"Autogynephilia": a disputed diagnosis

"Autogynephilia" is a sex-fueled mental illness made up by Ray Blanchard. Blanchard defines it as "a man’s paraphilic tendency to be sexually aroused by the thought or image of himself as a woman." [1]

Support for this disease model of gender variance is almost nonexistent, limited to a tiny online "autogynephilia" support group with fewer than 40 contributors out of a worldwide population of transwomen numbering in the millions. This support group was taken down in early 2005. The disease was also prominently featured in The Man Who Would Be Queen by J. Michael Bailey and has been heavily promoted by Anne Lawrence, a former anesthesiologist who has taken up "autogynephile" as a personal identity.

One of the key concepts in this model is the premise that everyone who is gender variant can be categorized based on one of two "male" sexual interests: homosexuality or paraphilia.

Among the few people who identify with this term, a significant number do not think this is what "autogynephilia" means. These people often interpret the word's Greek etymology quite literally and think it means an innocent and happy "love of oneself as a woman," or in apposition to a phobia. This is clearly not how the word is being used in the context of psychology or sexology, so we can dismiss comments from these people as irrelevant to the scientific debate.

Many mental health professionals and theorists question if this is a legitimate or scientifically useful descriptor. See parallels with other discredited illnesses below.

"Autogynephilia" describes a paraphilia

Blanchard continues to describe this illness as "a distinct paraphilia" worthy of differential diagnosis, and an improvement in terminology over what his mentor Kurt Freund labeled "cross-gender fetishism." [2]

When Blanchard says this is a paraphilia, what does he mean?

"Paraphilia" is the clinical term used by psychologists for problematic sexual desire or behaviors involving:

nonhuman objects

the suffering or humiliation of oneself or one's partner

children or other nonconsenting persons. [3]

Note that "paraphilias" can be diagnosed even if the person has no subjective distress or impaired function. According to Ray Blanchard, “autogynephilia” is “a distinct paraphilia,” but people with this disease are in the same clinical class as people who are attracted to animals, children, feces, etc.

In other words, proponents of this diagnosis are claiming that people express gender variance not only because they are aroused by possessing a certain body part, but also because they are sexually aroused by humiliating themselves or their loved ones, and that they get a sexual kick out of appearing in public as female, because they respond sexually to the responses of nonconsenting persons like strangers, coworkers and friends, in the same way an exhibitionist gets off by flashing people.

In fact, one of Blanchard and Bailey's theories is that paraphilias cluster, so if someone gender-variant is not attracted exclusively to men, they believe that person is far more likely to be sexually aroused by children, animals, etc.

Blanchard bases this on work he did not with transsexuals who had transitioned, but with anyone who came to his mental institution by force or choice to discuss a gender issue.

Blanchard's studies have never been repeated, and his ideas have been widely ignored until Anne Lawrence latched onto "autogynephilia" as a political identity. Since that time, Lawrence has been very busy trying to codify this spurious diagnosis as a legitimate descriptor.

"Autogynephilia" describes a psychosexual pathology

In the same way that some gay people feel they are mentally ill, some people interested in transition consider themselves to be mentally ill. Unfortunately, in both cases, they do not think only they are mentally ill, but that all of us are.

The small number of people who agree with the established scientific denotation and strongly identify as having this mental illness frequently conflate the phenomenon with the diagnosis. They seem to think that people concerned about the term "autogynephilia" are claiming that the observed phenomena do not exist.

Clearly, some people have sexual fantasies about gender variance. When viewed as a psychosexual pathology, as Ray Blanchard views it, these fantasies may be thought of as a "paraphilia."

Parallels with other discredited illnesses

For gender-variant women, "paraphilia" may be the diagnostic equivalent of historic attempts to pathologize non-transsexual women's sexual behavior that fell outside of heteronormative expectations. In the way that these made-up diseases were seen to emanate from the sex organs, Blanchard and colleagues spend a great deal of time looking for clues about male sexual behavior in their genitalia.

It is interesting to note that in Blanchard's world, the heteronormative transwomen need to be separated from those whose erotic interests do not fit the "natural" model of sexual selection.

"Nymphomania"

As with "autogynephilia" and similar bogus sexual pathologies and diagnoses, "nymphomania" was created by a clinician. Carol Groneman, author of Nymphomania: A History (2000) reports that the concept of "nymphomania" was first laid out by the French physician Bienville in his 1771 treatise, Nymphomania , or a Dissertation Concerning the Furor Uterinus. Groneman's book is an excellent overview of how medical ideas about sexuality can affect the general population and professionals in other fields

Psychologists like Freud added more crackpot theorizing that remained widely held beliefs until Kinsey's report on female sexuality in 1953 showed that "nymphomania" and "hypersexuality" had no scientific basis.

Evolving views of nymphomania were reflected in the successive editions of the American Psychiatric Association's official guide to madness, the Diagnostic and Statistical Manual of Mental Disorders. Nymphomania was listed as a "sexual deviation" in the first DSM, published in 1951; by DSM-III (1980) it had become a "psychosexual disorder," albeit a vaguely defined one. Sensing the winds of change, or maybe just having watched a few talk shows, the editors of DSM-III-R (revised third edition, 1987) dropped nymphomania and its equally quaint male counterpart, Don Juanism, and replaced them with "distress about a pattern of repeated sexual conquests or other forms of nonparaphilic [nondeviant] sexual addiction." In DSM-IV (1994) even sexual addiction was abandoned, perhaps because the non-gender-specific nature of the term laid bare the speciousness of the whole project

"Hysteria"

Like "nymphomania," the word "hysteria" is an imprecise term which is used both clinically and in everyday language. It is applied in various situations with different meanings. Similar to vague diagnoses like "autogynephilia," hysteria may describe a lack of self control over acts and emotions. It may describe morbid self-consciousness, anxiety or extravagant behavior. It also suggests the simulation of various disorders. This nebulous description allows nearly any behavior to be describes as "hysterical," as J. Michael Bailey has described transsexual women criticizing his book and his connections to neo-eugenicists.

Acute hysteria - subsumed in DSM IV as conversion (primarily physical) and dissociative (primarily mental) disorders - is the relatively abrupt appearance of an artifactual set of signs and symptoms that call attention to themselves.

Chronic hysteria - the form subsumed in DSM IV as somatization disorder or Briquet's syndrome - are characterized by habitual complaints of symptoms such as pains, faintness, abdominal cramping, nausea, coughing, shortness of breath that turn out to be groundless and artifactual.

This is a typical comment from someone who believes in the validity of an out of fashion diagnosis: "Hysteria is not disappearing but has taken on less conspicuous guises as people learn what can pass as disease today." One can expect that proponents of "autogynephilia" will see similar drift and attempt to shoehorn an ever-widening array of phenomena into an already nebulous diagnosis (using terms like "partial autogynephilia" etc.).

Hysteria has its roots in sexism, being derived etymologically from the Greek word for uterus. The uterus was also seen as the cause of "nymphomania" as well.

"Hystero-epilepsy"

A disease made up by famed neurologist Jean Marie Charcot. A skeptical student, Joseph Babinski, decided that Charcot had invented rather than discovered hystero-epilepsy. The patients had come to the hospital with vague complaints of distress and demoralization. Charcot had persuaded them that they were victims of hystero-epilepsy and should join the others under his care. Charcot's interest in their problems, the encouragement of attendants, and the example of others on the same ward prompted patients to accept Charcot's view of them and eventually to display the expected symptoms. These symptoms resembled epilepsy, Babinski believed, because of a municipal decision to house epileptic and hysterical patients together (both having "episodic" conditions). The hysterical patients, already vulnerable to suggestion and persuasion, were continually subjected to life on the ward and to Charcot's neuropsychiatric examinations. They began to imitate the epileptic attacks they repeatedly witnessed (Paul McHugh) .

"Ego-dystonic homosexuality"

The DSM-III committee and subcommittee charged with drafting the new manual (1976-78) settled on the diagnosis of ego-dystonic homosexuality , which, according to Dr. Jon Meyer, "...represented a compromise between those individuals whose clinical experience, interpretation of the data, and, perhaps, biases, led them to the conviction that homosexuality was a normal variant of sexual expression..." By the time DSM-III-R (revised version of DSM-III) came out in 1987, the tide had shifted again. The category of ego-dystonic homosexuality was eliminated. As DSM-III-R itself stated, "...the diagnosis...has rarely been used clinically, and there have been only a few articles in the scientific literature that use the concept..."

However, one could use the category of sexual disorder not otherwise specified to include cases that previously would have been called ego-dystonic homosexuality . Our present DSM-IV does not include homosexuality per se as a disorder, but still permits the diagnosis of "Sexual Disorder Not Otherwise Specified" for someone with "...persistent and marked distress about sexual orientation".

Note that like "ego-dystonic homosexuality," the diagnosis of "autogynephilia" is rarely used clinically, and there have only been a few articles in the scientific literature that use the concept.

"Partial autogynephilia"

One of the most laughable examples of the unscientific nature of this diagnosis is Blanchard's claims that cases of "partial autogynephilia" exist in order to explain phenomena that need to be shoehorned into the theory. This is about as valid as diagnosing someone with "partial cancer" or "partial paraphilia." The fact that this term was even introduced into the published literature suggests the general lack of rigor in journals devoted to sexual science.

Differential Diagnosis

"Autogynephilia" proponents wish to see a differential diagnosis, meaning they want to separate gender-variant people into two distinct "illnesses." Although the axis of sexual preference is the most persistent, it is not the only one proposed.

Their logic follows a disease model of gender variance. Bailey calls this "lumping and splitting." As they explain, some disorders have similar symptoms. The clinician, therefore, in his diagnostic attempt, has to differentiate against disorders which need to be ruled out to establish a precise diagnosis.

Below are some other diagnoses sometimes suggested for gender-variant people:

Factitious Disorder /Munchausen syndrome by proxy
Somatoform disorder
Hypochondriasis
Conversion disorder
Somatization disorder Briquet's Syndrome
Pain associated with psychological factors
True medical or psychiatric illness related to presenting complaints

Differential diagnosis is appealing to some gender-variant people and practitioners who wish to separate people who transition into different groups.

It is my hunch that "autogynephilia" and differential diagnoses are especially appealing to those with a deep-seated homophobia. It seems rooted in the same motivations that some cross-dressing social groups use to exclude gay members. I will be discussing this theory in upcoming revisions.

"Autogynephilia" is quackery

The pathologization of socially unacceptable erotic interests has a long history. As noted about, recent clinical diagnoses such as "ego-dystonic homosexuality" and "nymphomania" have fallen into disrepute. Many expect "autogynephilia" will be similarly discredited as a diagnosis in time.

In fact, the diagnosis is an example of quackery, which is defined as "overpromotion in the field of health."

Below is an example of how "autogynephilia" proponents like Ray Blanchard cannot separate the observed phenomena from the diagnosis:

"In the meantime, it is important to distinguish between the truth or falseness of theories about "autogynephilia", on the one hand, and the existence or nonexistence of "autogynephilia", on the other. The latter is also an empirical question, but it appears, at this point, to be settled." [2]

This conflation creates a false dilemma. Let’s replace "autogynephilia" with another spurious diagnosis as an example:

"In the meantime, it is important to distinguish between the truth or falseness of theories about nymphomania, on the one hand, and the existence or nonexistence of nymphomania, on the other. The latter is also an empirical question, but it appears, at this point, to be settled."

Quacks like Blanchard used to say exactly this before “nymphomania” was discredited as a diagnosis or a scientifically useful descriptor. “Nymphomania” is not a legitimate diagnosis or classification simply because there are observable phenomena that fit the denotation or clinical criteria. Saying that “nymphomania” does not exist is not the same as saying women who are extraordinarily sexually active do not exist. Of course they exist. That doesn’t mean that “nymphomania” exists, though. This is the primary problem with Blanchard's thinking.

Let’s replace "autogynephilia" with another pseudoscientific concept that could be written by a similar type of quack:

"In the meantime, it is important to distinguish between the truth or falseness of theories about clairvoyance, on the one hand, and the existence or nonexistence of clairvoyance, on the other. The latter is also an empirical question, but it appears, at this point, to be settled."

Just because someone observes something that fits the criteria for clairvoyance does not settle the empirical question of whether it exists or not. That’s not how science works. That’s called confirmation bias, or less formally, "begging the question." Blanchard comes to a questionable conclusion ("autogynephilia" exists) based on an assumed premise ("autogynephilia" is a scientifically useful term).

What's wrong with Ray Blanchard's logic?

Blanchard reminds me of this retarded kid I knew when I was younger. In fact, let’s call the retarded kid Ray. Ray worked at McDonald’s, and when I’d see him there, Ray would look at me with amazement and say, “Wow! I see you every time you come here!”

Classic case of bad induction.

In other words, Ray assumed that he observed an amazing pattern based on unscientific assumptions. It did not occur to Ray that there were factors he had not considered, such as my visits when he was not working.

If Ray fancied himself a scientist (which he clearly isn’t), he might take this confirmation bias one step further and give the phenomenon a name, like, say, McSynchronicity: the tendency for Ray to see Andrea every time she comes to McDonald’s. He would start forming all sorts of theories about why this exists and make it a bit of an obsession. After all, he “discovered” McSynchronicity, so he wants to defend the idea and get credit far and wide for his amazing observation. Heck, he might even convince a couple of others on his shift who share his level of scientific understanding: Mike over on the griddle and Anne over on the deep fryer.

This is textbook quackery and pseudoscience, but it's hard to bring people like Ray back to their senses once they have "discovered" something and feel a need to protect it.

I would speak slowly to Ray and try to explain that McSynchronicity doesn’t really exist as a phenomenon. Ray would indignantly retort:

"In the meantime, it is important to distinguish between the truth or falseness of theories about McSynchronicity, on the one hand, and the existence or nonexistence of McSynchronicity, on the other. The latter is also an empirical question, but it appears, at this point, to be settled."

I would say, “Ray, nothing has been settled. The phenomena you observed empirically do not validate the existence of the classification.” But then I’d remember that Ray is retarded, so I’d have to think a little to come up with a really simple explanation. That's where I am right now.

So in the meantime, I stroll into McDonald’s and Ray exclaims, “See, another case of McSynchronicity!” I just smile and sigh, and continue thinking about ways to explain this so even Ray and his coworkers can grasp it.

"Autogynephilia" is based on interlocking pseudoscientific claims and methodologies

Real discoveries of phenomena contrary to all previous scientific experience are very rare, while fraud, fakery, foolishness, and error resulting from overenthusiasm and delusion are all too common. (Cromer 1993)

The McSynchronicity example above is a simplistic description of several established phenomena common to pseudoscientists and quacks. Empiricists tend to emphasize the tentative and probabilistic nature of knowledge, while rationalists tend to be dogmatic and assert they have found a method to discover absolutely certain knowledge.

Some pseudoscientific theories can't be tested because they are so vague and malleable that anything relevant can be shoehorned to fit the theory, e.g., the the theory of multiple personality disorder,"partial autogynephilia," or the Myers-Briggs Type Indicator ®.

As a proud member of QuackWatch, I have helped debunk a number of pseudoscientific claims that affect the transgender community. In the case of Blanchard, the primary quackery involves:

As Dr. Madeline Wyndzen points out in a psychology trade newsletter [4] , Blanchard's key empirical findings:

1. have never been replicated

2. failed to include control groups of typically-gendered women

3. failed to covary the acknowledged age-difference from ANOVA

4. drew conclusions about causality from entirely observational data

Plethysmography

A plethysmograph is a primitive "lie detector" attached to the genitals. It is also one of Ray Blanchard's "scientific" tools, since it was invented by his mentor Kurt Freund.

I have found over my years of exposing medical fraud and quackery that inventors are frequently the most tenacious quacks. Not only do they want to herald their invention, they are also most likely to make scientific errors when fitting the device or concept to use. Because they see their reputation as tied closely with the reception of their device or their writings, and because many inventors have a certain eccentricity and sense of individualism, they will rarely back down from a position, even when they have proven to be frauds. Fortunately, we don't have to convince the quack he is wrong (which is frequently impossible); we only have to convince everyone else the quack is wrong.

For more on this, please see Plethysmograph: a disputed device.

Testimonials and anecdotal evidence

This is classic advertising trick: watch any informercial, and you will see all sorts of glowing testimonials and anecdotes supporting the promotional claims being made. Testimonials are always unscientific and are of little value in establishing the legitimacy of the claims they are put forth to support.

Bailey's book and Lawrence's essays are primarily supported by anecdotal evidence (or "narratives" as Anne Lawrence calls them). Quacks typically use testimonials which only back their side of the story. Lawrence and Bailey only present anecdotal evidence that supports their point. See the discussion of bias below. This pseudoscientific evidence is further aided by communal reinforcement: the process by which a claim becomes a strong belief through repeated assertion by members of a community.

Bias

One of the most insidious problems with the science proposed by proponents of "autogynephilia" is the profound bias inherent in their unproven assumptions.

These types of bias are also sometimes called hidden persuaders:

"Technically these hidden persuaders can be described as ‘statistical artifacts and inferential biases’ (Dean and Kelly 2003: 180)." Dean and Kelly argue that hidden persuaders explain why many astrologers continue to believe in the validity of astrology despite overwhelming evidence that astrology is bunk.

Psychologist Terence Hines, who has explored many varieties of hidden persuaders (Hines 2003), blames them for the continued use by psychologists of such instruments as the Rorschach test, despite overwhelming evidence that the test is invalid and useless:

"Psychologists continue to believe in the Rorschach for the same reasons that Tarot card readers believe in Tarot cards, that palm readers believe in palm reading, and that astrologers believe in astrology: the well-known cognitive illusions that foster false belief. These include reliance on anecdotal evidence, selective memory for seeming successes, and reinforcement from colleagues."

This bias takes many forms, and the major problems are outlined below:

Experimenter effect

Research has demonstrated that the expectations and biases of an experimenter can be communicated to experimental subjects in subtle, unintentional ways, and that these cues can significantly affect the outcome of the experiment ( Rosenthal 1998 ). i.e., people who wanted free treatment presented to Ray and told him what he wanted. People who think Anne Lawrence is a dangerously disturbed psychotic did not fill out a questionnaire.

Ad hoc hypothesis

Bailey, Blanchard and Lawrence explain away facts that refute the hypothesis: i.e., those who disagree are lying, and those whose stories match the model are open and honest.

Cognitive dissonance

This theory of human motivation that asserts that it is psychologically uncomfortable to hold contradictory cognitions. Particularly confusing for Bailey and Lawrence are people who are clearly quite open about their erotic interests (like Deirdre McCloskey) but do not consider "autogynephilia" to be a valid diagnosis. This is clearly incomprehensible to them; Bailey notes that Deirdre shows "all the hallmarks of autogynephilia" and Anne Lawrence asks (apparently rhetorically) can someone explain how this isn't autogynephilia?

This is equivalent to someone who believe "nymphomania" is a valid diagnosis. Because they cannot comprehend the possibility that the condition does not exist, their inability colors every observation they make.

Confirmation bias

This refers to a type of selective thinking, where favorable evidence is selected for remembrance and focus, while unfavorable evidence for a belief is ignored.

A pseudoscientist tends to notice and to look for what confirms one's beliefs (supportive data), and to ignore, not look for, or undervalue the relevance of what contradicts one's beliefs. Bailey, Blanchard and Lawrence do this by claiming those who disagree are lying, or by presenting only evidence that supports their arguments.

This type of biased thinking can be quite subtle. Some pseudoscientists seriously consider data contrary to their beliefs, but are much more critical of such data than they are of supportive data.

Pathological science

Nobel Prize winner Irving Langmuir described pathological science as "the science of things that aren’t so", using as examples the Davis-Barnes Effect, N-rays, mitogenetic rays, the Allison Effect, extrasensory perception, and flying saucers (Langmuir 1968).

Langmuir offered six characteristics of pathological science :

The magnitude of the effect is substantially independent of the intensity of the causative agent.

The effect is of a magnitude that remains close to the limits of detectability; or, many measurements are necessary because of the very low statistical significance of the results.

It makes claims of great accuracy.

It puts forth fantastic theories contrary to experience.

Criticisms are met by ad hoc excuses.

The ratio of supporters to critics rises up to somewhere near 50 percent and then falls gradually to oblivion.

The problem of induction

This gets into heady philosophy of science type stuff that's lost and Bailey and friends. For a brief formulation of the problem of induction we can turn to Born, who writes: '. . . no observation or experiment, however extended, can give more than a finite number of repetitions'; therefore, 'the statement of a law - B depends on A - always transcends experience. Yet this kind of statement is made everywhere and all the time, and sometimes from scanty material. ' 1

In other words, the logical problem of induction arises from (1) Hume's discovery (so well expressed by Born) that it is impossible to justify a law by observation or experiment, since it 'transcends experience'; (2) the fact that science proposes and uses laws 'everywhere and all the time'. (Like Hume, Born is struck by the 'scanty material', i.e. the few observed instances upon which the law may be based.) To this we have to add (3) the principle of empiricism which asserts that in science only observation and experiment may decide upon the acceptance or rejection of scientific statements, including laws and theories.

These three principles, (1), (2), and (3), appear at first sight to clash; and this apparent clash constitutes the logical problem of induction.

See my earlier discussion of McSynchronicity for this problem described in lay terms.

Apophenia

Dr. Martina Belz-Merk notes "There is currently a controversial debate concerning whether unusual experiences are symptoms of a mental disorder, if mental disorders are a consequence of such experiences, or if people with mental disorders are especially susceptible to or even looking for these experiences."

Forer effect (also called subjective validation)

Forer found that people tend to accept vague and general personality descriptions as uniquely applicable to themselves without realizing that the same description could be applied to just about anyone. The "symptoms" and "hallmarks" of "autogynephilia" continue to spread to explain away inconsistencies.

Argument to ignorance

This is a logical fallacy of irrelevance occurring when someone claims that something is true only because it hasn't been proven false. Bailey is especially fond of this one.

For more information

Below are some additional resources on this topic. Please see my essay A defining moment in our history for more on disease models of gender identity in historical context.

Draft version of 20 May 2004.

References:

1. In J. M. Bailey (Chair), Phenomenology and classification of male-to-female transsexualism. Symposium conducted at the meeting of the International Academy of Sex Research , Paris. June, 2000. Slide 38.

2. Blanchard R. Origins of the concept of autogynephilia. Published online February 2004 via http://www.autogynephilia.org/origins.htm

3. "Paraphilia." Diagnostic and Statistical Manual of Mental Disorders, version IV-TR.

4. Wyndzen MH. A personal and scientific look at a mental illness model of transgenderism. APA Division 44 Newsletter, Spring 2004, p. 3.

Recommended reading:

• LINK: "Autogynephilia": New Medical Thinking or Old Stereotype? by Dr. Katherine Wilson

• LINK: Bailey, Blanchard, Lawrence and the fallacy of "autogynephilia" by Jed Bland

• LINK: Everything You Never Wanted to Know About "Autogynephilia" but Were Afraid You had to Ask by Dr. Madeline Wyndzen

• LINK: "Autogynephilia" & Ray Blanchard's Mis-Directed Sex-Drive Model of Transsexuality by Dr. Madeline Wyndzen

• LINK: A personal and scientific look at a mental illness model of transgenderism by Madeline H. Wyndzen, Ph.D. (PDF: requires reader)

• LINK: "Autogynephilia" and disability

• LINK: "Autogynephilia" links compiled by Dr. Madeline Wyndzen

Further reading:

• LINK :"Autogynephilia": Views of one non-transitioner•

• LINK: BC on Gender: "Autogynephilia" by BC Holmes

• LINK: Men Trapped In Men's Bodies: an Introduction to the Concept of "Autogynephilia" by Dr. Anne Lawrence (taken offline in 2004)

• LINK: Sexuality and Transsexuality: A New Introduction to "Autogynephilia" by Dr. Anne Lawrence

• LINK: The "Autogynephilia" Resource (autogynephilia.org) by Lisanne Anderson

• LINK: Janice Raymond and "Autogynephilia" by Dr. Rebecca Allison