A Response to Bailey and Hsu (2022): It Helps If You Stop Confusing Gender Dysphoria and Transvestism

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Archives of Sexual Behavior
https://doi.org/10.1007/s10508-022-02418-0
LETTER TOTHEEDITOR
A Response toBailey andHsu (2022): It Helps If You Stop Confusing
Gender Dysphoria andTransvestism
CharlesMoser1
Received: 14 August 2022 / Revised: 26 August 2022 / Accepted: 26 August 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022
It is important to start with some history in order to put the
criticism of Bailey and Hsu’s (2022) article in perspective.
In the 1980s, Blanchard published a series of research arti-
cles that purported to explain why some individuals assigned
male at birth (AMAB) and who report gender dysphoria are
motivated to pursue gender transition from male to female.1
An essential component of this theory is the construct of
autogynephilia, which is defined as “a natal male’s para-
philic sexual arousal in response to the thought or fantasy of
being a woman (Blanchard, 1989a, 1991)” (Bailey & Hsu,
2022). Blanchard’s theory has had numerous proponents and
critics, sometimes evoking spirited defenses of the theory,
but at best there is a correlation (but not causation) of gen-
der dysphoria and autogynephilia. Moser’s (2010a) critique
questioned how strong the correlation might be; the answer
was, not very strong. In that paper, Moser reinterpreted the
data from the pivotal studies used to establish Blanchard’s
theory of autogynephilia and found serious flaws in the
original methods and interpretation of data. Data which
did not fit the theory were explained away by assuming that
respondents were mistaken or purposely misleading the
researchers (see Blanchard, 1985, 1989b; Blanchard etal.,
1985; Lawrence, 2005), while the data which supported the
theory were assumed to be accurate. These are questionable
assumptions to make in any research.
One aspect of the construct of autogynephilia not stud-
ied by the theory’s proponents, possibly until now, was the
conjecture that women assigned female at birth (AFAB) are
not autogynephilic. Independently, Veale etal. (2008) and
Moser (2009) tried to test whether women AFAB were auto-
gynephilic, and if so, another tenet of Blanchard’s theory
would not be supported. If both women AFAB and women
AMAB can be autogynephilic, their existence challenges the
assumption that autogynephilia is a male trait and women
AMAB are just generic men with an unusual sexual interest
(Lawrence, 2013).
Bailey and Hsu’s (2022) article is a bit odd. It attempts to
refute two studies (Moser, 2009; Veale etal., 2008) published
over a decade ago. These two articles were rarely cited or
even discussed, at least until this paper, so it is surprising
that Bailey and Hsu decided to focus on autogynephilia in
women. Veale and Moser, among many others, have pub-
lished extensively about the problems and inconsistencies
with Blanchard’s autogynephilia theory, but those issues,
which are more central to the theory, have not been refuted.
With all due respect to Bailey and Hsu, their article is another
confused attempt to justify a theory that has fallen out of
favor or maybe never was in favor. I will use this response
as another opportunity to highlight the problems with and
demonstrate some of the flaws inherent with the construct of
autogynephilia as applied to gender dysphoria.
Gender Dysphoria Is Not Erotic
Cross‑Dressing
There is a group of individuals who do report autogynephilia
(or at least something like autogynephilia as Bailey and Hsu
understand it) as a core of aspect of their erotic interests.
These are “erotic cross-dressers” or individuals with “trans-
vestism,” who report persistent erotic arousal to the thought
or fantasy of being a woman when cross-dressed. In gen-
eral, individuals with transvestism or transvestic disorder do
not meet the DSM-5-TR (American Psychiatric Association
[APA], 2022) diagnostic criteria for gender dysphoria and
* Charles Moser
Docx2@ix.netcom.com
1 Diverse Sexualities Research andEducation Institute,
4304-18th Street, #14752, SanFrancisco, CA94114, USA
1 There is debate in the scientific, psychiatric, and among individuals
with gender dysphoria on the correct and respectful way to discuss or
refer to individuals whose current gender identity differs from the gen-
der assigned at birth. At present, there is no consensus, though some
terms are known to be offensive. I have chosen to use AFAB/AMAB
but realize that it can be awkward and offensive to some. Please accept
my apologies in advance.

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do not pursue vaginoplasty, hormonal treatments, antiandro-
gens, or identify as female at all times. Individuals with gen-
der dysphoria and individuals with transvestic disorder are
discussed in separate chapters in the DSM-5-TR.2 It should
also be noted that unlike the DSM, the International Clas-
sification of Diseases, 11th edition, published by the World
Health Organization, both gender incongruence (dysphoria)
and transvestic disorder are no longer classified as mental
disorders.
Autogynephilia inWomen?
People tend to fantasize about what they want but do not
have; it would follow that an individual with a male body
and a desire to be female might find fantasizing about hav-
ing a female body arousing. After gender affirming surgery,
those individuals AMAB would have female bodies and their
reported autogynephilic arousal should decrease, which is
exactly what Lawrence (2005) found.
Veale etal. (2008) and Moser (2009) independently
decided to modify Blanchard’s research scales, which
purportedly measure autogynephilia in women AMAB
for women AFAB. Veale etal. (2008) and Moser (2009)
hypothesized that women AFAB may be aroused by imag-
ining themselves as more desirable or with more desirable
bodies. Both papers used different, modified versions of
Blanchard’s research scales, and both found significant auto-
gynephilia among women AFAB. Bailey and Hsu (2022)
compared the scores of women AFAB with “erotic cross-
dressers” (not individuals who have transitioned from male
to female) using the unmodified Core Autogynephilia Scale
(Blanchard, 1989a). They found that women AFAB did not
score as autogynephilic on this instrument. Bailey and Hsu’s
(2022) negative finding does little to support or refute the
question of whether autogynephilia exists in women AFAB
or not. To paraphrase Lawrence (2010), Bailey and Hsu
(2022) studied something superficially resembling autogy-
nephilia in women, but not how autogynephilia is expressed
in women (also see Moser, 2010b). It appears that Bailey and
Hsu (2022) may have confirmed the wisdom of modifying
the scale for women AFAB.
The problems of confounding “erotic cross-dressers” with
those seeking gender transition were noted previously and
remain a major criticism of Blanchard’s theory (see Moser,
2010a). It is not clear why Bailey and Hsu (2022) did not
avoid repeating this problem or explained why they thought
it was not important.
Confusing Gender Dysphoria
withaParaphilia
Bailey and Hsu (2022) also confound the concepts of para-
philia and gender dysphoria. Blanchard, in his role as chair
of the Paraphilia section for the DSM-5, promulgated a new
definition of a paraphilia, which is not a mental disorder. That
is, a “…paraphilia denotes any intense and persistent sexual
interest other than sexual interest in genital stimulation or
preparatory fondling with phenotypically normal, physically
mature, consenting human partners” (APA, 2013, p. 685;
APA, 2022, p. 779). A paraphilic disorder, which is a mental
disorder, is diagnosed when an individual has a paraphilia
and also experiences distress or impairment related to their
paraphilia. Among individuals AMAB with gender dyspho-
ria, any distress or impairment they experience is related to
their gender dysphoria, not their arousal from the fantasy of
being a woman.
It also is not clear that autogynephilia even fulfills the
criteria for the definition of a paraphilia, i.e., intense and
persistent sexual interest. For individuals AMAB with gender
dysphoria, autogynephilia does not appear to be intense. Only
49% of the individuals AMAB pursuing gender affirming
surgery report autogynephilic arousal “hundreds of times or
more” prior to surgery (Lawrence, 2005). Similarly, auto-
gynephilia is not persistent. These individuals reported that
their autogynephilic arousal “hundreds of times or more”
drops to 3% after gender affirming surgery (Lawrence, 2005;
see Moser, 2010a, for an in-depth discussion of these find-
ings). Among men with transvestism, their intense and per-
sistent sexual excitement in cross-dressing is often “replaced
by feelings of comfort or well-being” (APA, 2022, p. 800).
The sexual interest of individuals AMAB with gender dys-
phoria or transvestism is focused on the “genital stimulation
or preparatory fondling with phenotypically normal, physi-
cally mature, consenting human partners” (APA, 2022, p.
779). Even if one would suggest that after gender affirming
surgery that the individual is not phenotypically normal, it
is the individual’s desired partner, not the individual, who
is phenotypically normal. Even if someone believes that an
erotic interest in individuals with gender dysphoria is a type
of paraphilia (I do not), it does not follow that the individuals
with gender dysphoria necessarily have a paraphilia.
Individuals who report “erotic cross dressing” (transves-
tism) also do not fulfill the diagnostic criteria for a paraphilia,
as these individuals also are focused erotically on phenotypi-
cally normal, physically mature, consenting human partners.
Doctor and Prince (1997) found 83% of transvestites had
been married, 60% were currently married at the time of their
study. Lawrence (2005) found 62% of her sample were in a
stable partnered relationship “at some time since undergoing
SRS [sex reassignment surgery]” (p. 159).
2 A few individuals with transvestic disorder do evolve into individu-
als with a gender dysphoria diagnosis or satisfy the diagnostic criteria
for both diagnoses.

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There are no data to support the alternative definition of
a paraphilia, that autogynephilia for either individuals with
gender dysphoria or transvestism is a “sexual interest greater
than or equal to [their] nonparaphilic interests” (APA, 2022,
p. 779). There are also no data to suggest that an individual’s
interest in autogynephilia “equals or exceeds the individual’s
interest in copulation or equivalent interaction with another
person” (APA, 2022, p. 779).
To continue to argue that autogynephilia is a paraphilia
suggests that Bailey and Hsu are not using the current under-
standing of the term. If they wish to argue that the new defi-
nition is misguided, they should at least note that they are
aware of the changes and why they do not apply. There also
is a distinction between autogynephilia in individuals with
gender dysphoria (erotic arousal at the thought or fantasy of
being a woman) and in individuals with transvestism (erotic
arousal at the thought, fantasy, or behavior of cross-dressing
as a woman). It appears that Blanchard’s various scales do
not distinguish between these subtypes.
Discussion
So, what are the takeaway messages? Women AFAB did
not respond as men AMAB with transvestism to an autogy-
nephilia instrument. Women AFAB responded to an autogy-
nephilia scale modified for women. Women AMAB with gen-
der dysphoria may respond to something that is superficially
like the autogynephilia seen in erotic cross-dressers. Women
and men respond differently to instruments that measure their
sexual interests, as one might expect.
The last point is that despite the protests of the proponents
of Blanchard’s theory, autogynephilia does not explain the
motivation of some individuals AMAB with gender dys-
phoria to transition. It has little or no use clinically. There
are some individuals AMAB with gender dysphoria who
embrace the theory, but like those who believe the earth is
flat, they appear to be a shrinking minority. On the other
hand, antipathy toward the construct of autogynephilia
among individuals with gender dysphoria, professionals who
support individuals with gender dysphoria, and academics
appears to have grown. It seems autogynephilia is little more
than a dead end in our understanding of gender dysphoria,
what motivates individuals with gender dysphoria to transi-
tion, and what a paraphilia is.
Funding The author has not disclosed any funding.
Declarations
Conflict of interest The author has not disclosed any competing inter-
ests.
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