Anne A. Lawrence’s research while affiliated with University of Lethbridge and other places

Sexual scientists have recognized for over a century that biologic males who seek sex reassignment - male-to-female (MtF) transsexuals - are not a homogeneous clinical population but comprise two or more distinct subtypes with different symptoms and developmental trajectories. The most widely used typologies of MtF transsexualism have been based on sexual orientation and have distinguished between persons who are androphilic (exclusively sexually attracted to males) and those who are nonandrophilic (sexually attracted to females, both males and females, or neither gender). In 1989, psychologist Ray Blanchard proposed that most nonandrophilic MtF transsexuals display a paraphilic sexual orientation called autogynephilia, defined as the propensity to be sexually aroused by the thought or image of oneself as a woman. Studies conducted by Blanchard and colleagues provided empirical support for this proposal, leading to the hypothesis that almost all nonandrophilic MtF transsexuals are autogynephilic, whereas almost all androphilic MtF transsexuals are not. Blanchard?s ideas received increased attention in 2003 after they were discussed in a book by psychologist J. Michael Bailey. The concept of autogynephilia subsequently became intensely controversial among researchers, clinicians, and MtF transsexuals themselves, causing widespread repercussions. This article reviews the theory of autogynephilia, the evidence supporting it, the objections raised by its critics, and the implications of the resulting controversy for research and clinical care.

Gender dysphoria (GD), a feeling of persistent discomfort with one's biologic sex or assigned gender, is estimated to be more prevalent in male prison inmates than in nonincarcerated males; there may be 3000-4000 male inmates with GD in prisons in the United States. An increasing number of U.S. prison systems now offer gender dysphoric inmates diagnostic evaluation, psychotherapy, cross-sex hormone therapy, and opportunities, albeit limited, to enact their preferred gender role. Sex reassignment surgery (SRS), however, has not been offered to inmates except in response to litigation. In the first case of its kind, the California Department of Corrections and Rehabilitation recently agreed to provide SRS to an inmate and developed policy guidelines for its future provision. In other recent cases, U.S. courts have ruled that male inmates with GD are entitled to SRS when it is medically necessary. Although these decisions may facilitate the provision of SRS to inmates in the future, many U.S. prison systems will probably remain reluctant to offer SRS unless legally compelled to do so. In this review, we address the medical necessity of SRS for male inmates with GD. We also discuss eligibility criteria and the practical considerations involved in providing SRS to inmates. We conclude by offering recommendations for physicians, mental health professionals, and prison administrators, designed to facilitate provision of SRS to inmates with GD in a manner that provides humane treatment, maximizes the likelihood of successful outcomes, minimizes risk of regret, and generates data that can help inform future decisions.

Gender dysphoria (GD), a term that denotes persistent discomfort with one's biologic sex or assigned gender, replaced the diagnosis of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013. Subtypes of GD in adults, defined by sexual orientation and age of onset, have been described; these display different developmental trajectories and prognoses. Prevalence studies conclude that fewer than 1 in 10,000 adult natal males and 1 in 30,000 adult natal females experience GD, but such estimates vary widely. GD in adults is associated with an elevated prevalence of comorbid psychopathology, especially mood disorders, anxiety disorders, and suicidality. Causal mechanisms in GD are incompletely understood, but genetic, neurodevelopmental, and psychosocial factors probably all contribute. Treatment of GD in adults, although largely standardized, is likely to evolve in response to the increasing diversity of persons seeking treatment, demands for greater patient autonomy, and improved understanding of the benefits and limitations of current treatment modalities. Expected final online publication date for the Annual Review of Clinical Psychology Volume 12 is March 28, 2016. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.

After proposing in 1989 that some MtF transsexuals experienced autogynephilia—the propensity to be sexually aroused by the thought or image of oneself as a female—Blanchard continued to conduct research on this topic. He described four different types of autogynephilia: physiologic, behavioral, anatomic, and transvestic. He theorized that autogynephilia is a misdirected form of heterosexual attraction that coexists with and competes with sexual attraction to women. He observed that the anatomic type of autogynephilia—erotic arousal to the idea of having a woman’s body—was especially strongly associated with the desire for sex reassignment surgery. Blanchard and Kurt Freund proposed that autogynephilia is merely the most common example of a previously unrecognized paraphilic category in which individuals desire to impersonate or become facsimiles of the persons or things to which they are attracted. After Blanchard published his last research studies of autogynephilia in 1993, the topic was neglected until 2001, when other researchers began to study autogynephilia. Nevertheless, there remained a dearth of clinical case histories and first-person accounts of autogynephilia in MtF transsexuals. This made it difficult for clinicians to recognize autogynephilic transsexualism and difficult for autogynephilic transsexuals to believe that there were others who shared their feelings.

The transsexual informants reported all four types of autogynephilia described in the scientific literature: transvestic (erotic arousal associated with the act or fantasy of wearing women’s clothing), anatomic (arousal associated with the fantasy or reality of having female anatomic features), physiologic (arousal associated with the fantasy or simulation of being pregnant, menstruating, or lactating), and behavioral (arousal associated with the act or fantasy of engaging in female-typical behavior). Although many informants reported transvestic autogynephilia, a phenomenon usually associated with transvestic fetishism, some emphasized that the appeal of wearing women’s clothing lay primarily in its ability to facilitate the fantasy of having a woman’s body. A few informants described feelings of comfort or relaxation in association with cross-dressing. Several informants described anatomic autogynephilia, especially involving female genitals. A few informants reported that they experienced anatomic autogynephilia that was unaccompanied by any strong desire to live in a female-typical gender role. Although physiologic autogynephilia is probably the least common type, several informants had experienced it; fantasies involving pregnancy were especially frequent in this group. Informants described many different manifestations of behavioral autogynephilia, some of which involved erotic arousal associated with seemingly trivial and mundane aspects of female-typical behavior.

The transsexual informants expressed varying opinions concerning the meaning and significance of autogynephilia. Many believed that autogynephilia was a paraphilia that had given rise to their gender dysphoria, cross-gender identification, and desire to undergo sex reassignment. Others, however, looked at autogynephilia differently. Some informants suggested that autogynephilia might be a symptom, not a cause, of their gender dysphoria. They argued that their cross-gender wishes had begun before puberty and therefore could not be sexual, based on their belief that sexual feelings could only emerge after the onset of puberty. Other informants considered autogynephilia an epiphenomenon, an incidental effect of their female gender identities interacting with their male bodies or upbringings. Some informants suggested that autogynephilia was not a paraphilia but a manifestation of normal female sexuality. A few informants proposed that MtF transsexualism had a specific biologic etiology, probably related to hormonal abnormalities during prenatal development; their implication was that autogynephilia was not needed to account for desires that could be explained by prenatal hormonal factors. It can be argued, however, that attempting to account for the gender dysphoria and cross-gender identification that accompany autogynephilic transsexualism without invoking autogynephilia as a causal factor requires explanations that are circular and self-referential.