"Autogynephilia" and the Clinical Gaze

Starting last fall, when I wrote these posts on the American Psychiatric Association's ongoing project of drafting/revising the DSM-V, I've been kicking around a draft of a third post in that vein, this time concentrating on the doings of the Sexual and Gender Identity Disorders Work Group.

As you might infer from how long it's taken me to write said post, this entails opening up a huge can of worms.

I've also found I'm in way over my head with a lot of the issues involved, so I think I will intentionally avoid delving too deep into them; instead, I will point you to other people's writings that I've found illuminating.

Briefly, what's at stake is whether trans sexualities and gender identities will continue to be seen as "disordered" --- whether the category of Gender Identity Disorder* will be retained in the DSM-V. While the Gender Identity Disorders sub-workgroup is reportedly consulting trans advocacy organizations as part of its literature-review process, the makeup of the larger workgroup, and the prominence in leadership positions of two of its particularly worrisome members, introduces a strong bias towards viewing transgenderism and -sexuality as pathogies.

Here are some links that discuss the Sexual and Gender Identity Disorders Work Group --- and what its inclusion of Kenneth Zucker and Ray Blanchard means for trans people --- in greater detail:
Julia Serano, "Why feminists should be concerned with the impending revision of the DSM" (a guest post at Feministing.com)
Kelley Winters, "Transvestic Disorder and Policy Dysfunction in the DSM-V" (GID Reform Weblog)
Lena Dahlstrom, "Drafts from the DSM-V workgroup are out, and they're continuing to pathologize trans people" (Trans Group Blog)
Helen G, "APA Task Force reviews possible Gender Identity Disorder treatment guidelines" (Questioning Transphobia)

Now, I'd like to discuss one of the many trans-unfriendly ideas being brought to the DSM-V table: autogynephilia.

This nouveau-Greek concoction (meaning, I guess, "love of oneself as a woman") encapsulates Ray Blanchard's ideas about trans lesbians --- i.e., that they are straight men who fantasize about being women. (Blanchard also tends to refer to trans women as men: in his taxonomy, straight trans women are "homosexual transsexuals," while trans lesbians are "non-homosexual transsexuals." This can be quite confusing, apart from being just plain disrespectful to the people being talked about). Their femininity is thus taken for a sexual fetish rather than a component of their core identity.

Julia Serano has a lot to say on this topic --- not just about autogynephilia, but also about what she sees as the "sexualization" of MTF transgenderism by psychiatry.

Here's a summary of how she sees this sexualization play out (quoted from this description of a paper she presented at a 2007 conference for women in psychology, which became a chapter in her book, Whipping Girl):

The fact that MTF spectrum transgender people bear the brunt of our culture's fascination with, and demonization of, transgenderism, indicates that they are culturally marked, not for failing to conform to gender norms per se, but because they "choose" to be female and/or feminine. The notion that MTF transgender people are conceptualized within a traditionally sexist framework (i.e., one where femaleness/femininity are viewed as subordinate to maleness/masculinity) is perhaps most evident in the way that transsexual women (but not transsexual men) are hyper-sexualized in pornography and the media, wherein they are typically depicted as sex workers or as "sexual deceivers" who supposedly lure innocent straight men into sexual encounters. Implicit in all of these representations is a rigid, dualistic, heterosexual male-centered dichotomy in which only men can be viewed as legitimate sexual initiators and where womenare invariably viewed as sexual objects. In the context of this "predator/prey" dichotomy, transsexual women are consistently viewed as inviting their own sexualization by virtue of their feminine expressions and their physical transitions to female.

Understanding this predator/prey dichotomy allows us to make sense of psychological/psychiatric discourses of transgenderism, which have historically focused almost exclusively on MTF transgender individuals, while largely discounting female-to-male (FTM) transgenderism. For many decades, the diagnostic criteria devised for MTF transsexuals required them not only to be heterosexual and gender-conforming in the female role, but also to be sexually desirable in the eyes of heterosexual men. Those MTF spectrum transgender individuals who were unable or unwilling to meet all of the prerequisites for sexual object have typically been cast as sexual initiators and relegated to a distinct "paraphilic" category --- e.g., transvestic fetishism or autogynophilia. The positioning of this latter group (who are conceptualized as "men" who inappropriately fetishize female/feminine expressions in themselves) in opposition to "true" or "primary" MTF transsexuals (who are cast as willing objects of heterosexual male desire) reiterates the predator/prey dichotomy, thus preserving both the male/female and heterosexual/homosexual binaries. In this context, the invisibility and under-theorization of FTM transgenderism within psychology and psychiatry can be viewed as a direct result of the predator/prey dichotomy, which assumes that FTM spectrum individuals cannot be legitimate sexual initiators in their assigned sex (female), nor can their identified/preferred sex (male) be legitimately objectified.

Serano's thesis, in other words, is that the fear and hatred directed at trans women --- and the particular scrutiny the psychiatric profession directs at them --- derives from misogyny. If women are loathsome and inferior, then what kind of boy or man would choose to become a woman? The answer most commonly proposed by trans-misogynists is that such a man would have to be extremely, pathologically obsessed with sexuality (because, of course, women are sex!) of a particularly questionable stripe --- either the predatory sexuality of the transsexual "deceiver" of straight men, or the masturbatory and fundamentally narcissistic sexuality of the autogynephile.

Hopefully, you can now see where the "gaze" of my title comes in. The "autogynephilia" model does two things to the interaction between doctor and (trans lesbian) patient that skew it from a neutral, professional interaction to an exercise in sexualized power relations: first, it places the patient's sexuality on the clinical agenda, even when she has not made it an issue. Sexuality is seen as fundamental to her identity in a way that it would not be if she were cisgendered. Second, her sexuality is assumed to be wrong --- immature, paraphilic, disordered --- before anything is even said. She can therefore be silenced, or dismissed, or have her words twisted around, if what she says doesn't fit with the theory; because she is decided a priori to have deep-seated psychosexual issues, everything she says regarding her gender expression or sexuality can be considered suspect.

I think these two tendencies within this theoretical model constitute a pretty serious double standard --- the sexualities of trans women are probed and interrogated to a degree that no other sort of person's would be, unless that person had asked for help with a sexual problem. Thus, both because of a disproportionate rummaging through trans women's sexual quirks, and because of a selective attention to those trans women's own stories, the theory of autogynephilia as a cause of MtF transsexualism can't really be falsified. Nobody asks cis women if they find their own femaleness or femininity arousing, and Blanchard, Bailey and other "authorities" see no problem ignoring trans women who claim not to experience that.

*While the existence of GID as a category of mental illness perpetuates some seriously transphobic assumptions --- i.e., that trans people have something horribly wrong with them and need to be fixed, one way or another --- it also makes sex-reassignment surgery more accessible to those trans people who desire it, since by being the recommended "treatment" for the "disease" of GID, the surgery becomes much more justifiable in the eyes of insurance companies. I take this more as an indication that the U.S. health-care system sucks than a ringing endorsement by trans advocates of the medical model of transness, though.