Blanchard's transsexualism typology

Blanchard's transsexualism typology (also Blanchard autogynephilia theory (BAT) and Blanchard's taxonomy) is a psychological typology of male-to-female transsexualism created by Ray Blanchard through the 1980s and 1990s, building on the work of his colleague, Kurt Freund. Blanchard divides male-to-female (MtF or M2F) transsexuals into two different groups: "homosexual transsexuals", who are attracted to men, and "non-homosexual transsexuals", who are "autogynephilic" (sexually aroused by the thought or image of themselves as a woman). The typology does not purport to identify the cause of transsexualism in natal males, but it has some implications for the cause—specifically, that the cause of transsexualism may not be the same for both groups.

Scientific criticism of the research and theory has come from John Bancroft, Jaimie Veale, Larry Nuttbrock, Charles Allen Moser, and others who argue that the theory is poorly representative of MtF transsexuals, reduces gender identity to a matter of attraction, is non-instructive, and that the research cited in support of the theory has inadequate control groups or is contradicted by other data. Supporters of the theory include J. Michael Bailey, Anne Lawrence, James Cantor, and others who argue that there are significant differences between the two groups, including sexuality, age of transition, ethnicity, IQ, fetishism, and quality of adjustment.

The theory has been the subject of protests in the transsexual and larger LGBT community, although it has its supporters. The issues with Blanchard's work were again the subject of criticism with the publication of Bailey's The Man Who Would Be Queen in 2003. In 2005, Blanchard distanced himself from Bailey's affirmation of the scientific certainty of the etiology.

Background
The early history of the study of transsexualism is sparse; however, the concept of a categorization of transsexuals can be seen as early as 1923 with the work of Magnus Hirschfeld. In 1966, Harry Benjamin wrote that researchers of his day thought that attraction to men, as a woman was the factor that distinguished a transvestite from a transsexual. In 1980 in the DSM III, a new diagnosis was introduced, that of "302.5 Transsexualism" under "Other Psychosexual Disorders". This was an attempt to provide a diagnostic category for a gender identity disorders. The diagnostic category, "Transsexualism", was for gender dysphoric individuals who demonstrated at least two years of continuous interest in transforming their physical and social gender status. The subtypes were 1. asexual, 2. homosexual (same anatomic sex), 3. heterosexual (other anatomic sex) and 0. unspecified. This was removed in the DSM IV, in which Gender Identity Disorder replaced transsexualism. Previous taxonomies, or systems of categorization, used the terms "classic transsexual" or "true transsexual," terms once used in differential diagnoses.

New terminology
In 1982, Kurt Freund reported evidence that there exist two types of cross-gender identity in male-to-female transsexuals, coined the term "homosexual transsexual" and hypothesized that gender dysphoria in "homosexual males" (male-to-female transsexuals attracted to men) is different from gender dysophoria in heterosexual males. His protege, Ray Blanchard notes that "Freund, perhaps for the first time of any author, employed a term other than 'transvestism' to denote erotic arousal in association with cross-gender fantasy."

Blanchard's observations at the Clarke Institute began with four types of male transsexuals based on their sexual orientation relative to their sex assigned at birth: homosexual, heterosexual, bisexual, and asexual (i.e., transsexuals attracted to men, women, both, or neither, respectively.) Blanchard conducted a series of studies of biological males with gender dysphoria, including male-to-female transsexuals, concluding that there exist two distinct types. One type of gender dysphoria/transsexualism manifests itself in individuals who are exclusively attracted to men, whom Blanchard referred to as homosexual transsexuals, adopting Freund's terminology The other type includes those who are attracted to females (gynephilic), attracted to both males and females (bisexual), and attracted to neither males nor females (analloerotic or asexual); Blanchard referred to this latter set collectively as the non-homosexual transsexuals. Blanchard claims that the non-homosexual transsexuals (but not the homosexual transsexuals) exhibit autogynephilia, which he defined as a paraphilic interest in having female anatomy.

Autogynephilia
Autogynephilia (from Greek “αὐτό-” (self), “γυνή” (woman, though the stem is actually “γυναικ-”. ) and “φιλία” (love) &mdash; "love of oneself as a woman") is a term coined in 1989 by Ray Blanchard, to refer to "a man's paraphilic tendency to be sexually aroused by the thought or image of himself as a woman." Alternative terms proposed for this notion include automonosexuality, eonism, and sexo-aesthetic inversion. The DSM-IV-TR includes an essentially equivalent definition, and recognizes autogynephilia as a common occurrence in the transvestic fetishism disorder, but does not classify autogynephilia as a disorder by itself. The analogous term autoandrophilia refers to a woman's tendency to be sexually aroused by the thought or image of herself as a man. It classified as a type of transvestic fetishism in a proposed revision to the DSM-5. (Blanchard has served on the gender dysphoria sub-working group for the DSM-IV and of the paraphilia sub-working group for the DSM-5.)

Autogynephilia is most notable for its use in Blanchard's taxonomy to explain the presence of gender dysphoria in non-homosexual (gynephilic) male-to-female transsexuals, in contrast to the gender dysphoria observed in homosexual (androphilic) transsexuals. Autogynephilia has also been suggested to pertain to romantic love as well as to sexual arousal patterns. While Blanchard claims that autogynephilia does not exist in natal (from birth) women, Veale et al. (2008) and Moser (2009) report that it does exist in natal women at rates close to or equal to that of non-homosexual transsexuals. This is controversial.

Blanchard provides case examples to illustrate the autogynephilic sexual fantasies that people reported: "Philip was a 38-year-old professional man referred to the author's clinic for assessment....Philip began masturbating at puberty, which occurred at age 12 or 13. The earliest sexual fantasy he could recall was that of having a woman's body. When he masturbated, he would imagine that he was a nude woman lying alone in her bed. His mental imagery would focus on his breasts, his vagina, the softness of his skin, and so on—all the characteristic features of the female physique. This remained his favorite sexual fantasy throughout his life."

According to Blanchard, "An autogynephile does not necessarily become sexually aroused every time he pictures himself as female or engages in feminine behavior, any more than a heterosexual man automatically gets an erection whenever he sees an attractive woman. Thus, the concept of autogynephilia—like that of heterosexuality, homosexuality, or pedophilia—refers to a potential for sexual excitation" [emphasis in original].

Blanchard classified four subtypes of autogynephilic sexual fantasies, but noted that "All four types of autogynephilia tend to occur in combination with other types rather than alone."
 * Transvestic autogynephilia: arousal to the act or fantasy of wearing women's clothing
 * Behavioral autogynephilia: arousal to the act or fantasy of doing something regarded as feminine
 * Physiologic autogynephilia: arousal to fantasies of female-specific body functions
 * Anatomic autogynephilia: arousal to the fantasy of having a woman's body, or parts of one.

There also exist biological males who report being sexually aroused by the image or idea of having some but not all female anatomy, such as having female breasts but retaining their male genitalia; Blanchard referred to this phenomenon as partial autogynephilia.

Non-homosexual transsexuals versus homosexual transsexuals
In Blanchard's taxonomy, non-homosexual biological males (Kinsey Scale 0-4) with gender identity disorder exhibit autogynephilia and are either attracted to women, both women and men, or are asexual. Homosexual transsexuals are attracted exclusively to men and do not exhibit autogynephilia.

Support for the theory comes from a wide range of demographic and psychological aspects of the subjects studied Blanchard's practice in the 1980s. Criticism of the theory is generally focused in two categories: the use of the terms "homosexual" and "non-homosexual" to refer to transsexuals by their sex-of-birth, and the data underlying the theory itself.

Justification for the two classifications
According to Blanchard (1985, 1987) key characteristics of homosexual transsexuals include conspicuous cross-gender behavior from childhood through adulthood, and a "homosexual" sexual orientation. Blanchard (1987) found in his studies that homosexual transsexuals were younger when applying for sex reassignment The average age of the non-homosexual transsexuals in Blanchard's sample is around 39, whereas the average of the homosexual transsexuals was 23.6. Moreover, the homosexual transsexuals reported that cross-gender wishes preceded cross-dressing by 3–4 years, whereas the non-homosexual transsexuals reported that their first cross-gender wishes occurred around the time they first cross-dressed. Blanchard also reports that they have a more convincing cross-gender appearance and functioned psychologically better than "non-homosexual" transsexuals. A lower percentage of the homosexual transsexuals reported being (or having been) married, and feeling sexually aroused while cross-dressing. Early studies had variously found that between 10% and 36% of homosexual transsexuals report a history of sexual arousal to cross dressing. Bentler (1976) found 23%, while Freund (1982) reported 31%. In a follow-up study of post-operative transsexuals, Blanchard found that both types of male-to-female transsexuals respond well to sex reassignment, but that the homosexual transsexuals are less likely to regret doing so.

Sexologists quantitatively measure sexual orientation using psychological personality tests or rely on self reports. Blanchard and Freund used the Masculine Identity in Females (MGI), and the modified androphilia scale. Homosexual transsexuals averaged a Kinsey Scale measurement of 5-6 or a 9.86±2.37 on the Modified Androphilia Scale.

In The Man Who Would Be Queen, J. Michael Bailey (2003) stated that the homosexual transsexuals from Chicago gay bars he studied were comfortable with prostitution, and that this type of transsexual has a male sexual appetite, but lusts after men. He supported Blanchard's typology of two forms of transsexualism in males—one that is an extreme type of homosexuality, and one that is an expression of autogynephilia. In "The Transsexual Phenomenon", Harry Benjamin (1966) wrote that a few dozen transsexuals "find prostitution a useful profession for emotional as well as practical reasons" before surgery.

Ken Zucker (2002) and Yolanda Smith (2005) independently found that homosexual transsexuals are of lower average IQ, social class, and age. They were on average in their mid-teens to mid-20s when they reported to a gender clinic for sex reassignment. The homosexual transsexuals are more likely to have recent immigrant status, non-intact families, non-Caucasian race, and childhood behavior problems). Bailey found that most homosexual transsexuals he interviewed from Chicago gay bars learned to live on the streets, resorting to prostitution, or shoplifting.

Blanchard does not consider sex with males to be a sole defining characteristic of being "homosexual" versus "non-homosexual". Concerning "non-homosexual" autogynephilic transsexuals who sleep with men, Blanchard writes: "The effective erotic stimulus in these interactions, however, is not the male physique of the partner, as it is in true homosexual attraction, but rather the thought of being a woman, which is symbolized in the fantasy of being penetrated by a man. For these persons, the male sexual partner serves...to intensify the fantasy of being a woman."

Leavitt and Berger also mentioned studies by Blanchard which suggest that heterosexual transsexuals will adjust their life stories to ensure that they get sex reassignment surgery.(Leavitt 1990) Blanchard considers self-report to be unreliable. Morgan (1978), Blanchard (1985), Lawrence (2005) and other researchers have asserted that many "non-homosexual" transsexuals systematically distort their life stories because "non-homosexuals" were often screened out as candidates for surgery and because some see "homosexual transsexual" as a more socially desirable diagnosis.

Blanchard (1996) and Zucker (2007) came to the general conclusion that birth order has some influence over sexual orientation in biological males in general, and homosexual male to female transsexuals in specific. This phenomenon is called the "fraternal birth order effect". In 2000 Richard Green wrote "Homosexual male-to-female transsexuals have a later than expected birth order and more older brothers than other subgroups of male-to-female transsexuals. Each older brother increases the odds that a male transsexual is homosexual by 40%." Green did not find a higher incidence of homosexuality in the younger brothers of homosexual transsexuals. Zucker and Blanchard wrote that studies have consistently supported the "fraternal birth order effect" that homosexual transsexuals have more brothers than sisters and are born later in birth order. In contrast, in their study using an Asian sample they found that the transsexual men had significantly more sisters than controls. Zucker attributes this to the preference for males in Korean society causing parents to stop having children once they have a boy. Therefore all male children are less likely to have older brothers and hence no fraternal birth order effect is observed. According to Bailey's interpretation of Blanchard's theory the causes of homosexual transsexuality are extreme examples of the causes of homosexuality in males.

Research by Blanchard, Zucker, and Green argues that the causes of homosexual transsexualism, transsexualism, and homosexuality overlap to a large degree.

Blanchard (1995) also said homosexual transsexuals were comparatively shorter and lighter in proportion to their height than non-homosexuals. Independent research done by Johnson (1990) and Smith (2005) concur with most of Blanchard's observations. Smith did not find a significant difference in height-weight ratio. Subsequent research has found only partial support of Smith's findings. Johson's 1990 work used the alternative term "androphilic transsexual", Johson wrote that there was a correlation between social adjustment to the new gender role and androphilia.

MacFarlane found that in New Zealand that 90% of the transsexual prostitutes were Māori. Of these, 90% had sex with a male as a child and 22% had sex with a female. Every subject in the study considered their sexual activity with men to not be homosexual, as they considered themselves female. Maoris comprise 9% of the overall population. In The Man Who Would Be Queen J. Michael Bailey states that about 60% of homosexual transsexuals he studied in Chicago gay bars were Latina or black, while in his studies of gay males only 20% were non-white; to provide possible explanations for this disparity, Bailey quotes the opinions of two of his subjects who attributed the difference to genetics, or inflexible gender roles in their respective cultures. MacFarlane similarly concluded that cultural acceptance influenced the number of Māori transsexual prostitutes, but also greater detachment from their culture, a lower standard of education, fewer job opportunities, and cultural confusion due to the abandonment of old customs.

Scientific criticism of the terminology
Many sources, including some supporters of the theory, criticize Blanchard's choice of wording as confusing and degrading.

Harry Benjamin said in 1966: ....it seems evident that the question "Is the transsexual homosexual?" must be answered "yes" and " no." "Yes," if his anatomy is considered; "no" if his psyche is given preference.

What would be the situation after corrective surgery has been performed and the sex anatomy now resembles that of a woman? Is the "new woman" still a homosexual man? "Yes," if pedantry and technicalities prevail. "No" if reason and common sense are applied and if the respective patient is treated as an individual and not as a rubber stamp.

Many others agree with what Dr. Benjamin wrote about the use of this term. Bagemihl writes "..the point of reference for "heterosexual" or "homosexual" orientation in this nomenclature is solely the individual's genetic sex prior to reassignment (see for example, Blanchard et al. 1987[24], Coleman and Bockting, 1988[25], Blanchard, 1989[26]). These labels thereby ignore the individual’s personal sense of gender identity taking precedence over biological sex, rather than the other way around." Bagemihl goes on to take issue with the way this terminology makes it easy to claim transsexuals are really homosexual males seeking to escape from stigma. Leavitt and Berger stated in 1990 that "The homosexual transsexual label is both confusing and controversial among males seeking sex reassignment. Critics argue that the term "homosexual transsexual" is "heterosexist", "archaic", and demeaning because it labels people by sex assigned at birth instead of their gender identity. Benjamin, Leavitt, and Berger have all used the term in their own work.   John Bancroft also recently expressed regret for having used this terminology, which was standard when he used it, to refer to transsexual women. He says that he now tries to choose his words more sensitively.  Moser (2010) is likewise critical of the terminology.

Scientific criticism of the theory
In "Autogynephilia in Women", Charles Moser applies an analogue of Blanchard's autogynephilia criteria for "non-homosexual transsexuals" to natal (anatomically from birth) women. 93% were classified as autogynephiles. Even using a much more rigorous standard, 28% still fit the classification. Moser concludes that Blanchard's assertion that autogynephilia raises questions that require further study and that what is being probed is not a paraphilia, but is instead a normal part of female sexuality that is no more prevalent among MtF transsexuals than it is within the general female population. Lawrence criticized Moser (2009) for not accurately representing Blanchard's autogynephilia questionaire. Moser, in turn, defended his questions and accused Lawrence of making inaccurate comparisons.

Veale, Clarke, and Lomax (2008) did a similar, but larger scale test of Blanchard's theories, with a different set of equivalent autogynephilia questions than Moser. Veale found that while both autogynephilic and non-autogynephilic transsexuals averaged higher rates of autogynephilia than natal women in the study, they also showed a stronger incidence of childhood female gender identity (essentially identical for both autogynephilic and non-autogynephilic transsexuals). 52% of biological female subjects scored a six or higher on the Core Autogynephilia scale and 3 or greater on the Autogynephilia Interpersonal Fantasy scale, compared to Blanchard's mean of 6.1 and 2.7 for "autogynephilic" non-homosexual transsexuals. In stark contrast to Blanchard's data, Veale found no difference between autogynephilic and non-autogynephilic MtF transsexuals in terms of sexual orientation; 68% of those classified as non-autogynephilic scored the highest possible score on the Sexual Attraction to Females scale. Veale's conclusion is that while Blanchard's categorization of two groups of transsexuals may have merit in some cases, it does not completely represent the diversity among MtFs.

Nuttbrock et al. (2010) attempted to reproduce Blanchard's studies from Toronto in the 1980s in modern times with 571 MtF transsexuals from New York City. For the study, autogynephilia is assumed to be equivalent to transvestic fetishism. The study did confirm Blanchard's findings of three times higher rates of transvestic fetishism among non-homosexuals versus homosexuals, but the correlation was too weak to be considered deterministic. Blanchard (1992)'s finding of the highest level of transvestic fetishism being found with an intermediary level of gynephilia could not be reproduced. Age and ethnicity were found to be correlated with sexual orientation. Being caucasian was found to correlate with transvestism. Transvestism results overall are significantly lower than Blanchard's, prompting the hypothesis that transvestic fetishism is a historically fading phenomenon. Nuttbrock concludes that, "These limitations notwithstanding, we nonetheless conclude that a classification of the MtF population, based solely on sexual orientation, is fundamentally limited."

Moser (2010) conducts a wide-ranging review of the literature on the subject as a critique of Blanchard's theory over a range of issues. His claims include:
 * Blanchard's use of "ever" to define autogynephilia, including those who have only had a few incidents of arousal long ago, is akin to classifying someone as homosexual for ever having been aroused by a member of the same sex in their life.
 * Blanchard (1989)'s claim of clinical importance for autogynephilia because "it interferes with normal interpersonal sexual attraction" is contradicted by his own work in Blanchard, Clemmensen, & Steiner (1987). "Autogynephilias as an orientation" (Blanchard 1993) is criticized in that autogynephilic MtFs interest in transitioning does not overshadow interest in courtship, love, and cohabitation with a partner of the preferred sex, with most reporting stable partnered relationships after SRS (Lawrence, 2005).  No cases were found in the literature of differences between the gender dysphoria of homosexual and non-homosexual MtFs, or response to anti-androgens, or the clinical utility of distinguishing the two.  Data on rates of regret for both groups of transsexuals is contradictory, and is low in either regard (Lawrence (2003) and Olsson & Moller (2006)).
 * Blanchard's statement, "All gender dysphoric biological males who are not homosexual ... are instead autogynephilic ..." is contrary to Blanchard's own data; examples include Blanchard (1993), Blanchard (1985), Bentler (1976), Leavitt and Berger (1990), Lawrence (2005), and others.
 * Lawrence (2005, 2006)'s claim that self-identified homosexual transsexuals are misrepresenting themselves (evidenced by a history of marriage to a woman) ignores that 20% of self-identified "white homosexual men" have a history of marriage to a woman, 14% had heterosexual coitus in the last year, and 52% in their lifetime (Bell & Weinberg, 1978). The claim that MtFs deny their autogynephilia to win favorable SRS recommendations is contradicted by the fact that Blanchard's clinic did not discriminate between the two types, and in some cases autogynephilia could lead to a more favorable diagnosis.
 * Blanchard et al.'s reliance on phallometry is noted to be controversial, as per APA (2000) and Marshal & Fernandez (2000). Blanchard, Racansky, & Steiner (1986) is criticized for studying cross-dressers but attributing the results to transsexuals, for omitting any chance for the subject to test positive for a lesbian identity, and for offhand dismissing results that contradict the theory.  Moser notes that Blanchard, Lynkins, et al. (2009) interprets results in the opposite manner.
 * The treatment of autogynephilia as a paraphilia is criticized for failing to match with sex drive. That is, paraphilias are rare in natal women (autogynephilia was found in women in Veale et al. (2008) and Moser (2009)); decline with age (non-homosexual MtF transsexualism does not); and should correspond with a decreased interest in transition and discomfort under the presence of anti-androgens.  This is often the case with transvestites, but non-homosexual transsexuals generally report unabated interest and a feeling of relief from the anti-androgens, even without estrogens.  "Autoandrophobia" is suggested as an alternative explanation.
 * While Blanchard (1991) claims that "autogynephilia ... is the main correlate of transsexual tendencies and also of diminished capacities for heterosexual relationships and pair-bond formation", Lawrence (2005) found that 83% of MtFs interested in female partners before and after SRS were in a stable, partnered relationship versus 36% of those interested in males. Lawrence (2005)'s claims of transsexuals having trouble finding partners after SRS is criticized for using an older age range than the national baseline she compares to, as age is inversely correlated with sexual partners. Using a similar age range, the rate of sexual partners is similar.  Contrary to Blanchard (1989a, 1991)'s claims that male partners of "non-homosexual transsexuals" are "faceless" and not "desirable partners in their own right", Lawrence (2005) shows 71% in stable partnered relationships post-SRS versus 64% for "homosexual" transsexuals, with an average number of post-SRS male partners of 2.8 versus 8.4, respectively.
 * Bailey (2003)'s claims that "homosexual transsexuals" are extremely feminine gay men, and Lawrence (2004)'s claims that homosexual MtFs transition because it "seems obvious" for "greater social and romantic satisfaction and success" are criticized for lacking in supporting data and for the notion of amputation of one's genitals being an "obvious" route to sexual success.

Transsexual community reaction
The concept began receiving attention outside of sexology when sexologist Anne Lawrence, a physician and sexologist who self-identifies as autogynephilic, published a series of web articles about the concept in the late 1990s. Lynn Conway and Andrea James responded to Lawrence's essays. Conway started an investigation into the publication of Bailey's book by the United States National Academy of Sciences. Accusations of misconduct by Bailey were leveled. Northwestern University investigated Bailey, but did not reveal the findings of that investigation and did not comment on whether or not Bailey had been punished. According to intersex researcher and bioethics professor Alice Dreger, who declares herself a friend of Blanchard, two of the four women who accused Bailey of misusing their stories were not mentioned anywhere in the book. Conway contests Dreger's account of the affair.

According to Leavitt and Berger, "transsexuals, as a group, vehemently oppose the [homosexual transsexual] label and its pejorative baggage." Transwoman Andrea James has called the term "inaccurate and offensive," and transman Aaron Devor wrote, "If what we really mean to say is attracted to males, then say 'attracted to males' or androphilic... I see absolutely no reason to continue with language that people find offensive when there is perfectly serviceable, in fact better, language that is not offensive." Still other transsexuals are opposed to any and all models of diagnosis which allow medical professionals to prevent anyone from changing their sex, and seek their removal from the DSM.