Male-to-female Transsexualism Research Articles

Autogynephilia and the Typology of Male-to-Female Transsexualism

Abstract. 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.

Association study of ERβ, AR, and CYP19A1 genes and MtF transsexualism.

The etiology of male-to-female (MtF) transsexualism is unknown. Both genetic and neurological factors may play an important role. To investigate the possible influence of the genetic factor on the etiology of MtF transsexualism. We carried out a cytogenetic and molecular analysis in 442 MtFs and 473 healthy, age- and geographical origin-matched XY control males. The karyotype was investigated by G-banding and by high-density array in the transsexual group. The molecular analysis involved three tandem variable regions of genes estrogen receptor β (ERβ) (CA tandem repeats in intron 5), androgen receptor (AR) (CAG tandem repeats in exon 1), and CYP19A1 (TTTA tandem repeats in intron 4). The allele and genotype frequencies, after division into short and long alleles, were obtained. We investigated the association between genotype and transsexualism by performing a molecular analysis of three variable regions of genes ERβ, AR, and CYP19A1 in 915 individuals (442 MtFs and 473 control males). Most MtFs showed an unremarkable 46,XY karyotype (97.96%). No specific chromosome aberration was associated with MtF transsexualism, and prevalence of aneuploidy (2.04%) was slightly higher than in the general population. Molecular analyses showed no significant difference in allelic or genotypic distribution of the genes examined between MtFs and controls. Moreover, molecular findings presented no evidence of an association between the sex hormone-related genes (ERβ, AR, and CYP19A1) and MtF transsexualism. The study suggests that the analysis of karyotype provides limited information in these subjects. Variable regions analyzed from ERβ, AR, and CYP19A1 are not associated with MtF transsexualism. Nevertheless, this does not exclude other polymorphic regions not analyzed.

The (CA)n Polymorphism of ERβ Gene is Associated with FtM Transsexualism

Transsexualism is a gender identity disorder with a multifactorial etiology. Neurodevelopmental processes and genetic factors seem to be implicated. The aim of this study was to investigate the possible influence of the sex hormone-related genes ERβ (estrogen receptor β), AR (androgen receptor), and CYP19A1 (aromatase) in the etiology of female-to-male (FtM) transsexualism. In 273 FtMs and 371 control females, we carried out a molecular analysis of three variable regions: the CA repeats in intron 5 of ERβ; the CAG repeats in exon 1 of AR, and the TTTA repeats in intron 4 of CYP19A1. We investigated the possible influence of genotype on transsexualism by performing a molecular analysis of the variable regions of genes ERβ, AR, and CYP19A1 in 644 individuals (FtMs and control females). FtMs differed significantly from control group with respect to the median repeat length polymorphism ERβ (P = 0.002) but not with respect to the length of the other two studied polymorphisms. The repeat numbers in ERβ were significantly higher in FtMs than in control group, and the likelihood of developing transsexualism was higher (odds ratio: 2.001 [1.15-3.46]) in the subjects with the genotype homozygous for long alleles. There is an association between the ERβ gene and FtM transsexualism. Our data support the finding that ERβ function is directly proportional to the size of the analyzed polymorphism, so a greater number of repeats implies greater transcription activation, possibly by increasing the function of the complex hormone ERβ receptor and thereby encouraging less feminization or a defeminization of the female brain and behavior.

The Development of Standards of Care for Individuals with a Male-to-Eunuch Gender Identity Disorder

ABSTRACT Currently, the WPATH Standards of Care (SOC) provide guidelines for the treatment of male-to-female (MtF) transsexuals suffering from a gender identity disorder (GID). However, a large number of men with gender dysphoria who desire to be emasculated do not fit the classical pattern of MtF transsexualism. They loathe their manhood, but do not identify as, nor wish to be, female. Instead, they seek castration to become something outside the binary sexes. The formal term for such an individual is “eunuch,” which we here refer to as an MtE transgendered individual. The WPATH SOC, as currently written, are not applicable to these individuals. Indeed, neither the Diagnostic and Statistical Manual IV (DSM-IV) nor the International Classification of Diseases 10 (ICD-10) currently recognizes MtE transgenderism as a specific GID. The closest category into which MtE transgenderism fits in the DSM-IV is “GID Not Otherwise Specified” (GIDNOS). This vague diagnostic category has been a barrier for MtE individuals to receive treatment. An online survey posted at www.eunuch.org provided data on more than 300 individuals who have had voluntary genital ablations (as well as approximately 1,300 self-identified “eunuch wannabes”). More than half of the men who had surgery either did it themselves or resorted to medically unqualified underground “cutters.” This article offers a draft MtE SOC that outlines the criteria that we believe should be satisfied prior to surgical treatment. This draft MtE SOC is designed to initiate discussion of an unserved population of individuals with gender dysphoria, who are currently at risk of serious injury or death from the lack of medical care.

Societal Individualism Predicts Prevalence of Nonhomosexual Orientation in Male-to-Female Transsexualism

There are two distinct subtypes of male-to-female (MtF) transsexuals: homosexual and nonhomosexual. The relative prevalence of these two subtypes varies dramatically between countries, but no explanation of this variability has yet been proposed. This study examined the hypothesis that the prevalence of nonhomosexual MtF transsexualism, relative to homosexual MtF transsexualism, would be higher in individualistic countries than in collectivistic countries. I analyzed data from 22 studies of MtF transsexualism, conducted in 16 countries, examining the association between percentage of nonhomosexual participants and Hofstede's (Culture's consequences: Comparing values, behaviors, institutions, and organizations across nations, 2001) Individualism Index (IDV). IDV accounted for 77% of observed variance in the percentage of nonhomosexual MtF participants (r = 0.88, p < .0001). Controlling for differences in national wealth and in Hofstede's other indices of societal values (Power Distance, Uncertainty Avoidance, and Masculinity) did not significantly change the ability of IDV to account for variance in the percentage of nonhomosexual participants. The factors that contribute to the observed association between societal individualism and the relative prevalence of nonhomosexual MtF transsexualism remain to be determined, but a greater tolerance within individualistic countries for socially disruptive gender transitions by nonhomosexual gender dysphoric men, and the availability within many collectivistic countries of socially approved transgender roles for pervasively feminine homosexual gender dysphoric men, are plausible contributors.

A Polymorphism of the CYP17 Gene Related to Sex Steroid Metabolism is Associated With Female-to-Male But Not Male-to-Female Transsexualism

Transsexualism is a rare condition. Although its etiology is unknown, it has been speculated that sex steroids may play an important role during early brain development. There may be a genetic component based on reports of an association between male to female (MtF) transsexualism and a CA repeat polymorphism in the estrogen receptor beta gene. CYP17 A2 T>C is a functional single nucleotide polymorphism (SNP) of the common cytochome P-450 that is associated with elevated serum and plasma levels of estradiol (E 2 ), progesterone, and testosterone. The authors hypothesized that CYP17 A2 T>C is associated with transsexualism and that mutant alleles would be overrepresented among individuals with this condition. This case-control study assesses the association between transsexualism and allele and genotype frequencies of CYP17 A2 T>C SNP in a series of Caucasian transsexuals compared with controls. The participants were 102 male-to-female (MtF) and 49 female-to-male (FtM) transsexuals, 756 male controls, and 915 female controls. The mean age at presentation of FtM transsexuals was 33.2 and that of MtF transsexuals was 41.8 years. CYP17 A2 T>C SNP allele frequencies were statistically significantly different between FtM transsexuals and female controls (CYP17 T: 56% and CYP17 C: 44% versus CYP17 T: [69%] and CYP17 C: [31%], respectively). Genotype distributions were also different between FtM transsexuals and female controls. In contrast, no statistically significantly differences between MtF transsexuals and male controls were found in the CYP17 A2 T>C allele and genotype distributions. The allele distribution of CYP17 A2 T>C was gender-specific among male and female controls in that a higher mutant C allele frequency occurred in the male controls (CYP17 C: males; [40%] versus females [31%]), respectively; P ≤.001. Allele distribution in the MtF transsexuals was equivalent to male controls. In contrast, FtM transsexuals did not follow the gender-specific allele distribution of female controls but instead had an allele distribution equivalent to MtF transsexuals and male controls. The overrepresentation of CYP17 A2 T>C SNP among FtM transsexuals but not MtFs supports this polymorphism as a candidate gene of FtM transsexualism. The loss of a female-specific CYP17 A2 T>C allele distribution pattern may predispose women to become transsexuals.

Deconstructing the Feminine Essence Narrative

In Dreger’s history of the controversy surrounding Bailey’s (2003) work on femininity in biological males, she refers to the popular view of male-to-female transsexualism as the feminine essence narrative. Because my commentary considers the feminine essence view as a set of propositions rather than as a story, I will refer to it as the feminine essence theory. Dreger presents the main ideas of the theory quite clearly enough for the purposes of her history. She writes, for example, that according to the feminine essence theory, ‘‘trans people suffer from a sort of trick of nature, whereby they have the brain of one gender in the body typical of the other. Thus the trans person has a sort of neurological intersex condition, typically understood to be inborn.’’ She does not, however, formally enumerate the distinguishable elements and implications of the theory, an exercise that would have taken her beyond the scope of her article. Such an analysis is the subject of this commentary. My purpose in writing it is to present the feminine essence theory in a form that facilitates its comparison with other theories of male-tofemale transsexualism, including my own view. The remainder of this commentary has three main parts. First, I will list what I consider to be the central tenets of the feminine essence theory. There is no ‘‘official version’’ of this theory, and another author might come up with a shorter or longer list of tenets, or state some of them in different language. Second, I will explain each of the tenets as I conceive them, and third, I will compare the various elements of the feminine essence theory with my own conjectures.

A polymorphism of the CYP17 gene related to sex steroid metabolism is associated with female-to-male but not male-to-female transsexualism

To assess the association between transsexualism and allele and genotype frequencies of the common cytochrome P450 (CYP) 17 -34 T>C single nucleotide polymorphism (SNP). Case-control study. Academic research institution. 102 male-to-female (MtF) and 49 female-to-male (FtM) transsexuals, 756 male controls, and 915 female controls. Buccal swabs and multiplex polymerase chain reaction on a microarray system. Analysis of the CYP17 -34 T>C SNP. CYP17 -34 T>C SNP allele frequencies were statistically significantly different between FtM transsexuals and female controls (CYP17 T: 55/98 [56%] and CYP17 C: 43/98 [44%] versus CYP17 T: 1253/1826 [69%] and CYP17 C: 573/1826 [31%], respectively). In accordance, genotype distributions were also different between FtM transsexuals and female controls using a recessive genotype model (CYP17 T/T+T/C: 39/49 [80%] and C/C 10/49 [20%] vs. CYP17 T/T+T/C: 821/913 [90%] and C/C 92/913 [10%], respectively). The CYP17 -34 T>C allele and genotype distributions were not statistically significantly different between MtF transsexuals and male controls. Of note, the CYP17 -34 T>C allele distribution was gender-specific among controls (CYP17 C: males; 604 of 1512 [40%] vs. females; 573 of 1826 [31%]). The MtF transsexuals had an allele distribution equivalent to male controls, whereas FtM transsexuals did not follow the gender-specific allele distribution of female controls but rather had an allele distribution equivalent to MtF transsexuals and male controls. These data support CYP17 as a candidate gene of FtM transsexualism and indicate that loss of a female-specific CYP17 T -34C allele distribution pattern is associated with FtM transsexualism.

Becoming What We Love: autogynephilic transsexualism conceptualized as an expression of romantic love

The increasing prevalence of male-to-female (MtF) transsexualism in Western countries is largely due to the growing number of MtF transsexuals who have a history of sexual arousal with cross-dressing or cross-gender fantasy. Ray Blanchard proposed that these transsexuals have a paraphilia he called autogynephilia, which is the propensity to be sexually aroused by the thought or image of oneself as female. Autogynephilia defines a transsexual typology and provides a theory of transsexual motivation, in that Blanchard proposed that MtF transsexuals are either sexually attracted exclusively to men (homosexual) or are sexually attracted primarily to the thought or image of themselves as female (autogynephilic), and that autogynephilic transsexuals seek sex reassignment to actualize their autogynephilic desires. Despite growing professional acceptance, Blanchard's formulation is rejected by some MtF transsexuals as inconsistent with their experience. This rejection, I argue, results largely from the misconception that autogynephilia is a purely erotic phenomenon. Autogynephilia can more accurately be conceptualized as a type of sexual orientation and as a variety of romantic love, involving both erotic and affectional or attachment-based elements. This broader conception of autogynephilia addresses many of the objections to Blanchard's theory and is consistent with a variety of clinical observations concerning autogynephilic MtF transsexualism.

Clinical and Theoretical Parallels Between Desire for Limb Amputation and Gender Identity Disorder

Desire for amputation of a healthy limb has usually been regarded as a paraphilia (apotemnophilia), but some researchers propose that it may be a disorder of identity, similar to Gender Identity Disorder (GID) or transsexualism. Similarities between the desire for limb amputation and nonhomosexual male-to-female (MtF) transsexualism include profound dissatisfaction with embodiment, related paraphilias from which the conditions plausibly derive (apotemnophilia and autogynephilia), sexual arousal from simulation of the sought-after status (pretending to be an amputee and transvestism), attraction to persons with the same body type one wants to acquire, and an elevated prevalence of other paraphilic interests. K. Freund and R. Blanchard (1993) proposed that nonhomosexual MtF transsexualism represents an erotic target location error, in which men whose preferred erotic targets are women also eroticize their own feminized bodies. Desire for limb amputation may also reflect an erotic target location error, occurring in combination with an unusual erotic target preference for amputees. This model predicts that persons who desire limb amputation would almost always be attracted to amputees and would display an increased prevalence of gender identity problems, both of which have been observed. Persons who desire limb amputation and nonhomosexual MtF transsexuals often assert that their motives for wanting to change their bodies reflect issues of identity rather than sexuality, but because erotic/romantic orientations contribute significantly to identity, such distinctions may not be meaningful. Experience with nonhomosexual MtF transsexualism suggests possible directions for research and treatment for persons who desire limb amputation.

Psychophysiological correlates in male to female transsexuals studied with a P300 investigation

Transsexualism is thought to be related to cortical processes reflecting a complex mosaic of biological, psychological and social/cultural information. Since the P300 component of event-related potentials is considered as an index of attentional processes, the present study focuses on auditory P300 elicited during a short memory test in male to female (MF) transsexuals, compared with that in healthy controls. The P300 component was evaluated during the anticipatory period of a short memory test in 13 MF transsexuals who had a gender reassignment operation, at least 3 years previously (mean time 17-6 years, range 3-31 years) and 26 healthy subjects (11 males and 15 females) matched for age and educational level. MF transsexuals exhibited significant reduction of P300 amplitude in the left frontal and temporoparietal areas in comparison to the control group. Furthermore, the group of transsexuals showed a significant delay of P300 latency in comparison to the controls, at the central frontal region. These findings point to significant psychophysiological alterations of distributed cortical circuits in MF transsexuals. These alterations may be critically related to the biological substrate of MF transsexualism.

Masculinity, femininity, and transsexualism.

This study examined the relationship between sex role and gender identity in a Polish transsexual population where, unlike in Western countries, male-to-female (MF) transsexualism is much less common than female-to-male (FM) transsexualism. One hundred and three FM (82 primary, 21 secondary) and 29 MF (16 primary, 13 secondary) transsexuals plus 135 control males (CM) and 303 control females (CF) completed a Sex Role Inventory, which measures sex-role identification, that is, the degree to which one self-identifies with masculine and feminine characteristics. Data obtained from primary transsexuals revealed that, on a femininity scale, MF transsexuals scores exceeded not only CM but also CF. On a masculinity scale, MF transsexuals rated themselves significantly lower than CM, but at a level comparable to CF. The comparison of FM transsexuals and controls showed that, on a masculinity scale, transsexuals scored higher than CF but were not different from CM. On the femininity scale, FM transsexuals rated themselves in between the two control groups: lower than CF but slightly higher than CM. The relations of secondary transsexuals' scores to CF and CM scores, on both masculine and feminine scales, were in the same direction as the primary transsexuals' scores. Secondary transsexuals rated themselves very similarly to their primary counterparts (the exception was a much higher score of MF-primary transsexuals than MF-secondary transsexuals on the femininity scale). Our study revealed that transsexualism does not imply a simple inversion of sex-role patterns: transsexuals differ not only from nontranssexual individuals of the same anatomical sex but also from those of the opposite sex. Moreover, MF transsexualism is not a mirror image of FM transsexualism: it constitutes a more extreme condition in the identification with feminine versus masculine personality traits. These differences seem to be universal for different countries and regions. The diagnostic value of our findings is discussed.

A higher rate of hyperandrogenic disorders in female-to-male transsexuals.

In an effort to elucidate the aetiology of female-to-male transsexualism (FM-TS) 12 out of an annual sample of 16 untreated female-to-male transsexuals (FMT), aged 19 years 7 months (19;7) to 44 years 8 months (44;8) [median age (M) 27;5] were assessed by means of sexual-medical questionnaires, physical and endocrinological examination. The control group consisted of 15 healthy women (CF), aged 19 years 2 months (19;2) to 36 years 1 month (36;1) (M 22;7) without gender identity disorder, who were not under hormonal medication (including contraceptives). Baseline levels of testosterone (T; ng/dl), androstenedione (A4; ng/dl), dehydroepiandrosterone sulfate (DHEAS; ng/ml), luteinizing hormone (LH; IU/l), follicle stimulating hormone (FSH; IU/l), and sex-hormone binding globuline (SHBG; microgram/dl) were measured. A standard single-dose ACTH stimulation test (250 micrograms ACTH IV; Synacthen) was performed with all subjects. Aldosterone (ALDO), corticosterone (B), deoxycorticosterone (DOC), progesterone (PROG), 17-hydroxyprogesterone (17OHP), 11-deoxycortisol (S), cortisol (F), cortisone (E), pregnenolone (PREG) and 17-hydroxypregnenolone (OHPREG) were assessed before and 60 min after ACTH stimulation. Transvaginal ultrasound was performed in nine out of 12 FMT (20;11 to 44;8, M 27;5; m 29.1 +/- 7.5) but not in CF. Results showed that 10 FMT (83.3%) and five CF (33.3%) were above normal values for at least one of the measured androgens. Baseline levels of T and A4 were significantly higher in FMT than in CF (T: 54.0 +/- 13.8 vs. 41.1 +/- 12.8; A4: 244.8 +/- 73.0 vs. 190.5 +/- 49.3; p < .05), whereas DHEAS, SHBG, LH and FSH did not differ between the groups. Unbound T (T/SHBG ratio) was higher in FMT (72.0 +/- 67.6) than in CF (26.4 +/- 15.1). Baseline levels of 17OHP, OHPREG and DOC were higher in FMT than in CF (p < .05). After ACTH stimulation 17OHP and OHPREG remained higher in FMT than in CF (p < .05). Single case analysis of ACTH stimulation test together with physical examination revealed symptoms for non-classical congenital adrenal hyperplasia (NC-CAH) in six FMT (50%) and two CF (13.3%). Eight out of nine FMT who were assessed by means of transvaginal ultrasound (i.e. 88.9%; 50.0% of 16) had polycystic ovaries (PCO). Oligomenorrhoea or menstrual dysregularities (81.7% of 16 FMT vs. 0% of CF), hirsutism (56.2% of 16 FMT vs. 13.3% of 15 CF) and adiposity (25.0% vs. 0%) were frequent in FMT, but not in CF. Hyperandrogenism with polycystic ovarian syndrome (PCOS) and adrenocortical hyperresponsiveness to ACTH seems to be a common finding in FMT. This offers support for a hormonal factor in the genesis of FM-TS. Because the prevalence of PCOS and NC-CAH in the female population is higher than FM-TS, the true nature of this factor and its interaction with environmental influences remains unknown.