How Transphobia Gets Written Into Science and Medicine

DSM-V and the Science of Autogynephilia

Transphobia is written into our science and medicine and maintains a gender binary that denies lived experiences. Buried in the DSM-V’s (the universal authority for psychiatric diagnoses in the US) diagnosis of ‘Transvestic Fetishism’ is a little known term called ‘Autogynephilia’, or “Sexually Aroused by Thought or Image of Self as Female”. Learn more about how transphobia is perpetuated in science and medicine through inaccurate and dangerous medical terms and concept

It was clearly the handiwork of Blanchard. When the latest version of the Diagnostics and Statistics Manual of Mental Disorders (DSM) was released in May 2013, trans activists partook in a collective groan at finding the addition of ‘autogynephilia’. Blanchard, who had served as chair for the DSM group for Paraphilias (DSM speak for sexual perversions), had managed to insert his theories on trans identity into the Transvestic Disorder category. The inclusion of autogynephilia in the DSM-V not only meant that it has been institutionally endorsed by the American Psychological Association (APA), but that it had become part of the legal standard of care used by all American psychologists, clinicians, insurance companies, and lawyers.

So what is autogynephilia? And why was its inclusion so controversial?

Blanchard’s Typologies

Ray Blanchard is a sexologist best known for defining ‘Blanchard’s transsexualism typologies’. Blanchard published a series of papers based on clinical observations and self-report studies he conducted with trans women (people who were assigned male at birth, but identify as female) in gender identity clinics.

He divided trans women into four categories: androphilic (attracted to men), gynephilic (attracted to women), asexual (attracted to neither), and bisexual (attracted to men and women), and asked them if they had ever experienced arousal in response to wearing women’s clothing. While the majority of gynephilic (87.5%), asexual (75%), and bisexual (65.7%) trans women reported that they had at least one such experience in their lifetime, only 15% of androphilic trans women responded similarly. Based on these results, Blanchard concluded that there were two distinct types of transgender identity dictated by sexual orientation:

“there are only two fundamentally different types of gender identity disturbance in males: homosexual (aroused by men) and autogynephilic (aroused by the idea of being women).”

Let’s take a moment to unpack this jumble of gender identity, sexual orientation, and fetish.

Heteronormative Narratives

In distinguishing between two types of transgender people, Blanchard attempted to parse out who was a ‘true transsexual’ and who was motivated to seek medical transition resources out of ‘erotic desire’. This policing of gender legitimacy is rooted in heteronormativity, which asserts the traditional alignment of sex assigned at birth, gender identity, gender expression, and sexual orientation (i.e., someone who is male assigned at birth, identifies as male throughout his lifetime, has a masculine gender expression, and is attracted to women). In a heteronormative model, part of how womanhood is defined is being attracted to men. Because of this problematic type of thinking, trans women who were attracted to men were considered ‘true transsexuals’ and gender affirmation surgery provided an opportunity for ‘making people straight’.

Many of the doctors at gender identity clinics, who acted as gatekeepers to resources related to medical transitioning, enforced these biases. Before being approved for hormones or surgery, trans folks had to meet with a doctor to prove that they were transgender (a problem that persists today). Oftentimes this meant people had to conform to doctors’ stereotypes of trans people and trans narratives: presenting in a gender-binary way, knowing they were trans since childhood, and being attracted to people of a different gender. Given that all of Blanchard’s participants were patients at gender identity clinics, it’s not such a stretch to imagine that conducting studies in these transphobic settings could lead to inaccurate experimental results.

‘Nonhomosexual’ trans women (who were not exclusively attracted to men) did not fit these heteronormative narratives, prompting Blanchard to seek an alternative basis for trans identity. He insisted that for ‘nonhomosexual transsexuals’, gender dysphoria was motivated by the sexual fetish of autogynephilia, or “a male’s propensity to be sexually aroused by the thought of himself as a female”.

Female Embodiment Fantasy

Blanchard defined autogynephilia as a paraphilia, or a sexual deviation that falls within the same category as pedophilia and exhibitionism. This type of terminology is needlessly pathologizing, especially for trans folks who have historically been oversexualized. Therefore, I will use Julia Serano’s more neutral term: ‘female embodiment fantasy’.

Upon closer inspection, female embodiment fantasy seems less like a ‘paraphilia’ and more like a commonplace aspect of female identity. Many trans women who experienced female embodiment fantasies found that it was a passing phase that decreased over time. A significant percentage of cis women (women who were assigned female at birth) also report being aroused by images of themselves as women. One study found that 93% of cis women surveyed would fit Blanchard’s definition of autogynephilia. Based on Blanchard’s logic, we would have to conclude that the vast majority of cis women suffer from paraphilias – rather than admit that sexual interest in one’s own body (or ideal body) is an ordinary occurrence.

Serano theorizes that this phenomenon takes place because of the way women and femininity are sexualized in our culture, causing thoughts of female embodiment to be highly arousing. As trans women transition into a feminine social roles and develop their female identities, the sexual charge associated with female embodiment lessens.

The Legacy of Blanchard

In creating these typologies, Blanchard not only makes assumptions about  people’s motivations and desires, he also erases the diversity of the trans community. The trans spectrum encompasses folks from a wide range of gender identities and sexualities, all of whom have an equal claim to their identity, regardless of who they are attracted to or how well they fit into scientists’ narratives.

Unfortunately in today’s society, publishing papers in academic journals is more likely to make you considered an expert on a topic than lived experiences. Although Blanchard’s findings have been rejected by  the majority of trans women, his ideas continue to live on in scientific discourse as evidenced here, here, and here.

For a psychologist encountering a trans patient for the first time, the DSM is their first reference point for the diagnosis and treatment of their patients. Those unfamiliar with queer and trans issues will be relying on Blanchard’s transphobic science in their clinical decision-making and patient interactions. That could mean pathologizing and stigmatizing patients who are looking to get life-saving treatment.

**The author identifies as a cisgender straight woman. Please send an email to if any of the written material causes harm or offense.

Alexis Takahashi (aka ATAK) is a multiracial organizer who loves plants, sushi, and disrupting capitalism. Her personal superpowers are cat whispering and laying in trees.