January 3, 2010

Blanchard and the DSM-V, redefining paraphilia


As I pointed out in my previous post Ray Blanchard, who coined the term autogynephilia, seems to be obsessed with the classification of "paraphilias" or perversions.

It seems that any behavior out of the norm of middle-class WASP America must be included in the next edition of the US psychiatric Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

There is also a lot of controversy regarding the DSM's categorization of transgender issues. Many transsexual activists mean that gender identity issues are not to be categorized as mental illnesses, and that they therefore do not belong in this manual.

After having gone through the arguments underpinning the categorization in this manual, I must say I agree. This isn't science, this is the matter of stereotypes masquerading as science.

The DSM gender identity disorder work group

Blanchard is member of the DSM gender identity disorder work group, which is headed by Dr. Kenneth Zucker, one of Blanchard's colleagues in Toronto.

Zucker has never given up his effort to cure transgender children. Another member of the work group is recommending psychopharmacological treatment for crossdressing. Blanchard believes all M2F transsexuals are either gay men or fetishists. No wonder the transgender community is seriously pissed off.

Zucker and Co are willing to change the name of the condition, though. The term "gender identity disorder" is out, to be replaced by the less controversial term "gender dysphoria". But do not think that a new name will change the underlying understanding of these men; i.e. that the various forms of transsexual pheonomena are to be considered mental illnesses.

Gays are now OK, transsexuals are not


Homosexuality has already been removed from the DSM. Homosexuals may still be considered to be in need of psychiatric help, but that is no longer because homosexuality is considered a mental illness. Instead homosexuals may be in distress because of matters totally unrelated to their sexual orientation, or because it continues to be hard to come out as gay in some circles.

If you tell a doctor that you are a transsexual, crossdress or have erotic fantasies of becoming a woman, then the manual will tell him or her that it is the condition itself that is the cause of your suffering.

Dr. Madeline H. Wyndzen puts it this way:

"If a man sought therapy due to unhappiness over his attraction to other men, a therapist would likely diagnose him with depression. If a transsexual sought therapy due to unhappiness over his or her biological sex, a therapist would almost certainly diagnose him or her with Gender Identity Disorder (GID). Whereas gay men are diagnosed for how they suffer, transsexuals are diagnosed for who they are. I find the mental illness labels imposed on transgenderism just as disquieting as the label that used to be imposed on homosexuality. "

As I have noted before there are several reasons gays are now considered to be OK. The main reason is that the sociocultural context has changed. Homosexuality has become accepted in academic circles, and these doctors belong to this social group. Many of them have close friends that are homosexuals, and the ones that continue to believe that homosexuality is an illness, risk being ostracized.

Furthermore, many of these doctors are evolutionary biologists, i.e. they believe that a "sound" personality is one that can be explained as sensible from an evolutionary perspective. Although homosexuality continues to be a puzzle for these people -- as homosexuals are less likely to breed offspring -- there are just too many gays around to be considered an anomaly.

It should therefore come as no surprise that Blanchard has spent a lot of time trying to find an explanation for homosexuality. He has suggested the so-called fraternal birth order effect or "older brother effect". This theory is that the more older brothers a man has, the greater the probability is that he will have a homosexual sexual orientation. According to this hypothesis, anti-H-Y antibodies produced by the mother pass through the placental barrier to the fetus and affect aspects of sexual differentiation in the fetal brain.

Whether this means that Blanchard considers homosexuality a biological error or not, is unclear. It seems to me that he does. If that is the case what he calls feminine homosexual men (i.e. M2F transwomen) continue to be outside the norm of normalcy. What is totally clear is that he believes crossdressers and autogynephiliacs are mentally ill.

Paraphilia redefined

Blanchard presented a paper at the Annual Meeting of the Society for Sex Therapy and Research (SSTAR) on April 3,2009 in Arlington, Virginia. In this presentation he described the working group's thoughts on the new DSM-V. This should be of great interest to autogynephiliacs because it so clearly reveals the way Blanchard and his compatriots are thinking about paraphilias (perversions).

Traditionally paraphilia has been defined, according to Blanchard, as recurrent intense sexually arousing fantasies, sexual urges, or behaviors generally involving

1. non-human objects [female clothing in the case of the crossdresser]
2. the suffering or humiliation of one self or one's partner [e.g. BDSM]
3. children or other nonconsenting persons [e.g. pedophilia and rape]
4. an atypical focus involving human subjects (self or others) that occur over a period of at least 6 months [this must be some kind of miscellaneous "anything else I don't like" caregory]

This is the current DSM definition. Blanchard now proposes a new one:

"The term paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically, consenting adult human partners. "

Woooow!!! You have to admire the persistence of this man. If we are to interpret this paragraph in a strict manner, it actually means that the only normal sexual acts are foreplay and gential sexual intercourse between a man and a woman.

Phenotypically means "the manifest characteristics of an organism collectively, including anatomical and psychological traits, that result from both its heredity and its environment." Given Blanchard's background as a traditional evolutionary biologist this should mean vaginal penetration by a penis.

What's in? What's out?

However, Blanchard knows that such an interpretation is impossible in today's America. In his presentation he therefore gives some examples on what kind of behavior that is paraphilic and what is not. The criteria for what is considered parahilic seems completely random:

Not paraphilic:
  • cunnilungus
  • fellatio
  • anal penetration with the finger, penis or dildo
  • anilingus
  • intracrural intercourse [Masturbating the penis between the (lubrictaed) upper thighs of a partner]
  • cross-masturbation
  • kissing
  • fondling
Note that in -- let's say -- the 195o's many of these acts would be considered perversions.

Paraphilic:
  • enemas
  • feces or urine
  • generalized sexual interest in amputees, paralyzed persons, physical deformities
  • bondage
  • whipping
  • cutting
  • hypoxia
  • sneezing or smoking persons [!!!]
  • obscene telephone calls
Note that some of these acts, like bondage, would be considered normal by many. It seems to me that the lists are based purely on Blanchard's personal idea of what is normal and what is not. This has nothing to do with science.

Transvestic disorder and autogynephilia

In the old (an apparently the new) manual a transvestic fetich/transvestic disorder is present if
  1. over a period of at least six months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. [This is called a paraphilia]
  2. The fantasies, sexual urges, or behaviors causes significant distress or impairment in social, occupational or other important areas of functioning. [This is called a paraphilic disorder].
Blanchard proposes two new so-called specifier options:
  • With Fetishism (Sexually Aroused by Fabrics, Materials or Garments)
  • With Autogynephilia (Sexually Aroused by Thought or Image of Self as a Female)
Blanchard says:

"I made this recommendation according to the results of unpublished research, which I conducted specifically for the Paraphilias Subworkgroup. The results showed that transvestic patients who acknowledged autogynephilia had higher odds of reporting past or current desires for sex reassignment than transvestic patients who denied autogynephilia. The opposite result was found for fetishism, that is, transvestites who reported fetishism were less likely to report a desire for sex reassignment. It is noteworthy that these predictors were independent to a large extent."

If you find this explanation confusing, it is probably because he seems to reverse the order of categorization. Autogynephilia is normally a term that encompasses both crossdressers and what I call crossdreamers (men who dream about having a female body). Here "transvestism" seems to be a term that encompasses both fetishists (crossdressers?) and autogynephiliacs (crossdreamers?).

What he says is in essence that crossdreamers (men who fantasize about having a woman's body) are more likely to transition than crossdressers who do not (admit to have) have such erotic fantasies. In short, I am therefore more paraphilic than your average transvestite and deserves a separate "specifier option". This makes me so proud!

Freaks again

Blanchard now wants to include autogynephilia in the DSM and make everyone understand that we are either mild fetishists or suffering from a paraphilic disorder. This means that it will be impossible for transsexuals who have had erotic fantasies about having a woman's body or who have crossdressed to be considered a genuine woman. She will forever be labelled as a paraphilic freak.

And the thing is that this categorization is not based on Blanchard's research. Blanchard's data say nothing about what is a fetish or what is not, what is a paraphilia or what is not. His data just tell us what a specific selection of transsexuals have responded to a specific questionnaire. The design of that questionnaire and the interpretation of the date is solely based on the prejudices of him and his colleagues.

Gay men and women are left out

This disorder is only about heterosexual men. A homosexual man who crossdress is not considered a paraphiliac, probably because Blanchard expects homosexual men to be feminine and are therefore outside the realm of normal male behavior anyway.

Women are also allowed to crossdress. Why? Well, given today's fashions a woman can dress up as a male (boots, jeans and a t-shirt) and nobody will notice the difference. Besides, for some reason Blanchard seems to give women more freedom than men. Why, I wonder? I doubt there is a scientific reason for this.

Note also how the paraphilic disorder is defined by distress. It is understood that it is the transvestic condition that causes the disorder, not the reaction of the surrounding society. Blanchard does not understand that the very labeling of crossdressers as paraphiliacs could be the cause of such distress.

But this is a blog for autogynephiliacs, isn't it?

Some of my reader's may find it strange that I, as one of the few online bloggers who identify with the term autogynephilia, should be so upset with the inclusion of it in the DSM.

I do find the term useful, because I do believe there is a separate subcategory of transpeople that consists of men who :
  • Are predominantly gynephile (attracted to women)
  • Get sexually aroused by imagining themselves as women
  • Often (but not always) crossdress
  • Often have an ambiguous gender identity, that is they have -- to a varying degree -- a strong feminine side. Some of them identify as men, some as women.
The term helps us, because -- truth to be told -- important parts of the transgender community are reluctant to recognize us. We therefore have to develop a language that helps us understand ourselves.

But I have not concluded that this is a disorder, a fetish or a paraphilia. Nor do I believe that science has proved that is a paraphilia. It may be, but we do not know that, and because of that it does not belong in such a manual.

Besides, history shows us that what is considered a perversion in one culture or historic period, is considered a virtue in another. This means that we should be very careful when defining what is natural and what is not.

A petition against the work group gained more than 9000 signatures online.
DSM-V WorkGroup for Sexual & Gender Identity Disorders (All mixed up)
Autogynephilia: The Infallible Derogatory Hypothesis, Part 1 (GID Reform Weblog)



UPDATE ON TERMINOLOGY

Since this blog post was written I have stopped using the terms "autogynephilia" and "autoandrophilia" to describe people. The reason for this is that the terms implicitly communicates an explanation for why some people get aroused by imagining themselves as the opposite sex . This explanation, that this is some kind of autoerotic paraphilia,  is both wrong and stigmatizing. Instead I use the neutral term "crossdreamers".

Click here for a discussion of the dark side of the autogynephilia theory.



11 comments:

  1. I wish that I had a normal sexuality. Is that enough to consider it harmful? Probablly not.

    The distress I feel is not over my sexuality itself, but over the confusion that it causes. If Blanchard could better explain AGP (or anyone for that matter) I would think that the distress would be removed. The sam as GID is removed through Transition.

    ReplyDelete
  2. Jack,

    Thank you for posting the link to Blanchard's presentation. There are several important points in it:

    1. This presentation is a request for feedback (presumably from his peers) and the final result may be different than what is being presented.

    2. He is concerned about the semantics of the words. You say "toe mate oh" and I say "toh mah toe" but are we saying the same thing?

    3. A paraphilia is a disorder only if there is a diagnosis of distress and impairment. If one is not distressed or impaired, then there is no disorder.

    4. There is no automatic labeling of non-normative sexual behavior as pathological. In other words, no jumping to conclusions.

    Thank you for the compilation of links! One thing I noticed is that outside of Blanchard, Bailey, and Zucker, there seems to be very limited research being published regarding autogynephilia and gender identity. Are there any other researchers in this area who might have an impact on the upcoming DSM?

    If Blanchard is proposing adding autogynephilia to DSM, who has published any research as a counter-balance? (There are a number of very well thought out arguments by many people, but do non-scientific opinions count?) I may not agree with Blanchard's work or his methodology but I do not have the skills and resources to support or refute Blanchard's work...

    ReplyDelete
  3. Jack,

    Could you please call transsexuals people rather than men? There are definitely men who transition but there are people in this group who if you ever met, you would swear are female. Your terms are generally scientifically correct but lack some sensitivity.

    The thing about most of us who feel that we probably should have born female is that in general we don't mind men having AGP. We understand that AGP in itself is a normal variant of sexuality. We do tend to get a little upset when we are lassoed in and considered to be just a more feminine AGP person. We also do tend to get upset when we try very hard to portray ourselves as normal women and society adopts the image of seeing TS people as men in dresses. We are the minority but I would like to feel that we can respect each other's differences.

    A lot of transitioning people fear AGP like the plague whether they have it or not. Sexuality is very much a part of the human condition and when you tell anyone that they may have warped their sexuality to convince themselves to transition, the suggestion becomes powerful and frightening even when there is no real evidence to back it up.

    Personally, I would prefer that the AGP condition be presented with as little stigma as possible and treated the same way. I do not want people to become so ashamed of their issues that they feel they have to make often unfortunate life decisions (like transition) in order to deal with them. Besides which, there is evidence that AGP is biological. Why should anyone be ashamed of what god made them?

    Btw, so everyone knows, I am a feminine person who really wants to live and be accepted as a woman but is at times very scared with her decision and that society won't accept her and sometimes just all the more frightened that she is unsure whether she can control her desires. However, I am not a nazi and until I am living as a woman and have confirmed the way I feel inside, I am very open to people treating me personally however they will. I only ask to be accorded the respect of a normal human being.

    Oh.. and I will not claim to have never read any of the TG literature out there. It is very hard to go through life having to act in ways that run counter to your nature and a fantasy of having all those problems suddenly removed or satisfied is sometimes pleasing to all of us ;)

    In the case of TS people, the cure is often really frightening because you feel like you are literally betraying everyone who loves you and being horribly selfish. You are throwing upon those people a greater burden than if they simply found out you were dead. Eventually, you come to realize though that the greater sin is forcing people to live with someone who is really uncomfortable in their own skin and finds love and self acceptance difficult.

    ReplyDelete
  4. Gender Questioning, I agree with everything you said, also the part about not calling transsexuals men. I think it is pedantic by Blanchard to insist that people who feel, act and identify as women should be called men. The reason I used the term man/men in this post, is because I was presenting the thoughts of Blanchard.

    ReplyDelete
  5. GenderQuestioning,

    Thanks for saying so eloquently, what I find so hard to express!

    ReplyDelete
  6. I've been going through some of Blanchard's material and what strikes me right off is that it's all a matter of perspective.

    In the first place, he seems to conflate some things that are a normal part of (female) sexuality with other things in his model because he doesn't understand women. That, and of course he doesn't seem to accept that someone can be born "female brained".

    So in effect he mixes two unrelated conditions, transvestic-type fantasy and what he thinks of as "transsexual thoughts". Because he considers people as "male brained" and "broken male brained", the femaleness of transsexual women is dimissed. In the process he completes his theoretical circle by stating that that the actual transsexual condition does not exist.

    Of course we know this is not true. While Blanchard attempts to dismiss the very real differences between men's brains and transsexual women's brains as "markers of paraphilia", the science is sure to bear out the central thesis that transsexual people have stated since the condition was first recognized. That they are men and women who's brains simply do not match with their bodies.

    So where does this leave the "AGP" sufferer? There are two scenarios that come immediately to mind. One, is that "AGP" in men is merely an extension, or perhaps an overarching expression of the "transvestic" urge that some men develop. This is probably related to an even more broad system of dominance and submission in mammals, which is the true root of these behaviors. Nothing shameful there.

    The other aspect, the part that troubles me, is that Blanchard draws in what I would argue are normal feelings for some women who transition. His lack of understanding what makes a transsexual person tick clouds his judgment. This is purely his fault; he is purposefully obtuse on the subject.

    The conclusion I draw is that some of the people who think they are merely "AGP" are poorly served by this model. It lacks any true diagnostic power, and merely shuffles the truth untidily and sweeps it under a rug. "True AGP" as Blanchard describes it in men is probably related to the addictive response and highly correlated with people who have that tendency in other areas generally, such as food, drugs, etc. That, mixed with the specific "drug" of sex, is what creates the profound distress in these men who can't control the problem. The answer is to treat the addiction, not to shame as a sexual deviant.

    In transsexual women prior to transition, feelings that Blanchard describes will become highly problematic. She will misattribute what she is feeling to the Blanchard misdiagnosis, and not seek the treatment for her real problem.

    Neither of these populations are served well by Blanchard's model. The model itself depends heavily on a priori assumptions of "manhood" which simply aren't fact, and the conclusions drawn change based on point of view. I'd hardly call that scientific.

    The concept of AGP confuses rather than enlightens, and leads to shame and secrecy instead of a cure. Nobody benefits from this ad hoc construct but Blanchard and his career.

    PS

    ReplyDelete
  7. I believe that Madeline Wyndzen, in her critique of Bailey's book, said that Blanchard's original concept of the relationship of AGP to TS was that AGP-->Gender Identity Disorder-->Transsexual. Whereas Bailey simply said AGP-->Transsexual - and apparently Blanchard's now jumped onto that bandwagon. I agree with AriaBlue that this conclusion (AGP leads directly to TS/TG) is not helpful to either AGP or TS/TG's.

    I am NOT a Blanchard/Bailey fan in any way. I do, however, find it useful to identify AGP as a separate PHENOMENA unto itself. Separate from TS/TG, separate from transvestism, separate from fetish, separate from sex addiction. It has components of all of the above, but does not fall completely within any of those sets. I also believe that AGP MAY lead to GID, it may be a precursor in a truly TS woman, or it may NOT lead to either of those. Why it goes some ways in some and other ways in others, I don't know. But you have to define the phenomona to begin to work to identify a cause and/or "treatment" if that is what is warranted.

    Jack, you had once mentioned that it would be nice to come up with a different name for AGP. I completely agree! The association that AGP, the phenomena, has with AGP, the theory is not remotely useful to anyone. The phenomena has been recognized for far longer than Blanchard and Bailey have been around. Perhaps using an older term such as "automonosexuals" would be more beneficial - although I have to say I don't care for "automonosexuals", so maybe another one - how about Eonism? Are there any others?

    ReplyDelete
  8. To Susanne,

    Yes, we do need another name. Or maybe more: One for the underlying condition and one or more for what it causes: the various ways that condition can express itself.

    I'll come back to this in another blog post.

    ReplyDelete
  9. Thank you for your wonderful post! I'm doing a research paper for my abnormal psych class that's turning into a combo research/opinion paper.

    I wholeheartedly agree that the DSM V requires definition and classification. There's a lot of crap that just needs to be tossed out.

    My Focus is on BDSM as a paraphilia (and why it shouldn't be classified as one). I'm currently working on proving that it's not freaky, but different.

    ReplyDelete
  10. I have a question, Jack, arising from the last section of your post. When you say that you find the term autogynephilia “useful”, do you mean that we should retain it but narrow the definition to cover only the “separate category of transpeople” who fit the four criteria you list? Personally, I tick all those boxes, although I don’t think of myself as a “transperson”, as I shall be content to die in the same (male) body I was born in. When I first encountered the term, I was relieved to find a name for something I couldn’t define. Then I read a little of Blanchard’s work and was dismayed to find he had extrapolated from what was (possibly) an accurate insight to arrive at a universalizing theory which sounded highly implausible, thus threatening to obscure, or even invalidate, the original insight.

    Incidentally, you write so extensively and shrewdly on this subject – have you considered gathering your key postings into book form, so that we crossdreamers have something in print to counter the books by Bailey and Lawrence?

    Dabrela

    ReplyDelete
  11. @Dabrela

    Since I wrote this post I have stopped using the term "autogynephilia" for anything other as a description of Blanchard's theory.

    I have come to realize that the term carries too much toxic baggage. Besides, the term itself -- "love of one self as a woman" -- is misleading.

    That does not change the fact that there are people like us, who experience what many of Blanchard's patients have been experiencing, and we need a term to discuss this topic. This is why I now use the term "crossdreamers" instead.

    I do not think of crossdreamers as a separate category distinct from transgender or transsexuals.

    Some transgender and transsexuals experience crossdreaming, others not. There are also people who do not identify as transgender, but who nevertheless have crossdreamer fantasies.

    As I have noted elsewhere, I believe crossdreaming is the psyche's way of expressing a suppressed side of the personality, but the term is useful even if I am wrong about that.

    As for the book: Yes, I have considered collecting some of the blog posts into one or several books.

    However, I am not sure if I have the time or resources to get a book published by a regular publisher. That will take a lot of work, and I am not sure if they would publish a book like this under a pen name.

    I am looking into the possibility of making one or more ebooks, however, and maybe publish them on the Amazon Kindle and elsewhere.

    I would need a copy editor, though. English is not my mother tongue and there are too many grammatical errors in the texts as they now stand.

    Do you have any idea about how I could do this?

    ReplyDelete

Click here for this blog's Code of Conduct!

Discuss crossdreamer and transgender issues!