Blanchard's transsexualism typology

The American-Canadian sexologist Ray Blanchard proposed a psychological typology of gender dysphoria, transsexualism, and fetishistic transvestism in a series of academic papers through the 1980s and 1990s. Building on the work of earlier researchers, including his colleague Kurt Freund, Blanchard categorized trans women into two groups: homosexual transsexuals who are attracted exclusively to men and are feminine in both behavior and appearance; and autogynephilic transsexuals who experience sexual arousal at the idea of having a female body (autogynephilia). Blanchard and his supporters argue that the typology explains differences between the two groups in childhood gender nonconformity, sexual orientation, history of sexual fetishism, and age of transition.

Blanchard's typology has attracted significant controversy, especially following the 2003 publication of J. Michael Bailey's book The Man Who Would Be Queen, which presented the typology to a general audience. Scientific criticisms commonly made against Blanchard's research include that the typology is unfalsifiable because Blanchard and other supporters regularly dismiss or ignore data that challenges the theory, that it failed to properly control against cisgender women rather than against cisgender men in rating levels of autogynephilia, and that when such studies are performed they show that cisgender women have similar levels of autogynephilic responses to transgender women. The American Psychiatric Association includes with autogynephilia as a specifier to a diagnosis of transvestic disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2013); this addition was objected to by the World Professional Association for Transgender Health (WPATH), who argued that there was a lack of scientific consensus on and empirical evidence for the concept of autogynephilia.

Beginning in the 1950s, clinicians and researchers developed a variety of classifications of transsexualism. These were variously based on sexual orientation, age of onset, and fetishism.^[1] Prior to Blanchard, these classifications generally divided transgender women into two groups: "homosexual transsexuals" if sexually attracted to men and "heterosexual fetishistic transvestites" if sexually attracted to women.^[2] These labels carried a social stigma of mere sexual fetishism, and contradicted trans women's self-identification as "heterosexual" or "homosexual", respectively.^[2]

In 1982, Kurt Freund and colleagues argued there were two distinct types of trans women, each with distinct causes: one type associated with childhood femininity and androphilia (sexual attraction to men), and another associated with fetishism and gynephilia (sexual attraction to women).^{[1]: 533 [3]: 443} Freund stated that the sexual arousal in this latter type could be associated, not only with crossdressing, but also with other feminine-typical behaviors, such as applying make-up or shaving the legs.^[4]

Freund, four of his colleagues, and two other sexologists had previously published papers on "feminine gender identity in homosexual males" and "Male Transsexualism" in 1974.^[5][6] They occasionally also used the term homosexual transsexual to describe transgender men attracted to women.^[7] Blanchard credited Freund with being the first author to distinguish between erotic arousal due to dressing as a woman (transvestic fetishism) and erotic arousal due to fantasizing about being female (which Freund called cross-gender fetishism).^[3]: 443

Blanchard conducted a series of studies on people with gender dysphoria, analyzing the files of cases seen in the Gender Identity Clinic of the Clarke Institute of Psychiatry and comparing them on multiple characteristics.^{[8]: 10–15} These studies have been criticized as bad science for being unfalsifiable^[9] and for failing to sufficiently operationalize their definitions.^[10] They have also been criticized for lacking reproducibility, and for a lack of a control group of cisgender women.^[9][11] Supporters of the typology deny these allegations.^{[12][8]: 26}

Studying patients who had felt like women at all times for at least a year, Blanchard classified them according to whether they were attracted to men, women, both, or neither.^[3]: 444 He then compared these four groups regarding how many in each group reported a history of sexual arousal together with cross-dressing. 73% of the gynephilic, asexual, and bisexual groups said they did experience such feelings, but only 15% of the androphilic group did.^[8]: 10 He concluded that asexual, bisexual, and gynephilic transsexuals were motivated by erotic arousal to the thought or image of themself as a woman, and he coined the term autogynephilia to describe this.^[3]: 444

Blanchard and colleagues conducted a study in 1986 using phallometry (a measure of blood flow to the penis), demonstrating arousal in response to cross-dressing audio narratives among trans women. Although this study is often cited as evidence for autogynephilia, the authors did not attempt to measure subjects' ideas of themselves as women.^{[10]: 193 [13]} The authors concluded that gynephilic gender identity patients who denied experiencing arousal to cross-dressing were still measurably aroused by autogynephilic stimuli, and that autogynephilia among non-androphilic trans women was negatively associated with tendency to color their narrative to be more socially acceptable.^{[8]: 12–13} However, in addition to having methodological problems, the reported data did not support this conclusion, because the measured arousal to cross-dressing situations was minimal and consistent with subjects' self-reported arousal.^[13] This study has been cited by proponents to argue that gynephilic trans women who reported no autogynephilic interests were misrepresenting their erotic interests.^[13]

Blanchard's research and conclusions came to wider attention with the publication of popular science books on transsexualism, including The Man Who Would Be Queen (2003) by sexologist J. Michael Bailey and Men Trapped in Men's Bodies (2013) by sexologist and trans woman Anne Lawrence, both of which based their portrayals of male-to-female transsexuals on Blanchard's taxonomy.^[14][15][16] The concept of autogynephilia in particular received little public interest until Bailey's 2003 book, though Blanchard and others had been publishing studies on the topic for nearly 20 years.^[15] Bailey's book was followed by peer-reviewed articles critiquing the methodology used by Blanchard.^[15] Both Bailey and Blanchard have since attracted intense criticism by some clinicians and by many transgender activists.^{[14][15][17][18]: 366}

Sexologists may measure sexual orientation using psychological personality tests, self reports, or techniques such as photoplethysmography. Blanchard argues that self-reporting is not always reliable.^[19][20] Morgan, Blanchard and Lawrence have speculated that many reportedly "non-homosexual" trans women systematically distorted their life stories because "non-homosexuals" were often screened out as candidates for surgery.^[21]

Blanchard and Freund used the Masculine Identity in Females (MGI) scale and the Modified Androphilia Scale.^[22] Lawrence writes that homosexual transsexuals averaged a Kinsey scale measurement of 5–6 or a 9.86 ± 2.37 on the Modified Androphilia Scale.^[20][23]

The concept that androphilia in trans women is related to homosexuality in cisgender men has been tested by MRI studies.^[24][25] Cantor interprets these studies as supporting Blanchard's transsexualism typology.^[25] These studies show neurological differences between trans women attracted to men and cis men attracted to women, as well as differences between androphilic and gynephilic trans women. The studies also showed differences between transsexual and nontranssexual people, leading to the conclusion that transsexuality is "a likely innate and immutable characteristic".^[25]

According to a 2016 review, structural neuroimaging studies seem to support the idea that androphilic and gynephilic trans women have different brain phenotypes, though the authors state that more independent studies of gynephilic trans women are needed to confirm this.^[26] A 2021 review examining transgender neurology found similar differences in brain structure between cisgender homosexuals and heterosexuals.^[27]

Autogynephilia (derived from Greek for "love of oneself as a woman"^[13][a]) is a term coined by Blanchard^[14][28][15] for "a male's propensity to be sexually aroused by the thought of himself as a female",^[13][29] intending for the term to refer to "the full gamut of erotically arousing cross-gender behaviors and fantasies".^[13] Blanchard states that he intended the term to subsume transvestism, including for sexual ideas in which feminine clothing plays only a small or no role at all.^[30] Other terms for such cross-gender fantasies and behaviors include automonosexuality, eonism, and sexo-aesthetic inversion.^[28]

It is not disputed that autogynephilic sexual arousal exists and has been reported by both some transsexuals and some non-transsexuals.^[13][9][3] The disputed aspects of Blanchard's theories are the theory that autogynephilia is the central motivation for non-androphilic MtF transsexuals while being absent in androphilic ones, and his characterisations of autogynephilia, including as a paraphilia. Blanchard writes that the accuracy of these theories needs further empirical research to resolve,^[3]: 445 while others such as the transfeminist Julia Serano characterise them as incorrect.^[9]

Blanchard identified four types of autogynephilic sexual fantasy,^[28] but stated that co-occurrence of types was common.^{[31]: 72–73 [8]: 19–20}

• Transvestic autogynephilia: arousal to the act or fantasy of wearing typically feminine clothing
• Behavioral autogynephilia: arousal to the act or fantasy of doing something regarded as feminine
• Physiologic autogynephilia: arousal to fantasies of body functions specific to people regarded as female
• Anatomic autogynephilia: arousal to the fantasy of having a normative woman's body, or parts of one^{[31]: 72–73 [8]: 19–20}

The exact proposed nature of the relationship between autogynephilia and gender dysphoria is unclear, and the desire to live as a woman often remains as strong or stronger after an initial sexual response to the idea has faded.^[32] Blanchard and Lawrence argue that this is because autogynephilia causes a female gender identity to develop, which becomes an emotional attachment and something aspirational in its own right.^{[8]: 20–21}

Many transgender people dispute that their gender identity is related to their sexuality,^[33] and have argued that the concept of autogynephilia unduly sexualizes trans women's gender identity.^{[34]: 1729 [35]} Some fear that the concept of autogynephilia will make it harder for gynephilic or "non-classical" MtF transsexuals to receive sex reassignment surgery.^[36] Lawrence writes that some transsexual women identify with autogynephilia, some of these feeling positively and some negatively as a result, with a range of opinions reflected as to whether or not this played a motivating role in their decision to transition.^[8]: 55

In the first peer-reviewed critique of autogynephilia research, Charles Allen Moser found no substantial difference between "autogynephilic" and "homosexual" transsexuals in terms of gender dysphoria, stating that the clinical significance of autogynephilia was unclear.^[10]: 193 According to Moser, the idea is not supported by the data, and that despite autogynephilia existing, it is not predictive of the behavior, history, and motivation of trans women. ^[13] In a re-evaluation of the data used by Blanchard and others as the basis for the typology, he states that autogynephilia is not always present in trans women attracted to women, or absent in trans women attracted to men, and that autogynephilia is not the primary motivation for gynephilic trans women to seek sex reassignment surgery.^[13]

In a 2011 study presenting an alternative to Blanchard's explanation, Larry Nuttbrock and colleagues reported that autogynephilia-like characteristics were strongly associated with a specific generational cohort as well as the ethnicity of the subjects; they hypothesized that autogynephilia may become a "fading phenomenon".^[15][37]

Blanchard and Lawrence have classified autogynephilia as a sexual orientation.^[13][38] Blanchard attributed the notion of some cross-dressing men being sexually aroused by the image of themselves as female to Magnus Hirschfeld.^[39][29] (The concept of a taxonomy based on transsexual sexuality was refined by endocrinologist Harry Benjamin in the Benjamin Scale in 1966,^[40][41] who wrote that researchers of his day thought attraction to men while feeling oneself to be a woman was the factor that distinguished a transsexual from a transvestite (who "is a man [and] feels himself to be one").^[40]) Blanchard and Lawrence argue that just like more common sexual orientations such as heterosexuality and homosexuality, it is not only reflected by penile responses to erotic stimuli, but also includes the capacity for pair bond formation and romantic love.^{[31]: 73, 75 [8]: 20–21 [42]}

Later studies have found little empirical support for autogynephilia as a sexual identity classification,^[2] and sexual orientation is generally understood to be distinct from gender identity.^[43]: 94 Elke Stefanie Smith and colleagues describe Blanchard's approach as "highly controversial as it could erroneously suggest an erotic background" to transsexualism.^[44]: 262

Serano says the idea is generally disproven within the context of gender transition as trans women who are on feminizing hormone therapy, especially on anti-androgens, experience a severe drop and in some cases complete loss in libido. Despite this the vast majority of transgender women continue their transition.^[45]

Blanchard conjectured that sexual interest patterns could have inwardly instead of outwardly directed forms, which he called erotic target location errors (ETLE). Autogynephilia would represent an inwardly directed form of gynephilia, with the attraction to women being redirected towards the self instead of others. These forms of erotic target location errors have also been observed with other base orientations, such as pedophilia, attraction to amputees, and attraction to plush animals. Anne Lawrence wrote that this phenomenon would help to explain an autogynephilia typology.^[8]: 26

The concept of autogynephilia has been criticized for implicitly assuming that cisgender women do not experience sexual desire mediated by their own gender identity.^[2] Research on autogynephilia in cisgender women shows that cisgender women commonly^{[clarification needed]} endorse items on adapted versions of Blanchard's autogynephilia scales.^[46][47]

Moser created an Autogynephilia Scale for Women in 2009, based on items used to categorize MtF transsexuals as autogynephilic in other studies. A questionnaire that included the ASW was distributed to a sample of 51 professional cisgender women employed at an urban hospital; 29 completed questionnaires were returned for analysis. By the common definition of ever having erotic arousal to the thought or image of oneself as a woman, 93% of the respondents would be classified as autogynephilic. Using a more rigorous definition of "frequent" arousal to multiple items, 28% would be classified as autogynephilic.^[47]

Lawrence criticized Moser's methodology and conclusions and stated that genuine autogynephilia occurs very rarely, if ever, in cisgender women as their experiences are superficially similar but the erotic responses are ultimately markedly different.^[15][48] Moser responded that Lawrence had made multiple errors by comparing the wrong items.^[49] Lawrence argues that the scales used by both Veale et al. and Moser fail to differentiate between arousal from wearing provocative clothing or imagining that potential partners find one attractive, and arousal merely from the idea that one is a woman or has a woman's body.^[8]: 176

In a 2022 study, Bailey and Kevin J. Hsu dispute that "natal females" experience autogynephilia based on an application of Blanchard's original Core Autogynephilia Scale to four samples of "autogynephilic natal males", four samples of "non-autogynephilic natal males" and two samples of "natal females".^[50] Serano and Veale argue that Bailey and Hsu's results do not support their conclusion, because most "natal females" in their research reported at least some autogynephilic fantasies. Furthermore, Bailey and Hsu's "autogynephilic natal male" samples 1, 2, and 4 do not apply to trans people as the majority of the sample were cis crossdressers, not trans women. Sample 3, which was majority trans women, did not have high rates of autogynephilia compared to the other two samples. Serano and Veale also criticize Bailey and Hsu for leaving out two scales that played a central role in Blanchard's original conception of autogynephilia, saying that this implies a much narrower definition of autogynephilia which would have excluded many of Blanchard's original trans subjects.^[51]

Similar to Serano and Veale, Moser also criticizes Bailey and Hsu for mainly comparing the scores of cisgender women with cisgender male crossdressers instead of transgender women.^[52]

Critics of the autogynephlia hypothesis include transfeminists such as Julia Serano and Talia Mae Bettcher.^[2] Serano describes the concept as flawed, unscientific, and needlessly stigmatizing.^[53] According to Serano, "Blanchard's controversial theory is built upon a number of incorrect and unfounded assumptions, and there are many methodological flaws in the data he offers to support it."^[54] She argues that flaws in Blanchard's original studies include: being conducted among overlapping populations primarily at the Clarke Institute in Toronto without nontranssexual controls; subtypes not being empirically derived but instead "begging the question that transsexuals fall into subtypes based on their sexual orientation"; and further research finding a non-deterministic correlation between cross-gender arousal and sexual orientation.^[9] She states that Blanchard did not discuss the idea that cross-gender arousal may be an effect, rather than a cause, of gender dysphoria, and that Blanchard assumed that correlation implied causation.^[9]

Serano also states that the wider idea of cross-gender arousal was affected by the prominence of sexual objectification of women, accounting for both a relative lack of cross-gender arousal in transsexual men and similar patterns of autogynephilic arousal in non-transsexual women.^[9] She criticised proponents of the typology, claiming that they dismiss non-autogynephilic, non-androphilic transsexuals as misreporting or lying while not questioning androphilic transsexuals, describing it as "tantamount to hand-picking which evidence counts and which does not based upon how well it conforms to the model",^[9] either making the typology unscientific due to its unfalsifiability, or invalid due to the nondeterministic correlation that later studies found.^[9] Serano says that the typology undermined lived experience of transsexual women, contributed to pathologisation and sexualisation of transsexual women, and the literature itself fed into the stereotype of transsexuals as "purposefully deceptive", which could be used to justify discrimination and violence against transsexuals.^[9] According to Serano, studies have usually found that some non-androphilic transsexuals report having no autogynephilia.^[9]

Bettcher, based on her own experience as a trans woman, has critiqued the notion of autogynephilia, and "target errors" generally, within a framework of "erotic structuralism," arguing that the notion conflates essential distinctions between "source of attraction" and "erotic content," and "(erotic) interest" and "(erotic) attraction," thus misinterpreting what she prefers to call, following Serano, "female embodiment eroticism." She maintains that not only is "an erotic interest in oneself as a gendered being," as she puts it, a non-pathological and indeed necessary component of regular sexual attraction to others, but within the framework of erotic structuralism, a "misdirected" attraction to oneself as postulated by Blanchard is outright nonsensical.^[55] Activist and law professor Florence Ashley writes that the autogynephilia concept has been "discredited", and that Bailey's and Blanchard's work "has long been criticised for perpetuating stereotypes and prejudices against trans women, notably suggesting that LGBQ trans women's primary motivation for transitioning is sexual arousal."^[56]

The concept that trans people with different sexual orientations are etiologically different goes back to the 1920s,^{[57][58][40][59]} but the terms used have not always been agreed on.^[58][40]

Blanchard said that one of his two types of gender dysphoria/transsexualism manifests itself in individuals who are almost if not exclusively attracted to men, whom he referred to as homosexual transsexuals.^[60] Blanchard uses the term "homosexual" relative to the person's sex assigned at birth, not their current gender identity.^[13] This use of the term "homosexual" relative to the person's birth sex has been heavily criticized by other researchers.^{[61][58][62][63][64][40]} It has been described as archaic^[57] confusing,^[23][59][65] demeaning,^[66] pejorative,^[23] offensive,^[62][67] and heterosexist.^[58] Benjamin states that trans women can only be "homosexual" if anatomy alone is considered, and psyches are ignored; he states that after sex-reassignment surgery, calling a male-to-female transsexual "homosexual" is pedantic and against "reason and common sense".^[68] Many authorities, including some supporters, criticize Blanchard's choice of terminology as confusing or degrading because it emphasizes trans women's assigned sex, and disregards their sexual orientation identity.^[26] Leavitt and Berger write that the term is "both confusing and controversial" and that trans women "vehemently oppose the label and its pejorative baggage."^[23]

In 1987, this terminology was included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) as "transsexual, homosexual subtype".^[57][63] The later DSM-IV (1994) and DSM-IV-TR (2000) stated that a transsexual was to be described as "attracted to males, females, both or neither".^[63]

Blanchard defined the second type of transsexual as including those who are attracted almost if not exclusively to females (gynephilic), attracted to both males and females (bisexual), and attracted to neither males nor females (asexual); Blanchard referred to this latter set collectively as the non-homosexual transsexuals.^[69][70] Blanchard says that the "non-homosexual" transsexuals (but not the "homosexual" transsexuals) exhibit autogynephilia,^[60] which he defined as a paraphilic interest in having female anatomy.^[29][30]

Professor of anatomy and reproductive biology Milton Diamond proposed the use of the terms androphilic (attracted to men) and gynephilic (attracted to women) as neutral descriptors for sexual orientation that do not make assumptions about the sex or gender identity of the person being described, alternatives to homosexual and heterosexual.^{[citation needed]} Frank Leavitt and Jack Berger state that the label homosexual transsexual seems to have little clinical merit, as its referents have "little in common with homosexuals, except a stated erotic interest in males"; they too suggest "more neutral descriptive terms such as androphilia".^[23][21] Sexological research has been done using these alternative terms by researchers such as Sandra L. Johnson.^[71] Both Blanchard and Leavitt used a psychological test called the "modified androphilia scale" to assess whether a transsexual was attracted to men or not.^[4][23] Sociologist 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."^[62]

According to the typology, autogynephilic transsexuals are attracted to femininity while homosexual transsexuals are attracted to masculinity. However, a number of other differences between the types have been reported. Cantor states that "homosexual transsexuals" usually begin to seek sex reassignment surgery (SRS) in their mid-twenties, while "autogynephilic transsexuals" usually seek clinical treatment in their mid-thirties or even later.^[32] Blanchard also states that homosexual transsexuals were younger when applying for sex reassignment, report a stronger cross-gender identity in childhood, have a more convincing cross-gender appearance, and function psychologically better than "non-homosexual" transsexuals.^[60] A lower percentage of those described as homosexual transsexuals report being (or having been) married, or report sexual arousal while cross-dressing.^[72] Bentler reported that 23% of homosexual transsexuals report a history of sexual arousal to cross-dressing, while Freund reported 31%.^{[73][23][74][75]} In 1990, using the alternative term "androphilic transsexual", Johnson wrote that there was a correlation between social adjustment to the new gender role and androphilia.^[71]

Anne Lawrence, a proponent of the concept,^[16][76] argues that homosexual transsexuals pursue sex reassignment surgery out of a desire for greater social and romantic success.^[13] Lawrence has proposed that autogynephilic transsexuals are more excited about sexual reassignment surgery than homosexual transsexuals. She states that homosexual transsexuals are typically ambivalent or indifferent about SRS, while autogynephilic transsexuals want to have surgery as quickly as possible, are happy to be rid of their penis, and proud of their new genitals.^[42] Lawrence states that autogynephilia tends to appear along with other paraphilias.^[31]: 79 J. Michael Bailey argued that both "homosexual transsexuals" and "autogynephilic transsexuals" were driven to transition mainly for sexual gratification, as opposed to gender-identity reasons.^[14]

Blanchard and Zucker state that birth order has some influence over sexual orientation in male-assigned people in general, and androphilic trans women in specific.^[77][78][79] This phenomenon is called the "fraternal birth order effect".^[78] In 2000, Richard Green reported that androphilic trans women tended have a later-than-expected^{[clarification needed]} birth order, and more older brothers than other subgroups of trans women. Each older brother increased the odds that a trans woman was androphilic by 40%.^[79]

Blanchard's typology is mainly concerned with transgender women.^[16] Richard Ekins and Dave King state that female-to-male transsexuals (trans men) are absent from the typology,^[16] while Blanchard, Cantor, and Katherine Sutton distinguish between gynephilic and androphilic trans men. They state that gynephilic trans men are the counterparts of androphilic trans women, that they experience strong childhood gender nonconformity, and that they generally begin to seek sex reassignment in their mid-twenties. They describe androphilic trans men as a rare but distinct group who say they want to become gay men, and, according to Blanchard, are often specifically attracted to gay men. Cantor and Sutton state that while this may seem analogous to autogynephilia, no distinct paraphilia for this has been identified.^{[32]: 603–604 [80]}

In 2000, Meredith L. Chivers and Bailey wrote, "Transsexualism in genetic females has previously been thought to occur predominantly in homosexual (gynephilic) women." According to them, Blanchard reported in 1987 that only 1 in 72 trans men he saw at his clinic were primarily attracted to men. They observed that these individuals were so uncommon that some researchers thought that androphilic trans men did not exist, or misdiagnosed them as homosexual transsexuals, attracted to women. They wrote that relatively few studies had examined childhood gender variance in trans men.^[7]

In a 2005 study by Smith and van Goozen, their findings in regards to trans men were different from their findings for trans women.^[72] Smith and van Goozen's study included 52 female-to-male transsexuals, who were categorized as either homosexual or non-homosexual. Smith concluded that female-to-male transsexuals, regardless of sexual orientation, reported more GID symptoms in childhood, and a stronger sense of gender dysphoria. Smith wrote that she found some differences between homosexual and non-homosexual female-to-male transsexuals. Smith says that homosexual female-to-males reported more gender dysphoria than any group in her study.^[72]

In the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (1980), the diagnosis of "302.5 Transsexualism" was introduced under "Other Psychosexual Disorders". This was an attempt to provide a diagnostic category for gender identity disorders.^[81] 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.^[82] The subtypes were asexual, homosexual (same "biological sex"), heterosexual (other "biological sex") and unspecified.^[81] 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.^[83]

The DSM-IV-TR included autogynephilia as an "associated feature" of gender identity disorder^[11] and as a common occurrence in the transvestic fetishism disorder, but does not classify autogynephilia as a disorder by itself.^[84]

The paraphilias working group on the DSM-5, chaired by Ray Blanchard, included both with autogynephilia and with autoandrophilia as specifiers to transvestic disorder in an October 2010 draft of the DSM-5. This proposal was opposed by the World Professional Association for Transgender Health (WPATH), citing a lack of empirical evidence for these specific subtypes.^{[85][86][10]: 201} WPATH argued that there was no scientific consensus on the concept, and that there was a lack of longitudinal studies on the development of transvestic fetishism.^[85] With autoandrophilia was removed from the final draft of the manual. Blanchard later said he had initially included it to avoid criticism: "I proposed it simply in order not to be accused of sexism [...] I don't think the phenomenon even exists."^[87] When published in 2013, the DSM-5 included With autogynephilia (sexual arousal by thoughts, images of self as a female) as a specifier to 302.3 Transvestic disorder (intense sexual arousal from cross-dressing fantasies, urges or behaviors); the other specifier is With fetishism (sexual arousal to fabrics, materials or garments).^[88]

In the 2010 U.S. Tax Court case O'Donnabhain v. Commissioner, the Internal Revenue Service cited Blanchard's typology as justification for denying a transgender woman's tax deductions for medical costs relating to treatment of her gender identity disorder, claiming the procedures were not medically necessary.^[89] The court found in favor of the plaintiff, Rhiannon O'Donnabhain, ruling that she should be allowed to deduct the costs of her treatment, including sex reassignment surgery and hormone therapy.^[90] In its decision, the court declared the IRS's position "at best a superficial characterization of the circumstances" that was "thoroughly rebutted by the medical evidence".^[91][92]

According to the Southern Poverty Law Center (SPLC), autogynephilia has been promoted by anti-LGBT hate groups.^[93][94][95] These include the Family Research Council (FRC), United Families International (UFI), and the American College of Pediatricians (ACPeds).^[93][94][95] Both Blanchard and Bailey have written articles for 4thWaveNow, which the SPLC describes as an anti-trans website.^[93]

Nic Rider and Elliot Tebbe characterize Blanchard's theory of autogynephilia as an anti-trans theory that functions to invalidate and delegitimize transgender individuals.^[96]

Serano writes that trans-exclusionary radical feminists, self-described as "gender-critical" feminists, have embraced the idea of autogynephilia beginning in the 2000s.^[53] One early proponent of autogynephilia was radical feminist Sheila Jeffreys.^[53] The concept has been used to imply that trans women are sexually deviant men.^[53][97] The concept of autogynephilia became popular on gender-critical websites such as 4thWaveNow, Mumsnet, and the Reddit community /r/GenderCritical.^[53]

• Classification of transsexual and transgender people
• Autoeroticism
• Partialism
• Transgender sexuality
• List of transgender-related topics

The dictionary definition of autogynephilia at Wiktionary