner. As with his/her heterosexual cousins, tensions rise if the cross-gender needs grow stronger with age. It is just as common for gay relationships to falter after one partner's gender transition as it is for heterosexual ones.

Part-time cross-living (for instance working as a male while living socially in the female role) provides its own complexities. M2F transgenderists can experience distress when reverting back to the masculine role. If his/her cross-living has a measure of secrecy, the transgenderist will need to deal with all of the typical problems involved with subterfuge living - fear of discovery and the need to lie or be evasive, and this tends to limit their ability to achieve satisfying friendships with others, which may lead to feelings of isolation.
The "out" transgenderist can expect some ghettoization of his/her social life, with social contacts and venues being limited to those who are accepting, often tightly restricted to the "queer scene" or social work/artistic/hedonistic scenes, so it is fair to say that this option is most accessible to certain personality types and those with certain interests and/or abilities.

The androgyny/"genderfuck" option can be even more complicated - where a person projects an indeterminate gender identity - with the same issues as the part-time transgenderist, although minus the subterfuge complications.
Again, the fields of potential long-term partners and social contacts are very limited for such individuals. In addition, the choice to live in "the gray zone" is only possible if the person's work environment tolerates it. Some organizations which deal with either the creative arts, academia, social work, the sex industry and the "gender industry" (eg. selling cross-gender prosthetics) will be the most likely realistic options.
It is also fair to expect that they will experience problems with work in any area that requires employees to declare themselves as "Mr" or "Ms", or to don semi-formal business attire. Highly talented individuals may carve a niche for themselves in a business enterprise, but there are perhaps not a lot of other options.
The above two options tend to be chosen by those with strong political beliefs in regard to visibility, and it is not uncommon for them to engage in trans-activism.

If the person finds none of the above-discussed options feasible, then they may seek to move towards permanent cross-gender living, with or without surgery. The wish for full-time transsexuals to have surgery may be affected by the following factors, either in isolation or in combination:
  • Feasibility: some individuals may wish to change their sex but feel that they will be unable to "pass", so changing roles will result in too much rejection and harassment.

  • Health: the person must be of sufficiently robust health to safely undergo major surgery.

  • Sexuality: the kinds of sexuality the person enjoys and believes his/her desired partners will prefer.

  • Pragmatism: surgery may be undertaken in order to better lead a "normal" life, for example, gaining greater legal and social recognition; freedom of dress such as being able to easily wear tight pants and swimming costumes; reducing fear of discovery, especially in toilets and change rooms, and relieve anxiety in regard to potential admittance in hospital wards or jails.

  • Politics: some people refuse surgery due to their political beliefs ("Why should I have surgery when I'm not sick?" or "What's wrong with being a woman 'with a little bit extra'?"). On the other hand, some may seek surgery due to experience internalized homophobia, perhaps due to religious beliefs, and struggle against their basic natures.

  • Validation: to feel more "bona fide" as a woman and not be confronted with evidence of their past on a daily basis.

  • Genital issues: those who resent their genitals for forcing them into a life they feel is wrong for them will be more likely to seek surgery.
It is an unfortunate fact of life that prejudice often shapes the life choices those who are not gender-normal make. Further, full transsexualism with genital surgery presents its own problems, the main issue being that it is harder to "backtrack" if the person has doubts or finds the problems of transition too difficult.
In addition, for those who "pass" as woman, there can be problems with intimacy and openness - both in relationships and friendships - which are covered further inChapter 8. Further, it is not unusual for the surgery to prove unsatisfactory to some extent.

8. How to treat?

At some stage, a number of those who experience ongoing and intense autogynephilia present themselves at psychiatrists' offices and gender clinics, requesting assessment for a sex change.

Assessing psychiatrists, as things stand at present, usually do not base their decisions to treat patients on levels of autogynephilia, but on whether a change will be in the patient's best interests overall.
More enlightened practitioners will sensitively present the available alternatives discussed in Chapter 7 (eg. gay, bi or hetero androgyny / gender-bending, transgenderism, crossdressing, etc).

Popular opinion regarding treatment

The above-mentioned approaches are humane, compassionate and practical, given the depth and longevity of many patients' autogynephilic feelings. However, such an enlightened approach flies in the face of common community attitudes, which are not always known for wisdom or compassion. The community at large, for the most part, tends to split loosely into three camps:
  • Phobics believe that transsexualism is never right and that no assessing psychiatrist should ever recommend hormone treatment or surgery. Often these people hold fundamentalist religious beliefs and maintain that those seeking gender reassignment should either be given intensive cognitive treatment, be healed through faith in God, or rejected and punished for their "unnatural perversions".
    Another type of phobic is the redneck type which can be male or female; their (often) low levels of education being reflected in their high levels of fear of the unknown and unfamiliar. Some phobics feel threatened by gender-transgressors due to fear of their own unexpressed bisexuality. Others are simply misinformed by negative images of transsexualism presented in the populist media.
    Phobics are usually strongly supportive of patriarchy. Yet ironically, another form of phobic is the feminist ideologue, who believes that sex and gender are inseparable, and as such engage in their own form of dogmatic fundamentalism.

  • Pragmatists have little or no interest in trans-issues and therefore judge transpeople by conventional standards. That is, they tend to make strong distinctions between feminine and masculine types, often responding especially badly to those with a "genderfuck" approach. Many will be fairly tolerant of transsexuals who "pass" (if they find out) but ridicule those who don't. The pragmatic layperson's logic generally tends to go like this: "I can only understand it if she is exactly like a woman".

  • Accepters are probably the smallest group (surveys seen by the author would indicate under 20%), often referred to as "the latte left", "the chattering class" or "left wing intelligentsia" by the tabloid press. These people have strong beliefs regarding human rights and may even gain pleasure in meeting those in minority groups because it gives them the opportunity to express their tolerant attitudes and satisfy their curiosity. Accepters will usually strongly in favor of women's rights and racial tolerance.
It should be said that there is much room for overlap between the groups, and the above is only intended as a rough guide.
Phobics and Pragmatists will suspect the motives of transsexuals who look, sound and and come across as unmistakably male. They think "Who on earth does this person think he/it is?". As such, there would be a strong majority of support in the community at large for non-surgical treatment of such autogynephilic individuals, a viewpoint almost invariably reached without regard to transsexual candidates' full circumstances.
Those who debunk the validity of sex change surgery as a matter of principle tend to share a single attribute: an almost complete lack of knowledge of the subject of transsexualism, usually making off-the-cuff motherhood statements based on simplistic belief systems. It could be argued that even former transsexuals who later claim that their sex change was invalid know little or nothing of transsexualism. By definition, they are not genuine transsexuals and have never experienced what transsexuals who are happy with their change (the vast majority) have experienced.
Plato's famous quote, "As empty vessels make the loudest sound, so they that have the least wit are the greatest blabbers", would appear to apply most neatly to most debates in regard to transsexualism.

Anti-trans activists

Some offshoots of religious organizations engage in reversion therapy. Given that, as stated in Part 4, trauma results in permanent changes to the brain, resulting in a permanent hair-trigger reaction to the primary trauma stressor (in this case, emasculation), such approaches seem doomed to failure in all but the mildest cases.
An exception is the former crossdresser/transsexual who engages in vociferous anti-trans activism; anti-transsexualism becomes their raison d'etre.
In this case, the person will frequently refer to his former days of cross-presentation and often there will be pictures of himself cross-presented on public display. Such people often seek as much media exposure as possible, again, with obligatory cross-presentation images and talk about wearing women's clothing. This is essentially the same dynamic seen in the crossdresser who carries pictures of his crossdressed self in his wallet; he simply cannot let go.
Thus, anti-trans activists can still satisfy their cross-gender needs, most likely an autogynephilic desire to be publicly emasculated / humiliated.
As such, their approach could be thought of as parasitic, in that it satisfies their own needs while attempting to deny those of others, and lacking a medical background, risks causing considerable damage to any naive or desperate persons who come to them for help.

Assessment safeguards

Because of the variability of transsexuals, existing in any combination of femininity, masculinity, androphilia, gynephilia or autogynephilia, they can be notoriously difficult to assess accurately.

While there is a 1 - 2 year real life test prior to approval being given for surgery, how can a doctor really be sure how a patient will feel in 3, 5, 10 or even 20 years' time? The author has observed one writer to a web forum who declared her intention to revert back to the male role an extraordinary 20 years after transition.

Many laypersons intuit a certain air on "invalidity" around sex changes, with its unscientific "woman trapped in male body" claims and transsexuals' own history of conforming slavishly to female stereotypes. On the other hand, the hardline "it's never right" attitude of conservative psychiatrists, reformed transsexuals and fundamentalists rings similarly hollow.
Some may believe that an emasculation trauma model pathologizes autogynephilic transsexuals. In a sense it does, but only in the context that one of the most common and highly effective "cures" for such trauma is gender reassignment.
Given the permanency of strong autogynephilic needs, any attempt at alternative cures would appear counter-productive unless patients are so disturbed by their feelings that their lives become dysfunctional. The issue becomes, what is the best manner for such a person to express or deal with his/her autogynephilia?


The last thing a deeply gender dysphoric person (or any person with life difficulties) needs is "treatment" at the hands of an ideologue. Treatment of transsexuals by ideology was proven to be ineffective at best, and dangerously damaging at worst, some decades ago.
It is arguable whether advancements in behavioural therapy in recent years are capable of being appreciably more effective than the failed methods of the past. This is not to say that cognitive therapy should not be considered or attempted, but hormonal and surgical interventions should never be disregarded out of hand.
To refuse to consider all options, disregarding the extreme intensity of some sex change applicants' needs, is to invite the return of "backyard jobs" - self-mutilation, suicide and extreme marginalization. In this sense, transsexual issues parallel those surrounding abortions. In both issues, a failure to empathize to any extent with the people seeking treatment can result in disastrous waste. In both cases, those with limited or no knowledge of the issues seek to tell individuals what they should be doing with their lives and bodies.
In the heavily overpopulated world in which we live, surely the time is long overdue to discard primitive belief systems based on our "populate or perish" instincts?
It could be argued that the recent swing towards conservatism and fundamentalist religious belief systems is a backlash against a rapidly changing world and may well be a prelude to further social advancement, as per the usual "two steps forward, one step back" pattern of growth.
While this is not the forum to discuss sociology in detail, the basic point is that applicants for gender reassignment pose no threat to the species or the fabric of society and they deserve a fair hearing, even if this flies in the face of (poorly informed) majority opinion.
As mentioned earlier, certain types of feminist ideology is also anti-transsexual. Proponents of this viewpoint assert that transsexuals misguidedly, perhaps naively, believe that sex and gender are purely physical issues, and ignore the psychological aspects of our being.
While this may be true in some cases, this viewpoint undersells the many transsexuals who are acutely aware of this fact, often to a greater degree than most. Some transsexuals would argue that it is the wider public's view that sex and gender are purely physical that makes the surgery so essential. That is, to not have surgery would invite non-recognition of their changed gender status and their psychological femininity. This attitude is clearly encapsulated in a newspaper headline observed by the author, "If it's got tackle, then it's a bloke".
Despite their disparity, all brands of anti-transsexual ideologues share one thing in common: lack of empathy for transsexuals and their life situations. Any psychiatrist who strictly subscribes to the above ideologies is not suitable for any role that involves treatment of transsexuals because they will be unable to appropriately relate to their transsexual patients and could put their own ideologies ahead of their patients' welfare.

Risk assessment

It is inevitable that a small minority of unsuitable sex change candidates will "slip through the net" and come to regret what is, essentially, irreversible surgery and/or hormone treatment. However, we must accept that risk is a reality of life. No activity in life, and certainly no treatment, is failsafe.

Almost all professional and/or corporate activities incorporate risk management principles into their planning processes, a tacit acknowledgement that perfection is simply not possible.
Transsexual assessment is no different, hence the 1 to 2-year "real life test". In practical terms, this period is often longer because of the time it takes for pre-op transsexuals save up for the surgery.

The risk of misdiagnosed sex change applicants being adversely affected by social and hormonal gender changes they undertake, with or without surgery, must be balanced against the risks created by not treating applicants; suicide, self-mutilation, debilitating depression, with accompanying loss of productivity are typical results of poor or non treatment.

Unrealistic expectations

Nonetheless, assessments can still be improved by way of more sophisticated models. The "woman trapped in a male body" cliche has quite simply become an impediment to realistic assessment. Any such statement made by a gender change applicant should act as a trigger for the assessing psychiatrist to further explore the patient's issues; it demonstrates either a disconnectedness with reality and/or a desire to gloss over the issues.

Other clichés which should be removed from the trans-treatment lexicon are, "I am a woman" or "I will become a woman" when the word "woman" is spoken with naive conviction, as opposed to being used as short-hand for realistic self-images such as "a woman-like person" or a "woman for all practical means and purposes".

As previously discussed, an M2F transsexual not only cannot be a woman (any more than a F2M can be a man), but has never felt quite like a woman or thought quite like a woman.

A highly feminine applicant may think in feminine ways - that is, in ways more similar to most women than that of their male peers - but that is not quite the same, as any woman will tell you. Some of the obvious differences between the experiences of transsexuals and those of genetic females are:
  • Transsexuals were not brought up with the expectation of becoming a mother.

  • They are rarely taught the arts of "proper" feminine presentation, homecrafts and behavior in their youth.

  • They were not shaped by estrogen during puberty, with budding breasts, widening hips and the onset of periods.

  • They were, at best, honorary members of "the girls club" in their childhood and teens, with their subtle games of acceptance and exclusion.

  • They have not known the frustration of being over-protected sexually by their parents to safeguard against pregnancy, especially by fathers.

  • They have not experienced those unique mother-daughter, father-daughter and sister-sister bonds.

  • They have not experienced the pain and, sometimes, madness of the monthlies.

  • They have not been pregnant, nor felt the expectation, hope or fear of becoming pregnant.

  • They have not given birth or been a mother.

  • Prior to changing over they have never been patronized by men as "useless" or "dumb" women.
By contrast, most transwomen were brought up with typical male expectations of, and tutoring in, independence and enterprise, advantages too many girls women still do not enjoy. Boys are told to be tough, to be logical, to make and fix things around the house, to not cry, to excel at sports, to date girls. Regardless of how successful, or welcome, those lessons were, the experience is still different.

While it is impossible for a male to feel quite like a woman or vice versa, this does not render their cross-gender invalid. Nor does it mean they cannot benefit by making the change. However, it does mean that those needs need to be realistically defined.

Realistic claims and expectations

Despite the above, transwomen can still become women in the world for all practical means and purposes. Feminine transwomen can be so much like normal women that the difference is not important in the greater scheme of things, at least for those without an ideological axe to grind. The only real exception in this regard is relationship issues, where a male partner may feel threatened by the potential stigma of being with a transwoman.
Transwomen may not be quite like genetic women, however normal female diversity is their ally. That is, we do not expect all women to be the same, so if a transwoman looks, speaks and smells enough like a woman and basically "vibes" like a woman, then it is perfectly possible for them to lead a fairly normal woman's life.
Less feminine transsexuals, too, can also find relief in making the change and, knowing that "passing" is a lost cause, many still manage to carve satisfying and effective niches for themselves in life.

Below are some of the more valid scripts for seeking a sex change:
  • My personal qualities and attributes (physical and/or mental) are better suited to a feminine life than to a male one. I have felt uncomfortable and/or miserable in all of the male roles I have attempted to fulfil and I believe that I would function better in all aspects of life, and experience less rejection, as a woman.

  • I will make a better woman than a man and will have a better chance of attracting the sort of partner I desire as a woman.

  • I dislike being a man and being a man upsets me. I would prefer to be a woman and wish I had been born a girl.

  • My male genitals are of limited use because I have desires to be sexually receptive but not to be in the active role, so I have little to lose.

  • People don't recognize my feminine mentality or treat me in a way that feels right to me when I am in the male role because they see me through the lens of my male identity, so if I change my physical presense then people will simply take me "as is".

  • I am worn out with the endless focus on cross-gender issues and/or the difficulties I face in swapping over and just wish be "one" - to reconcile my dual-identities and "just get on with life".

  • I am sick of the obsession of it all - the waste of time and energy, the selfishness and self-absorption, the deceits, the subterfuge and the fears.
These are all valid and realistic issues and some, if not addressed, can be crippling and play havoc with a person's self-esteem and general productiveness in life.
In a patriarchal society that devalues femininity, a male seriously lacking in stereotypical masculine traits could be regarded as having a social disability because his social and sexual functionality is so limited.

Professional responsibilities

Psychiatrists and other professionals not only have a responsibility to their patients but also to the community at large.
If a therapist believes that giving a patient "the go-ahead" for surgery will help her be a more useful, better functioning and more productive citizen, then it is hard to argue with the validity of that decision, especially if it later proves to be the right one. This approach places the importance of spirit, or mind, over that of the body.
Pioneer in gender dysphoria studies, Dr Harry Benjamin, was quoted as saying that if you cannot change the mind to fit the body, then change the body to fit the mind. Religious types may comfort themselves with Jesus' words: "If your right eye causes you to sin, pluck it out and cast it from you; for it is more profitable for you that one of your members perish, than for your whole body to be cast into hell".
In this context, the "sin" can be seen as a person being unable to lead a productive and happy life because s/he is too caught up on a maelstrom of inadequacy or dysphoria, "hard-wired" from childhood. Jesus' words could be seen as an affirmation of the of mind/psyche/soul over the body. This stands in stark contrast with the materialistic values of modern society.
Nonetheless, many gender swap applicants do have a change of heart during the real life test, a strong affirmation of RLT's effectiveness as an assessment tool. Some applicants' transsexual (ie. autogynephilic) desires may have been temporarily exacerbated by major events in their lives - marriage or career failure, or some other traumatic event. Once again, trauma can play a key role.
Some "failed" candidates suffer from psychiatric problems such as narcissistic, borderline or psychotic personality disorders, schizophrenia or, rarely, multiple personality disorder.
Again, issues must be explored thoroughly, with the guiding principle being: "Will the change be to this person's, and society's, long-term benefit?"

Exploring the issues

Freed of the baggage of ideology and cliches, psychiatrists are more able to practically help their patients to explore the genuine reasons behind their wish to change over. This may or may not result in a rethink on the patient's part. A psychiatrist's role here is not to push for a certain result but to help the patient realistically explore their issues, to mediate facilitatively rather than transformatively.

Surprisingly, there seems to be almost no discussion - either in the medical or trans communities - about the relativity of emasculation trauma and its role in transgender expression. In fact, the way contemporary medicos and TSs themselves appear to have missed the obvious link between autogynephilia and emasculation trauma is extraordinary.
Dr Ray Blanchard, while providing us with some useful ideas, has unfortunately done so without sensitivity or an apparent desire to understand the deeper nature and roots of transsexualism. His overly black-and-white, "snap-out-of-it-and-face-the-truth" approach has pushed transsexuals and TS applicants with autogynephilic backgrounds towards even deeper denial and self-delusion as they dig in to defend the validity of their life positions.

Why wouldn't transsexuals deny their autogynephilic feelings when faced with the invalidating presentation of his ideas by his successor, Dr Bailey? Autogynephilic people often need to be reassured that there is nothing wrong with autogynephilia, and that it does not necessarily mean they are unfeminine, apart from its problems of self focus - where arousal (be it sexual or emotional) is associated with the self rather than with others, which can be alienating and depressing.
Further, the sexual aspect of autogynephilia generally gives way to emotional attachment, the result being that the common stark definitions which are based on sexual arousal cease to apply, providing those who have moved on from a fetishistic past with an easy "out", as evidenced in numerous transsexual forums.

Some autogynephiles may benefit by channelling their self-oriented drives into more productive, other-centered, areas. Patients need help in examining the roots of their early emasculation feelings to give these feelings an identity, something with which they can grapple. To this end it may be possible to transfer autogynephilic desires, at least in part, to human-human contacts in some cases. For example, psychiatrists may subtly suggest to a sex change applicant with, say, crossdressing attachments that to be made love to by a man can also be thought of as an "emasculating" experience. This may help to move the focus further from the self and facilitate personal development.

Importantly, "emasculating experience" in this context refers to an autogynephile's view of emasculation as a child, because this is nearly always the driving force of autogynephilia. In adulthood, autogynephilic people may well develop mature, cosmopolitan attitudes towards sex with men, but still retain the sense of childhood taboo. This approach will be especially useful with autogynephiles with repressed attraction to those of the same genetic sex.
Such an approach needs to be handled with more subtlety than common approaches used, such as "Couldn't you try being gay?" or "You could always try anal sex", which are at best tokenistic and lazy, at worst, unempathetic and undermine the therapist-patient relationship.
Most budding transsexuals will bristle if a psychiatrist does not properly acknowledge the difference between gender dysphoria and homosexuality. This reaction could be the fact that homosexuality and transsexualism have a number of significant dynamic differences, despite certain similarities; it could also be due to internalized homophobia.
In the end, Gender Identity Disorder and autogynephilia are not disorders as such, but the result of friction between innate characterists due to simple human diversity and societal norms.

Early-onset transsexuals (EOTs)

Early-onset (up to early 20s) and late-onset TSs face certain unique issues:
  • Having been exposed to the masculinising effects of testosterone for a shorter period, EOTs are more likely to "pass" and be therefore more capable of living a normal woman's life. This can at times create a sometimes-false impression that they are more "real" that late onset TSs.
  • In cases where the person is extremely androgynous physically and feminine mentally, EOTs can essentially be seen as having a social disability, always being targeted for abuse or ridicule, being rejected in many social circlesand being unable to attract the kinds of partners they desire, and the pain experienced in their teens may drive some self-aware individuals towards requesting the role change.
  • EOTs almost always experience less denial of their feminine aspects than LOTs, so they tend to be less affected by psychopathologic conditions that are caused by sustained denial over long periods LOTs. However, without considerable parental and/or peer support (which is more the exception than the rule) they may suffer trauma-related conditions in relation the bullying, violence and ostracism. Self eeteem issues and overcompensatory narcissism can result.
  • EOTs have less life experience and are usually less established in life than LOTs at the time of transition, so they are at greater risk of "going off the rails", falling into drugs and/or prostitution. They are therefore more in greater need of parental or other adult support.
  • Young people are necessarily more unstable than older people, and usually have had less time to ruminate on the issues, and less able to analyse their issues clearly. In some cases, they may be capable of living happy lives as gay men if they can find a suitable partner (bearing in mind that most hyper-feminine boys grow up to be gay men, not transsexuals).
  • Some young TSs may simply be late developers and, without medical intervention, may grow into normal-range masculine physicality over time.
  • EOTs sometimes struggle during the real life test, feeling frustrated at not being able to act out on their sexual feelings (without complications), lacking the experience to understand that one year is not such a long time in the greater scheme of things.

Late onset transsexuals (LOTs)

  • Due to the long-term effects of testosterone, LOTs tend to be less likely to "pass" than EOTs. A number are too masculine in appearance to ever hope to lead a normal life as a woman. This can create depression and suicide risks.
  • Some late-onset, autogynephilic transsexuals provide difficult-to-prove reports of their past history, such as childhood femininity and same sex attraction in order to make their transsexualism appear more valid. In some cases their attraction to men is more of an extension of emasculation needs than a desire for the men themselves.
  • The additional life and career experience of LOTs means they can more readily deal with the costs of transition, especially in areas with strong anti-discrimination protections. However, transition for LOTs may involve significant risks and losses (eg. career, family, social networks), again presenting a significant depression risk.
  • A homophobic social climate may contribute to their dissatisfaction with the male role. In some cases, moving to a more cosmopolitan locale may make it possible for a LOT to make an acceptable life as a gay male or "out" crossdresser.
  • Similarly, internalized homophobia may be present, making the choice to be a woman more attractive than being a gay man or crossdresser.
  • Some may, after a long period or struggling with trans-issues, suffer from established personality disorders and mental illness.
  • Another potential souce of depression can occur when the person realizes that the friendships and relationships they have formed were conditional on their pretending to be someone they are not.
Trauma therapy for autogynephiles

Again, the word "emasculation", as used in the above context, refers to the remnant "child" portion of the personality that drives autogynephilic desire, not necessarily current feelings. By the same token, small and sensitive boys who felt inadequate as children can grow to be strapping, competitive and impressive men who later marry and have children. Nonetheless, strong autogynephilia based on childhood trauma may still be present.
If the trauma is great, the individual's self image may not have adjusted to his new physicality and/or mentality. As with any trauma victim, treatment takes patience; it can take some time for trauma patients to face their feelings and their realities head on.
Regularly reassuring sex change applicants that explorations of childhood issues are not a threat to their assessment, but simply a way of helping them enjoy better relations with others (and themselves), may encourage them to open up.
This is one reason why it is essential to not dismiss gender-swap applicants on autogynephilia alone. Sincere assessing psychiatrists sometimes find this conflict of interest between their dual roles of helper and gatekeeper to be frustrating and an impediment to proper treatment.

It is therefore important that possible feelings of emasculation in formative years - and the current triggers and reactions to those triggers - are properly investigated. Trauma patients generally suffer gnawing, faceless fears. If these fears can be rendered tangible, then patients can start feeling them as an adult rather than experiencing the sensations they felt as children when the triggering crises had actually occurred.
Once an autogynephilic person faces his/her demons, then cognitive and behavioural approaches such as P-A-C (transactional analysis) and game theory may help consolidate the therapy. Again, the aim is to heal, not to judge. Good results in this regard can be achieved regardless of the outcome of the assessment.

"Passing" the test

If, one to two years of real-life test has been completed and a thorough investigation of the applicant's possible emasculation issues have been conducted, and the applicant appears to be balanced with adequate social support systems, and she still wishes to push ahead with the change, then it is hard to argue that the wish to change over is invalid.

If that is the case, you will very likely (taking into account risk management principles) be left with a mix of what is politically-incorrectly termed "true transsexuals"; that is, males who are more feminine in body and mind than the vast majority of other males. There will also be some individuals who may still appear to be masculine in mind and/or body but whose autogynephilia is so "hard-wired" that comfortable life in the original gender role is impossible, being impervious to medication and/or cognitive treatment.
If the latter group are otherwise realistic and balanced (using any other recovering trauma patient as a guide), then one would expect that surgery or hormone treatment should help them become happier and better people and citizens.

And that is what treatment is really all about, rather than deciding who would "make a good woman" or not, or trying to enforce simplistic ideologies.

9. Superficiality: passing concerns

Assessing psychiatrists will necessarily take a sex change applicant's appearance, voice and mannerisms into account when making their decisions.

Some may believe this to be superficial and discriminatory. At worst, focusing too much on superficialities can result in "rewarding" stereotypical patient behaviour - always wearing dresses and heels, obsessing over cooking and homecrafts, seeking a subservient role in relationships with men, and so on.

It is essential that sex change applicants are not encouraged to replace one "mask" with another. Ideally, this should be a journey where the applicant is seeking to be as true as possible to his/her true self - be that in the original, or opposite, gender. Nonetheless, superficial concerns are not trivial when it comes to transsexualism; they can mean the difference between contentment and disaster.

A person who looks and sounds the part will not only have an easier time of it as a transsexual woman, but may have less to lose (at times, literally [sic]) than their less feminine peers. Changing sex may resolve some issues but it is not a cure-all, and unresolved psychological problems may well be exacerbated by the pressures of transition.

Bear in mind that some very attractive and "passable" transsexuals have later come to later regret their decision to change over, while some very masculine TSs have been content and productive in their new role. There is no simple formula.

Therefore all factors need to be balanced against each other. For example, a realistic and stable "masculine" autogynephilic transsexual with an established career in a tolerant workplace and reliable family or other relationships may well have a better chance of making a workable life for herself as a woman than an unstable feminine type with unresolved psychiatric issues and who lacks emotional support.
Nonetheless, an attractive and vivacious transsexual will probably have a better chance of finding herself supportive others than a masculine transsexual with no hope of even coming close to "passing". 

"Passing" can help but it isn't the be-all and end-all

While psychiatrists logically tend to be more relaxed in other criteria with feminine TSs than masculine ones, "passing" should never be a sole criterion. Physically androgynous features do not guarantee a feminine psychology.

Male psychiatrists need to be on guard that they do not give "an easy ride" to applicants who they find sexually attractive or punish those who look like "men in dresses". By the same token, female psychiatrists need to ensure that they do not punish transsexuals who may appear to be "overdoing it" and attempting to be too stereotypically feminine.
On the other hand, not all transsexuals want to pass as genetic women. In some cases where the applicant does not want to pass, an assessing psychiatrist may need to determine whether there is an unhealthy level of narcissism, exhibitionism or masochism present that requires further exploration. However, some transsexuals hold strong political or ideological viewpoints in regard to honesty, visibility, and the need to change societal attitudes. Therefore therapists should not punish people for non-conformity to standard female roles.
It is not rare for these kinds of people to actually relish and embrace their difference to the norm; they tend to be very strong individuals, capable of giving as good as they get in the hurly burly of transsexual discrimination. So there is a danger that conservative therapists may misinterpret radicalism as psychopathology, simply because they cannot relate personally to their patients', possibly radical, viewpoints and approaches.
Therefore therapists need to ensure that they themselves do not hold any hidden biases that could interfere with their professional objectivity.
By imposing their own morality and ideology onto what are otherwise healthy and lucid people they have the potential to inadvertently cause at the least inconvenience and, at the most, significant harm.

Proposed new categories of transsexual

As discussed in Chapter 3, Dr Blanchard's categorization of transsexuals is too simplistic to be credible or useful in itself. While his autogynephilia hypothesis is a useful contribution to the area, opening the door towards cognitive treatments which may help autogynephilic individuals achieve greater intimacy in their lives, it is of limited use as a transsexual assessment tool.

With the level of diversity within the so-called trans-community (which is generally just a disparate group of individuals), it is too simplistic to break transsexuals into two groups: homosexual/primary type" and autogynephilic/secondary type.
In order to render what is a useful addition to transgender analysis more practically functional, the classification system should be expanded and redefined.

A proposed expansion of the theme may go as follows:
Mentality/emotionalityPhysicality/voiceColloquial name
Type 1FeminineFeminineClassic
Type 2FeminineAndrogynousSemi-classic
Type 3FeminineMasculineQueen
Type 4AndrogynousFeminineTomboy
Type 5AndrogynousAndrogynousBorderline
Type 6MasculineFeminineTough Nellie
Type 7AndrogynousMasculineSNAG
Type 8MasculineAndrogynousSoft butch
Type 9MasculineMasculineButch


For the above table to imbue meaning to the classification process it is necessary to define "androgynous", "feminine" and "masculine". Of course, gray areas will exist between categories. For example, "androgynous" will necessarily include both feminine-leaning and masculine-leaning androgyny. The below definitions should only be seen as a rough guide, not a definitive or black-and-white decree. After all they are only stereotypes.
The suggested colloquial names are simply a means of easy referral through evocative language that "paints the picture", and no offence is meant.
Feminine mentality (note that the stress of seeking help and the dynamics of assessment may skew the manner in which an applicant presents)
  • Unusual (for a male) levels of sensitivity - awareness of, and concern for, others.
  • Typically feminine interests and aptitudes, eg. babies, cooking, grooming.
  • Good oral and written expression (relative to education).
  • Desire for approval from, or closeness with, others.
  • A cooperative rather than competitive / aggressive approach.
  • Anger expressed covertly / subtly / non-physically.
  • Relative comfort with strong emotions.
  • Interest in determining hidden meanings rather than taking comments at face value.
  • A relative lack of certainty, or indecisiveness, in his/her positions (as compared with typical males).
Masculine mentality (note that the stress of seeking help and the dynamics of assessment may skew the manner in which an applicant presents)
  • High levels of self-centeredness and egotism.
  • Poor oral and written expression (relative to education).
  • More interest in success and respect than approval and closeness/platonic intimacy.
  • Competitive and openly aggressive approach.
  • Anger openly expressed, perhaps with a tendency towards physical expression.
  • Relative discomfort with strong emotions.
  • Takes comments at face value and tends not to read between the lines. Dogmatic approach.
Physical feminine and masculine factors
  • Height: Average feminine height is around 5'4". Up to around 5'6" could be considered feminine, from 5'7" to 5'9" androgynous, and above 5'9" is typically masculine.
  • Build: Factors such as hirsuteness, musculature, breadth of skeleton, "man boobs", wide hips/narrow waist, size of hands and feet, prominence of arm/hand veins and size of Adam's Apple, and skin texture.
  • Face: Beard density and distribution, degree of hair loss, nose size, chin/jawline size and shape, ear size and shape, eyes (size and shape), sunkenness of eyes, eyelashes, prominence of cheekbones, prominence of brow bones, fullness of lips, natural shape and color of lips, prominence of smile lines, and skin texture.
  • Speech: Voice timbre, pitch, inflections and intonation, use of language.
The above table was constructed with the view that sexual orientation in the assessment context is relatively unimportant. Once severe mental illnesses and disorders have been eliminated it is more important to consider the patient's physical and mental gender and social environment with a view to the following lines of inquiry:
  • How easily will the applicant adapt to the new gender role? That is, how feminine is the applicant's mindset and emotionality?

  • How capable is the applicant of leading the kind of life she desires? It is less important that a transsexual be capable of mainstream acceptance if an alternative lifestyle is preferred. If a transsexual seeks to live a mainstream lifestyle but has little or no potential to be recognized as a woman, a reality check may be required.

  • How well does the applicant relate to others? Will she have support from family/friends/workmates? Does she live in a conservative or broad-minded area?
  • What are her career prospects? Will they be severely and adversely affected by a changeover?
10. Problems and reversion

So what of those who make the change and who later decide it was a terrible mistake?

Testimonies provided by these people often appear to revolve around discrimination and stigma. In one account in the media about a decade ago a transsexual said she regretted making the change due to her heartbreak at being rejected by her children, which also meant she could not keep in touch with her grandchildren. 

Discrimination and the importance of support

While this is a terribly sad case, there was no evidence of misdiagnosis (in an admittedly superficial news article), only rejection. However, this does demonstrate the importance of support.
Changing sex, while generally thought to be a lonely path (and it may well be that at times), is far from being a solitary enterprise. The changes affect not only family, friends and workmates, but also involve to some extent every passerby and acquaintance who may "pick" her.

It is too easy to be glib and for a transsexual to say, "Well, that's not my problem. It's everyone else's problem". The trouble is that others' problems can become our problems because we are social beings.

There is an inevitable sense of trade-off with sex changes. While a person may gain by relieving internal tensions and emotional turmoil, they may also lose relationships and, quite simply, any peace in their lives. What they gain in inner peace may be offset by external turmoil. This is often the case during early transition, at least. Transitioning transsexuals need to be able to cope with the pitfalls of celebrity status - minus the money, glamour and prestige. Some revel in the attention. Others find it repellent.
To quote a former transsexual, when asked why he changed back, he answered simply, "I kept getting sprung". Again, he had no issue with the change itself, only with the discrimination.

Going stealth

The question is, how can anyone gain inner peace - generally the stated wish of any transsexual applicant - when the world around her is hostile?

This is where the "safe haven" of supportive family and friends can make so much difference. An exceptional sense of self assurance is another "haven". However this, by definition, is the exception. The continued stigmatization of transsexuals is the reason why so many "go stealth", hiding their transsexualism from some or all - if they are able.

Nonetheless, carefully hiding one's transsexuality carries its own problems; the need to be evasive when speaking of the past or when "women's issues"are raised in conversation with other women may impede the building of friendships or intimacy. It can also seriously limit the degree of intimacy in romantic situations. Transwomen who attempt to lead a normal woman's life without revelation may also be left wondering if their friends or lovers would still love them if they knew about their background.

Reversions after a long period of time

Some who make the change come to regret it, even after many years after transition. Transsexuals suffering from narcissistic personality disorder may be attractive as women in earlier years and enjoy the attention of men, in stark contrast with the homophobic abuse they may have experienced as youths. However, beauty fades in time, and once it is gone, they may feel that there is no longer any point in remaining female and that s/he has a better chance of being attractive as a male, especially if she has not had the operation.
One case in the news described a transsexual who reverted to the male role after 10 years of feminine life, claiming that s/he was misdiagnosed. His/her current treating psychiatrist publicly stated that his/her issues related to a lack of proper male role modeling.

On the face of it, this explanation sounds too simplistic to be credible. If a lack of male role modeling was the reason for the person's gender dysphoria, then why is it that so many males lacking accessible or desirable male role models have no issues with their gender? If lack of male role modeling creates transsexuals then, in the current environment of marriage breakdown, one would expect transsexualism to be rife, which of course is not the case.

However, inappropriate male role models may engender a feelings of inadequacy as a male in some boys, perhaps feeling unable to live up to masculine expectations, which could create emasculation trauma with resultant autogynephilia. After an extended period of outwardly successful life as a transwoman, it seems quite probable that a person may well have had good reason to doubt his masculinity. After all, only a small percentage of males have sufficient physical and emotional femininity to be capable of "passing" regularly over a sustained period.

There is clearly a danger of reversion in Type 3 transsexuals (as per the table in Chapter 9) - physically feminine and psychologically masculine - who were traumatized by their physical lack of masculinity and resultant bullying. again, therapists may be seduced by the fetching physical femininity of such individuals into glossing over their masculine mentality.


So there is a need for flexibility in thinking from both the patient and the therapist; there are not just two options for gender-crossed individuals. If the patient lacks that flexibility then the therapist must help him/her to see that there are a number of options available (as per Chapter 7).
To be fair, in the past these various options were less known, and the stigma surrounding options such as part-time transgenderism and androgyny was so intense at the time that therapists may have baulked at suggesting them, especially if the patient appeared to be sensitive / reactive to stress.

However, as mentioned earlier, the vast majority of unsuitable sex change candidates quit the process before or during the real life test. Only a small percentage go through the real life test, have surgery, and then have regrets later on.

The number of transsexuals who decide that they changed over in error has been assessed in various studies. The results range from 2 - 13%, depending on the study. The former is more likely a more credible figure. Importantly, many of those who expressed regret at the change experienced unsatisfactory surgical outcomes.

In this light, risk management principles (as described in Chapter 8) should be applied to the assessment process. It makes little sense to risk inflicting major harm (depression, self-mutilation or suicide) to between 87% and 98% of "satisfied customers" in order to protect the interests of the remaining 2% to 13%.

At some point, would-be transsexuals without major disorders must take at least some level of personal responsibility for their actions and take steps towards their own welfare. Once psychopathology has been ruled out, there is only so much a psychiatrist can do. While therapists may explore the issues surrounding a patient's stated need to change gender roles, they can only "lead a horse to water", especially now that the Internet provides plenty of information that can help would-be transsexuals to provide the "standard script".

A more enlightening statistic - not currently available - would be the percentage of those who regretted the change who did have successful surgeries and transitions. That is, how many transsexuals who both "pass" and who have adequate width and depth for heterosexual sex, along with full orgasmic ability and no physical pain, have regretted making the change?

Very likely this figure would be extremely low.

Quality of surgery

This raises the issue of success in surgery. Transsexuals need to go into this process with their eyes open [preferably not during the surgery itself - sic]. Gender reassignment surgery is extremely complex so things can easily go wrong. Does the patient have a contingency plan in case the surgery does not work out? Will she feel life is still worthwhile if she cannot enjoy normal sex or experience orgasm? Due to the risks involved, then surgery should not be performed until cognitive therapy is undertaken.
Statements of blind faith masquerading as positive thinking such as, "I refuse to even entertain the possibility" hardly suffice when the stakes are so high. While the mind is capable of affecting our physicality to some extent, one would be hard-pressed to see how a "positive attitude" could significantly affect a surgeon's performance on the day.

So, without a contingency plan, a transsexual whose surgery is less than ideal could leave herself vulnerable to deep, even crippling, disappointment if the surgery is performed badly. This can lead to disillusionment in the entire process, especially if the transsexual had high expectations of a fabulous love life post-op, and may then decide to "throw the baby out with the bathwater" and question the validity of the process per se.

Associated disorders and discrimination

A logical question to ask any transsexual who changes back after an outwardly-successful transition is - will s/he one day have regrets about their reversion as well? Could the reversion itself be the result of an inherent instability, as opposed to unsuitability? Double-reversion can - and does - occur, where the transsexual discontinues hormone treatment and reverts to the male role, only to change back over to the female role later on.
Only time can answer such questions, hence the risk management approach advocated earlier. Reversion should be treated with as much caution as the original change; a sex change is a sex change. Many transsexuals of religious conviction have reverted without proper consideration or professional help, relying on religious cronies' assurances that "God will provide".

Psychiatrists are well aware that some mental illnesses and/or disorders can lead a person to seek a sex change, along with internalized homophobia. It can take considerable analysis to determine whether a disorder has facilitated the desire to change sex, or if disorders are in fact the result of discomfort with the current gender role.

It is also possible that disorders can lead a person who would otherwise benefit from a sex change to blame the sex change for their problems. Few aspects of transsexualism are clear-cut or easy.

Wrapping up

Because of the complex issues surrounding transsexualism, few groups of people are more stigmatized or misunderstood (hence this website).
Few groups experience more human tragedy and heartbreak. Few groups experience such high levels of depression, unemployment and suicide.

And, of course, few psycho-sexual states have caused more confusion and perplexity amongst professionals. This makes the need for compassionate and flexible - as opposed to prejudiced and black-and-white - thinking all the more important in their treatment.

While attitudes within the psychotherapeutic community have greatly improved to this end over the fast few decades, there is a danger that current hyper-conservative and reactive elements within the broader community may undermine those improvements. Therefore the trans and therapist communities need to refine the current approaches to protect the gains made since "the sexual revolution" of the 60s.

As mentioned earlier, the first step to this end is to debunk the myths surrounding transsexualism - the misguided claims of bona fide womanhood as well as the biased and pseudo-scientific validations, invalidations and misguided claims of the "it's not natural" advocates.

This will allow us to review the situation with open eyes and see that, in the end, people have always been diverse and they have always altered their physical realities. It is simply a matter of deciding on the best approach on a case-by-case basis.

11. Overview and summary

To answer the questions posed earlier:

  • Why do some quite masculine males who are clearly not at that extreme end of the feminine scale - tall, strong, aggressive and excelling in fields like engineering or the military - seek to undergo genital surgery and change their sex roles?
  • Why do some extremely feminine men and masculine women not seek to make the change?
The most likely answer to these questions needs to be made in two parts, for each of the types.
Emasculation trauma, which very likely has a large bearing on autogynephilic behavior, can affect young males who may be extremely feminine mentally and/or emotionally (as per standard human diversity).
In the case of homosexual/androphilic transsexuals, it would be fair to say that the very most feminine examples of these people make the change because it was impossible for them to find any male role in which they did not feel inadequate or ridiculous. After much rejection they essentially change over in order to gain greater social acceptance as human beings.
The main danger for such individuals is that male development can occur even up to age 20 or so, and some very small and unmasculine youths, without hormonal intervention, may eventually grow tall and bulk up. In a more tolerant social environment, these people may find more acceptance as gay males than in the past, although their choice of partners will tend to be limited by the strong emphasis in the gay community towards classic masculine physical beauty.
Hyper-feminine boys can experience problems described by both homosexual and autogynephilic transsexuals (to use Dr Blanchard's terminology). Parental denial may lead such children to deny their basic natures leading to internal pressures. In the face of both internal and external assaults such individuals may present with considerable psychopathology.
Ultimately, the existence of an autogynephilic or transvestic history should be no bar to a sex change applicant being given the go-ahead for a sex change. The bottom line must always be a decided on the basis of whether transition will improve the patient's wellbeing and functioning in society.

Some males who are quite masculine by nature can also experience emasculation trauma (with subsequent autogynephilic feelings), believing themselves unable to live up to the model of masculinity they encountered as children - due to their social environment and/or traumatic/sensitizing events.

It has been reported that up to 90% of males who ask their doctors for treatment for gender identity order (GID), at some stage change their minds and discontinue treatment. It would be safe to say that most of these would be reasonably masculine autogynephilic males who find the female role uncomfortable or difficult to fulfil.

Cognitive treatment for GID should include a focus on that sense of childhood emasculation, that is, the reasons why the patient seeks a sex change, as opposed to being a gay man or crossdresser.

The aim in treatment should not be changing the person's mind so much as raising self-awareness and helping to explore feelings.
If this exploration leads to a change of heart, then such self-knowledge may help the patient find a life path more suited to him/her. If the patient wishes to continue treatment s/he will at least have a better understanding of his/her needs and desires and perhaps be motivated to work towards less dependence on cross-gender behavior for happiness. Whatever, once people "face their demons", they are in a better position to make informed decisions.

Due to stigma, false morality, ignorance, and a failure to understand risk management principles, there is a widely-held belief that sex changes are wrong per se, and that therapists should try to talk gender reassignment applicants out of making the change. Some some therapists do, in fact, take a watered-down version of this approach, only recommending patients for surgery if they determinedly resist this subtle coercion and succeed in the 2-year real life test.

This win-or-lose "gatekeeper" approach only serves to undermine meaningful treatment of any underlying problems. It may at times raise competitive or rebellious instincts in sex change applicants, who are already oversensitized to judgmental attitudes, almost encouraging them to "prove the therapist wrong".
Many observers believe that transsexualism should be avoided at all costs and that therapy should be targeted towards either diverting androphilic types towards life as gay men and more masculine "heterosexual" autogynephilic types to recognize and embrace their masculinity. Given the issue of emasculation trauma, the only possible "cure" for transsexualism would be the complete removal of stigmas in relation to sexuality and differentiated social gender expression.
While these may be laudable goals, unfortunately they are not achievable in the short, or even the medium term, if at all. It is therefore unrealistic and cruel to expect transsexuals to offer themselves to be sacrificed on the altar of ideology. Given that transsexuals comprise of at most 0.01% of the population, their role in changing the gender consciousness of the public at large is minimal.
There is a common view that the human body is sacred and that cosmetic surgical changes to it are wrong, immoral or tragic. When emotive words like "mutilation", "false" and "fake" are used to describe surgical changes to a person's body, this indicates that the speaker/writer subscribes to this "body is sacred" viewpoint.
An alternative viewpoint would be that our psyches and social roles are more "sacred" than our bodies, which are essentially carriages with which to do the bidding of our minds and emotions. For many gender reassignment applicants, their cross-gender needs are so ingrained from such an early age that is easier to, as Dr Harry Benjamin once put it, "to change the body to fit the mind".
There is no tragedy in a person choosing to modify his or her body surgically if it relieves psychological, emotional or existential problems and allows him or her to "get on with life" and move onto more productive activities rather than wasting it agonizing over gender, or other distracting, issues.
Finally, it should be said that changing sex is such an extraordinarily difficult enterprise that those who successfully traverse its many pitfalls and hardships, and end up relatively unscathed, may well be endowed with some extraordinary personal qualities for having survived the experience. It could even be said one needs to possess some extraordinary qualities to survive the experience intact.

Chapter summaries

Chapter 1 - Nature vs nurture: humans are diverse
  • There are many forces aligned against transsexuals - conservatives, rednecks, anti-trans groups run by ex-transsexuals, religious fundamentalists, radical feminists and non-empathetic gays.
  • If transsexuals are to survive these assaults upon their credibility they need to start making clearer what transsexualism is and what it means, beyond the standard "woman trapped in a male body" cliches. [** key point **]
  • Ever since prehistoric times there have been people or either sex who have taken on opposite sex roles in their societies /tribes / groups. [** key point **]
  • There will necessarily be some females who are extremely masculine women and some males who are extremely feminine.This is standard diversity, and it can be found in all areas of nature.
  • Gender diversity can be caused by intersex conditions, genetics, hormones, hormonal conditions during gestation and conditioning.
  • It is the interplay between the biological and social that decides how a cross-gendered person chooses to deal with his or her situation.
  • Society / customs play a role in sex changes.
Chapter 2 - Diversity in society
  • Some tribal groups and small communities pragmatically accepted gender diversity, making the best possible use of their "human resources". They did not have the luxury of wasting the effort put into bringing up community members by forcing them into unsuitable roles.
  • In societies dominated by Christianity and Islam, crossing gender boundaries has generally been thought of as "sinful" and "unnatural", and gender transgressors often became outcasts or were killed.
  • Persecution of (especially) male-to-female gender transgressors is still happening to some extent, even in so-called "enlightened" Western societies. This is due to continuing patriarchy, where feminine traits are widely considered to be inferior to masculine attributes (reflected in the wage scales of teachers, nurses other caring professions. [** key point **]
  • This persecution plays out most dramatically in schools, where masculine males are often abused.
Chapter 3 - A woman trapped within a man's body or autogynephilia?
  • Most people don't see standard cliches like "I'm a woman trapped with in a man's body" or "I'm a woman inside" as credible.
  • It is impossible for a male to actually become a female, being shaped by the imperatives of those who carry large sex cells (ovaries) as opposed to those who carry small sex cells (sperm).
  • There are two main sex strategies in nature - "He-man" (dominant male with a harem) and "Domestic Bliss" (female forces a greater nesting / rearing investment from males). Both are present in human society and shape psychological "maleness" and "femaleness".
  • The major differences between male and females can be broken into physical (gonads, size, body shape, skin texture, body hair, facial features, voice, voice intonation and mannerisms) and psychological & emotional (desire for closeness and approval, emotionality, sensitivity, empathy, forcefulness, competitiveness, use of language and our manner of speaking, decisiveness).
  • Dr Ray Blanchard created a theory of autogynephilia - where transsexuals can usually be grouped into two categories - homosexual and autogynephilic. The homosexual type is at that extreme feminine end of the male spectrum. autogynephiles usually have a fetish history, marry and are "heterosexual" in their old lives and are sexually aroused by feminization.
  • Autogynephilia need not be sexual in the usual sense of the word, just as intimate relationships need not be sexual due to factors such as familiarity, morality, etc.
  • The autogynephilia theory's main flaw is the black-and-whiteness of Ray Blanchard's definitions. Being as diverse as any other group, many transsexuals do not fit neatly within one camp or the other. That is, focusing on extremes tends to exclude the majority of cases. [** key point **]
  • There is little obvious consistency in the backgrounds of gender transgressors. This is because the consistency lies, not so much in the events gender transgressors experienced during childhood/youth, but how those experiences affected them. [** key point **]
Chapter 4 - Trauma can shape us
  • Many researchers believe that childhood trauma is the usual cause of displaced sexual desire. A common thread between the most profound traumas experienced is feelings of humiliation. [** key point **]
  • Humiliation is one of the more intense sensations, as capable of creating trauma as it is of facilitating suicide and warfare.
  • Intense humiliation during a person's formative years can shape their sexuality. Coping mechanisms can lead them to keep replaying the trauma later in life as a fetish or fixation - but with the important difference having some control over the replayed trauma. This has a short-term palliative effect. [** key point **]
  • If the person doesn't understand the feelings that lie beneath his / her desires then the compulsion may become increasingly intense with age. The effects of his/her self-administered "cure" will become increasingly weak through familiarity. The person may then seek more intense "medicine". [** key point **]
  • There is a direct analogy here with drug abuse, where people seek more and more extreme remedies to regain the intensity needed to properly "repeat" the trauma.
Chapter 5 - Emasculation trauma and autogynephilia
  • The humiliation that creates "emasculation trauma" does not necessarily come from abuse (although it may do), but from the person's sense of self[** key point **]
  • The cause of traumatic emasculation may range from being a boy who is, in fact, highly feminine by nature but in denial. A highly homophobic / macho environment can also deeply affect a sensitive boy, as can bullying and/or abuse at school or at home, "petticoat training" - or any combination, or all, of the above. [** key point **]
  • A boy's innate sensitivity is an important factor in how traumatic an event or series of events are perceived. Other traumas may sensitize a child further, such as family conflict, deaths, broken home, etc, making him more vulnerable.
  • There are various ways a boy may cope with feeling emasculated to the point of trauma. Often the boy overcompensates - either trying to be exaggeratedly masculine or camp. Or he may seek refuge in privately living out the emasculating trauma - which them renders it under his control. In this instance he privately gives up the fight for masculinity while continuing to fight for it in public.
Chapter 6 - Trauma and sexuality
  • Intensity is a common link between trauma and sexual response. The link between childhood/adolescent trauma and sexuality is a well-documented area of psychological enquiry. [** key point **]
  • The coping mechanism of repeating the trauma carries its own problems, because it reinforces the behaviors, which can then become habitual. This can create all manner of complications in people's lives, including subterfuge, self-loathing, impediments to productivity, isolation and stigma.
  • There is a distinction between "sexual experiences" and "masturbation" when dealing with autogynephilia (it is common for transsexuals to furiously deny sexual response to feminization). Masturbation is only one type of sexual experience and is not universal behavior in autogynephilic people. In this context "sexual experience" is an experience that serves to arouse or enliven or stimulate, which can be felt mentally and emotionally. It does not necessarily include genital arousal, stimulation or orgasm. [** key point **]
  • Some people suppress the desire to masturbate due to religious or value-based (upbringing) reasons. If there is genital-based autogynephilia (desire for removal of the penis since it is seen as the root of the problem) then there may be an aversion to touching their genitals.
  • autogynephiles may experience repressed sexual tension, so they merely feel comfort and relaxation from feminization (like a partner in a long-term relationship). This explains the comfort people report from fantasy or actual feminization[** key point **]
  • Youths and teenagers who engage in of "emasculating" behaviors in private (crossdressing, folding the penis and scrotum into the body, creating pseudo-breasts by cupping the chest or with prosthetics, castration fantasy, etc) will generally gain some level of "payoff" or arousal from it - be it physical or emotional - or they wouldn't do it. It is also why they frequently do not seek a cure; it makes them feel good. [** key point **]
  • Young person who unworriedly engage in public cross-gender behavior probably don't feel the same level fear or stress in relation to identity and will probably be less, or not, autogynephilic. Usually these individuals have no fear of parental authority.
Chapter 7 - Perversion or lifestyle choice?
  • Since sublimated or actual sexual feelings for feminization start very early, people with these feelings have had a "self-relationship" for some years by the time they start acting on those feelings in a serious way.
  • People can go through great, even crippling, grief and pain when they break up after many years together. The analogy holds if an autogynephilic person, who has been in a "self-relationship" since an early age, feels that the "relationship" is no longer viable (perhaps due to ageing or life situations). So cross-gender identity or fantasy can be extremely important to transvestites and autogynephiles. [** key point **]
  • The scorn and abuse such people experience is based on misunderstanding of their motives. They are often not sexually or dubious intention, just regular people who have developed the habit of using an unusual psychological support mechanism to alleviate the emasculation trauma experienced during formative years.
  • There are a number of lifestyle choices available for gender transgressors in these relatively liberated times : [** key point **]
    · surgical transsexuality
    · non-surgical transsexuality
    · part-time cross-living
    · androgyny / "genderfuck"
    · crossdressing with gay, bi or hetero sexuality.
  • Each solution carries its own problems. Prejudice often shapes the life choices non-normal people make.
Chapter 8 - How to treat transsexuals?
  • Assessing psychiatrists tend to base their decisions on whether the change would be in the patient's best interests , taking into account the alternative options listed above in Chapter 7. Whether a patient is autogynephilic or not is only one factor.
  • There can be no certainty as to whether a diagnosis of transsexuality will be correct because some transsexuals change back much later, even up to 20 years later on.
  • Treatment by ideology (ie. a black and white view that transsexual wishes are the result of a curable mental illness) was proven to be ineffective at best, and dangerously damaging at worst, decades ago so we have to accept that it is inevitable that a small minority of patients will regret the change. As with any other endeavor in life, risk management principles should be applied to transsexual assessment. [** key point **]
  • A large majority of transexuals report benefiting from the change. The risk of not treating needs to be balanced against the risks of treating. Not treating can lead to dire consequences in some cases. [** key point **]
  • The "woman trapped in a male body", "I am a woman" and "I will become a woman" cliches are impediments to realistic assessment and should be challenged by assessing psychiatrists. Such comments either demonstrate a disconnectedness with reality and/or a desire to gloss over deeper issues. [** key point **]
  • Transsexual males can become women - for all practical means and purposes. However, they can never be quite like genetic women due to biology and conditioning. While this fact does not invalidate patients' cross-gender needs, it needs to be reinforced to keep expectations realistic. [** key point **]
  • M2F Sex change applicants can validly say that:
    · they are mostly feminine in their thoughts and feelings
    · they feel their various personal qualities and attributes are better suited to a feminine life
    · if they had their time over they would have preferred to be born female
    · they have felt uncomfortable and/or miserable in the male role
    · they are tired focusing on cross-gender issues and the complications of swapping over.
  • Psychiatrists and other professionals not only have a responsibility towards their patients, but also to the community. The psychiatrist needs to make a decision based on the belief that a sex change will most likely help a patient become a more useful, better functioning and productive citizen. [** key point **]
  • There appears to be little discussion, either in the medical or trans communities, of the relativity of emasculation trauma. While bringing to light an important concept, Ray Blanchard's overly black-and-white presentation of his hypothesis has been counter-productive. [** key point **]
  • The real issues in dealing with autogynephilia are examining the roots of early emasculation feelings to make them more tangible and to attempt to channel those desires into more human-to-human sexual orientation, if that is the patient's wish.
  • The conflict of interest between the dual roles of helper and gatekeeper is frustrating for sincere assessing psychiatrists. When the assessment is free of ideology, cognitive approaches like P-A-C (transactional analysis) may help consolidate treatment, without threatening a positive diagnosis.
Chapter 10 - Problems and reversion
  • When transsexuals express regret at their change, it is usually because of prejudice, lack of support, poor surgical outcomes, or rigid ideas of what the feminine role entails. (This rigidity is expressed with comments like "I don't want to wear makeup, stockings and heels any more", as if this is a compulsory requirement for women).
  • Transsexuals need to have a contingency plan pre-surgery so they have a fallback position if the surgery is unsatisfactory. [** key point **]
  • There is a need to debunk the myths surrounding transsexualism - the misguided claims of bona fide womanhood, the biased and pseudo-scientific validations and invalidations, and wrongful claims that it is unnatural.
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