Ray Blanchard, Head of the Clinical Sexology Program of the Clarke Institute of Psychiatry in Toronto, knows more about transsexualism than just about anyone else. Like so many sex researchers, Blanchard's introduction to sex research was fortuitous rather than intentional. A rat psychologist by training, his first job was as a clinical psychologist at the Ontario Correctional Institute. He worked full time evaluating and treating inmates and was miserable. "I didn't want to spend 100 percent of my time as a front-line clinician. I wanted to make a scientific contribution. Plus, the prison environment was stressful, if never dull." During that time, the eminent sex researcher, Kurt Freund, consulted at the hospital. Someone suggested that they meet, and during their first conversation, they made plans to collaborate. In 1980 Blanchard took a job at the Clarke, where he has remained, recently taking Freund's position after his death.

Blanchard is irreverent, cynical, and politically incorrect. During the opening ceremony of the International Academy of Sex Research, during the eulogies for members who died during the previous year, he regularly engages in wickedly entertaining whispered commentary about the deceased, unsentimentally recalled. (His eulogy for Freund, however, was serious and touching.) He has little patience for arguments about whether research is good for people (such as "Are homosexual people hurt or harmed by research on the genetics of sexual orientation?"), preferring instead to dwell on whether scientific findings are true. A transsexual colleague of Blanchard's tells how she once sought his advice regarding a professional dilemma. A member of a task force about transsexualism, she disliked the first draft of their report, but was worried she would offend the other (nontranssexual) members of the committee. Blanchard's characteristic advice: "What's the point of being a sacred cow if you don't moo?"

Academics remember each other by their "contributions," or ideas that make a mark, ideas that get the attention of other academics, motivating others to study the same thing. Blanchard has made two contributions so far. His most recent work has shown convincingly that gay men tend to have more older brothers compared with heterosexual men, and he is pursuing an interesting biological theory to account for this. But I think his more revolutionary contribution has been to the classification and explanation of transsexualism. In a series of articles beginning in 1985 and continuing for about a decade, Blanchard established that there are two very different types of men who change into women, who have very different presentations, motivations, and probably, causes. Blanchard's observations transformed male-to-female transsexualism from a seemingly chaotic and bizarre collection of phenomena into two straightforward and clinically comprehensible patterns.

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When Ray Blanchard began studying and treating transsexuals during the early 1980s, the field was rife with different confusing diagnostic typologies, including anywhere from one to four kinds of transsexuals. At a merely descriptive level, most clinicians saw a similar array of gender patients. First was the kind of transsexual that most of us think of when we hear "transsexual," the classic, homosexual type, like Terese. From soon after birth, these males behaved like, and desired to be, female. No one who spent much time with them could be very surprised that eventually they would choose sex reassignment surgery. Of all transsexual types, this was the one that most seemed to consist of "women trapped in men's bodies."

Another type of transsexual that specialists recognized, but which is less familiar and comprehensible to most people, was the heterosexual transsexual. These males frequently came to treatment as married men who claimed to have had hidden or suppressed longstanding wishes to be female that they could no longer deny. The clinical picture of this type was much different than the homosexual transsexual. Obviously, of course, one was attracted to men and the other to women, but there was another striking difference. Most heterosexual transsexuals, and virtually no homosexual transsexuals reported a phase beginning during adolescence, in which they secretly wore women's clothing such as lingerie, became sexually aroused, and masturbated. Cher has a history that is characteristic of many heterosexual transsexuals. However, she has had sexual fantasies about both men and women, and has had sex with both. She is bisexual.

There was at least one other type of transsexual that experts wrote about, one that presented a much fuzzier picture. This was a transsexual type whose sexuality was either unclear or absent. These transsexuals claimed to be attracted to neither women nor men, and some of them claimed to have no sexual feelings at all. Some called this type "asexual."

To make matters more complicated, there were at least two other types of man who cross-dressed, but who did not want sex changes. Drag queens were gay men who cross-dressed in public, often for the purpose of entertainment (especially lip synching and dancing to music). Transsexualism researchers knew that drag queens existed, but did not know much about them, because drag queens did not often seek treatment for their cross-dressing; it caused them no problems. The other group of men who cross-dressed were called transvestites. These were heterosexual men, typically married, who dressed in women's clothing without any intention of getting a sex change. Like heterosexual transsexuals, they frequently acknowledged an erotic component to their cross-dressing, at least during adolescence. The official psychiatric diagnostic manual of the time, The Diagnostic and Statistical Manual of Mental Disorders(DSM III-R) called heterosexual transvestism "transvestic fetishism," and put it in an entirely different section of disorders from transsexualism. The diagnostic label implied that transvestites are motivated by an erotic connection to women's clothing. Heterosexual transvestites are an important part of this story, and they are probably far more common than transsexuals (no one knows for sure). So before proceeding, let's meet one.

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Stephanie Braverman is, despite the name, a 50-ish married man who holds a high-level position in a national bank, and whose wife is a well-known administrator in a local university. When Stephanie is a man-which is most of the time-that man is named "Don." I have never met Don. Stephanie always looks the same, dressed in tastefully elegant style-wig, makeup, and all-as a middle-aged matron. After reading about my interest in gender in a newspaper article, Stephanie called me to "educate" me about heterosexual cross-dressers. We have met several times, and I have learned much. Still, we disagree fundamentally (if good-naturedly) about many things related to cross-dressing. One thing we mostly agree on, however is her basic story.

Stephanie remembers Don having early (age six or so), vague wishes to be a girl, but does not think that others found him remarkably feminine. In adolescence, Don periodically wore his mother's lingerie, looked in a mirror, and masturbated. He felt ashamed and guilty about cross-dressing, and tried to stop several times, but each time was unable to refrain for long. In his early 20s, he met the woman he would marry. Before proposing, he told her about his cross-dressing and said that he intended to stop. His future wife, in love with him by then, did not even pause to reconsider her commitment. They have had, by most appearances, a successful marriage, with three children. Several times, during the marriage, Don "purged," throwing away all his women's clothing and vowing to quit cross-dressing. (Over all his purges, Don probably threw away several thousand dollars worth of clothing.) Following each purge, he felt relieved and virtuous for a time, but these feelings eventually transformed into irritability, tension, and despair. Each time, Don gave in to his cross-dressing urges. After his last (and final, Stephanie hopes) purge attempt failed, he sought counseling, and his therapist helped him find the Chicago chapter of Society for the Second Self (or Tri-Es), an organization for heterosexual cross-dressers. Stephanie has become a leader in the chapter, and speaks frequently (and always as Stephanie) to college students and other receptive audiences. She wants ultimately to diminish the stigma felt by cross-dressers.

Stephanie claims that the erotic component of cross-dressing was never Don's primary motivation-which was the expression of an inner femininity-and that he rarely feels aroused any more when cross-dressed. Once in a while, a glimpse in the mirror of how good Don looks as Stephanie (especially his legs) gives him an erection, but this is more annoying than satisfying. Stephanie insists that the primary benefit of cross-dressing these days is relaxation. When business and family duties prevent Don from cross-dressing for much longer than two weeks, he feels tense and irritable. To me, it sounds as if Don's cross-dressing was at one time primarily sexually motivated, and indeed I suspect it still is to a large extent. This is our ongoing argument, and I will return to it.

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Diagnosis can advance by either splitting or lumping. Splitting occurs when someone notices two or more superficially similar conditions that had previously been called the same thing. The history of medical diagnosis has mostly been a story about splitting. Some early classification systems, for example, included the category "fever," which subsumed every problem that caused a temperature. In contrast, modern diagnosis distinguishes thousands of conditions that cause fever, from chicken pox to Ebola.

More rarely, diagnosis progresses by lumping. Lumping occurs when two or more apparently different conditions are found to be different forms of the same, underlying pathology. In the early history of AIDS, doctors noticed an increase in a variety of seemingly unrelated conditions, such as pneumocystitis carinii pneumonia, Kaposi's sarcoma, and cytomegalovirus retinitis, among gay men. Eventually, they hypothesized that these were all consequences of the same infection, and when it was possible to test for HIV, its presence was confirmed in virtually all cases.

Ray Blanchard's contribution to transsexual science was of the lumping variety. Distinguishing "homosexual," "heterosexual," "bisexual," and "asexual" transsexuals diagnostically makes sense only if the different types have fundamentally different causes. Otherwise, why not distinguish "tall," "medium-sized," and "short" transsexuals, or "blonde" and "brunette" subtypes? Blanchard noticed some similarities between some of the subtypes that made him suspect that they were fundamentally similar. In particular, the homosexual subtype seemed different from all the others, who seemed similar in important respects. (In order to avoid wordiness, he called the heterosexual, bisexual, and asexual transsexuals the "nonhomosexual" transsexuals.)

For one, the nonhomosexual types were older when they came to the Clarke Institute for treatment. This was partly due to the fact that many of them had postponed their gender concerns to raise families. But even the asexual subtype, who was typically unmarried, came to treatment later than the homosexual subtype. On average, the nonhomosexual types showed up at the Clarke eight years later than the homosexual type. The nonhomosexual types also gave somewhat different childhood histories than the homosexual type, who universally acknowledged marked and noticeable femininity from early on. In contrast, many of the nonhomosexual types said that they were unremarkably masculine boys, though they typically reported early memories of secret longing to be girls.

The most noteworthy difference between the homosexual and nonhomosexual transsexuals concerned cross-dressing. Homosexual transsexuals recalled that they cross-dressed from early on, but few of them reported that cross-dressing provoked a sexual response. Most nonhomosexual transsexuals admitted sexual arousal to cross-dressing, at least in the past. Even the asexual subtype did so.

Blanchard made a good case that "heterosexual," "bisexual," and "asexual" transsexuals were more like each other than like homosexual transsexuals, and he suspected that they were subtypes of a more general condition. But what general condition? Then Blanchard saw a patient named Philip, who proved to be the exception that revealed the rule.

Philip was a 38-year-old unmarried business executive who was referred to the Clarke Institute of Psychiatry because of the persistent wish to be a woman, accompanied by depression that he was not one. Philip was a happy, masculine boy, who was popular and competent. Philip had cross-dressed only once in his life, at age six. Although he lived alone and could cross-dress easily, he simply had no desire to do so. Since puberty, he had masturbated fantasizing that he was a nude woman, lying alone in his bed. He would focus on the picture of having breasts, a vagina, and other female physical characteristics. Although Philip had had sex with several women, there were indications that this was not especially rewarding to him. In his only long-term relationship, he stopped having sex with his girlfriend after only a few months. In his last time with a woman, he had difficulty getting an erection. He has never had sex with a man. However, he had begun to fantasize about having intercourse with a man, as a woman. The man in his fantasies was a faceless abstraction rather than a real person. Philip never fantasized about having gay sex with a man, as a man.

Philip was near the borderline of nonhomosexual transsexualism, but he lacked a cardinal sign of that disorder, a history of erotic cross-dressing. It dawned on Blanchard that what Philip had in common with most nonhomosexual transsexuals, as well as cross-dressers for that matter, was sexual arousal at the idea of himself as a woman. This strange sexual desire-for oneself to be transformed into a woman-seemed to be the fundamental motivation for nonhomosexual transsexualism. Blanchard called it "autogynephilia" (pronounced Otto-guy-nuh-feel-ee-ya). "Gynephilia" means attraction to women, and "auto" means self. Autogynephilia accounts for a variety of phenomena that seem otherwise disconnected.

Take cross-dressing. At the time that Blanchard came up with autogynephilia, the prevailing explanation of erotic cross-dressing was that it was like a fetish, a mere association of sexual arousal with inanimate objects. But there were obvious problems with this conceptualization. Most men find garter belts and bras to be sexy, probably because of their association with scantily clad women, but most men do not put them on and look at themselves in the mirror. Nor do cross-dressers merely wear women's clothing. While cross-dressed, they typically pretend to be women: taking female names, trying to walk and sometimes talk like women. According to Blanchard, even cross-dressers who do not want to change their sex have autogynephilia, which they share with nonhomosexual transsexuals. This is sensible because during the teenage years, it is probably impossible to distinguish males who will become nonhomosexual transsexuals from those who will remain cross-dressers. They are all autogynephiles.

Autogynephilia also accounts for the homosexual-like fantasies of some autogynephilic (i.e., nonhomosexual) transsexuals. These fantasies are quite unlike the homosexual fantasies of gay men and homosexual transsexuals. They do not focus on characteristics of the male partner, but on the transsexual's female self interacting with the male. Stephanie, the cross-dresser, once told me a fantasy she had been having about me. In her fantasy, I would treat her "like a lady,"-take her out to a nice restaurant and then out dancing. She reassured me that she did not want to do anything sexual with me (and I had never sensed that she was sexually attracted to me). As she told me about the fantasy, however, it was clearly an erotic one. But in contrast to gay men's fantasies about other men, I was merely a prop in Stephanie's; I could have been any male. Even in more explicitly sexual fantasies, the male usually has no face, just a penis and body, which penetrates the imagined vagina. To many autogynephiles, the act of being penetrated by a penis is the ultimate statement that one is a woman, and this is perhaps why it is so arousing to some autogynephiles (such as Cher).

Blanchard noticed different forms of autogynephilia in the different patients he saw. Some patients were sexually aroused by cross-dressing, others by the fantasy that they were pregnant, others by the fantasy that they had breasts, and others by the fantasy that they had vaginas. One patient even masturbated while fantasizing about knitting in a circle of other knitting women or being at the hairdressers with other women.

Blanchard hypothesized that the type of autogynephilia that a man has should predict whether the man would become transsexual. A cross-dresser with only transvestitic or behavioral autogynephilia can probably satisfy his urges by periodically cross-dressing in private or in the company of other transvestites. But a man whose primary fantasy is having a vulva cannot enact his fantasy so easily. (Not everyone is as creative as Cher, and eventually, wearing fake vaginas did not work for her either.) Blanchard confirmed that, indeed, it was men who fantasized about themselves as nude women, and who focused on the image of having a vulva, who felt the strongest desire to change their sex. He also found that patients who fantasized about themselves as nude women were younger at their first appointment compared with those patients who fantasized about themselves wearing women's clothing. This suggests that autogynephilic transsexualism is not merely a progression from cross-dressing. If it were, the patients who fantasized about cross-dressing should have been younger, not older (because by the incorrect interpretation, they would not have yet advanced to the "nude fantasizing" stage of their condition).

Once Blanchard asked a group of autogynephilic transsexuals: "Suppose you had the following choice. You could get your sex reassignment surgery but continue to live as a man forever or live as a woman but never obtain sex reassignment surgery. Which would you do?" About half of the group chose each alternative. Those whose autogynephilia focused on the vagina chose the surgery, and those focused on the female role chose the role change. Of course, most autogynephilic transsexuals want both.

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How are we to think of autogynephilic men? Are they more like gay men, or like heterosexual men? Do they really have a woman hidden inside them? If so, why do they hide their inner femininity, when some gay men, drag queens, and homosexual transsexuals are extremely and openly feminine from an early age?

The word "autogynephilia" is difficult, even jarring, and this is appropriate-the concept it names is bizarre to most people. In order to understand autogynephilia, it is important to recognize that it differs so much from ordinary experience that it cannot be understood simply. For example, even heterosexual people can understand homosexuality by thinking, more or less accurately, "It's just as if I were attracted to my own sex instead of the other sex." Autogynephiles are more difficult to fathom.

Blanchard believes that autogynephilia is best conceived as misdirected heterosexuality. These men are heterosexual, but due to an error in the development of normal heterosexual preference, the erotic target (a woman) gets located on the inside (the self) rather than the outside. This is speculative, and what causes the developmental error is anyone's guess.

Autogynephilia is not primarily a disorder of gender identity, except in the obvious sense that the goal of the transsexual is to become the other sex. At the cross-dressers' meeting I attended, the wife of one of the men asked me: "When they say they feel like women, how do they know what that feels like?" This question, which reflected the woman's skepticism about the men's account, is profound. How do we ever know that we are like someone else? Unless you believe in extrasensory perception (and I don't), the answer must be found in overt behavior, which somehow signals fundamental similarity. Evidently, the woman did not get those signals from the men. (If instead of being the wife of an autogynephile, she were the sister of a homosexual transsexual, I doubt she would have asked an analogous question.) The fact is that despite their obsession with becoming women, autogynephilic transsexuals are not especially feminine. One told me, for example:

I had a fairly early onset (certainly before age six) of an intense desire to be a girl (or "like a girl") physically; or to put it another way, to be female--but not necessarily to take on the feminine gender role. This took different forms as I grew older. To a six-year old, the difference between boys and girls physically is not primarily genital: girls wear long hair and dresses, and that's what I wanted. As I got older, I grew to want other things: breasts, a vagina, menstruation, pregnancy. In the early stages the dysphoria wasn't painful, like a wound; it was more like a yearning for the unobtainable, like a thirst I couldn't quench.

However, I didn't play with dolls, nor do many of the traditional feminine things that the classic primaries often report. I didn't like to compete athletically, and I was always afraid of getting hurt; but I liked model cars and airplanes, and toy guns, too.

This contrasts greatly with the childhood histories of homosexual transsexuals, whose femininity was remarkable to anyone who observed them closely. Nor are autogynephiles especially feminine adults. After all, most have been married, and to most observers, appear to be conventional husbands. Autogynephiles rarely have stereotypically female occupations. On the contrary, many have served in the military. I even met one who was in the Green Berets. Technological and scientific careers seem to me to be over-represented among autogynephiles. (Ray Blanchard remarked to me that he saw a seemingly close relation between autogynephilia and computer nerdiness.) Autogynephiles have claimed that they chose stereotypically masculine occupations to hide their feminine side, but I doubt this. It seems more consistent with the overall picture to say that autogynephilia is not associated with stereotypically feminine interests. Finally, autogynephiles do not typically look or act very feminine, especially in comparison with homosexual transsexuals. To the extent that autogynephiles achieve a feminine presentation, it is with great effort. Cross-dressers attend workshops in talking, walking, standing, and gesturing like women. The work usually pays off eventually in a passable feminine presentation, but it is work.

Autogynephiles are not "women trapped in men's bodies." (Anne Lawrence, a physician and sex researcher who is herself a postoperative transsexual, has called them "men trapped in men's bodies.") Homosexual transsexuals, so naturally feminine from early on, can make this claim more accurately, but as we shall see, it is not completely true even of them. Autogynephiles are men who have created their image of attractive women in their own bodies, an image that coexists with their original, male selves. The female self is a man-made creation. They visit the female image when they want to have sex, and some became so attached to the female image that they want it to become their one, true self. This explains the name of the transvestite organization "Society for the Second Self." It also explains the maddening tendency of some autogynephilic research subjects to put down two answers to every question-one by the female self, and one by the male self. Homosexual transsexuals do not do this. They have one self that is a mixture of masculine and feminine traits, and not alternating selves. No, autogynephiles are not women trapped in men's bodies. They are men who desperately want to become women.

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We do not have even the beginnings of a respectable theory of the causes of autogynephilia. This differs from sexual orientation, in which we have a reasonably well articulated if unproven theory. Recall from Chapters 3 and 6 that femininity in boys and homosexuality in men is probably caused by incomplete masculinization of the brain during sexual differentiation.

Autogynephilia in the form of cross-dressing is still called "transvestic fetishism" in the DSM IV-TR, and many people have suggested that fetishism arises as a kind of conditioning experience. As the guy at the cross-dressers' meeting put it, panties are sexy, so some men become aroused wearing them. The problem with this account is that although it might explain a fetish for panties, it does not explain why men should want to wear the panties. Conditioning explanations of both sexual preferences and fears (the other domain where they are common) have received little convincing support, although many people believe them. Blanchard's conceptualization of cross-dressing, as arousal to an image of oneself as a woman, is very different from the idea of a fetish. Conceptualized Blanchard's way, it is difficult to see how cross-dressing could arise through conditioning.

Some autogynephiles claim that their first cross-dressing experience was in the context of being punished (usually by some female friend or relative, who forced them to cross-dress to humiliate them), and that this is how they acquired their taste for cross-dressing. I find these reports dubious. They sound more like fantasies or attempts to explain their behavior in ways that sound plausible to others. In any case, the fact that most autogynephiles do not claim these experiences suggests that they cannot be causally crucial.

Regarding the fundamental question of whether autogynephiles are born or made, my intuitions are with "born." Perhaps every day, in this country, at least one adolescent boy by himself puts on his mother's or sister's lingerie, becomes sexually aroused, and masturbates. As far as anyone can tell, there is nothing unusual about the environments of these boys, and certainly nothing in their environments obviously contributes to their unusual preoccupation. This smells innate to me. (I do not claim to be making a strong case here.)

Anecdotally, I have heard several accounts of first-degree relatives (brothers, or fathers and sons) who discovered that both were cross-dressers. The discovery was invariably after both relatives had a great deal of cross-dressing experience, which they had hidden from each other. This smells genetic to me. Again, though, this is not meant to be a strong argument.

Autogynephilic cross-dressing usually begins in late childhood or early adolescence, but this does not mean that it is not biological. (Pubic hair also begins at adolescence.) Some autogynephiles claim that they have early memories of their condition, such as the desire to be female. I have tended to be skeptical about these memories, but a recent case seen by psychologist Ken Zucker at the Clarke Institute has made me more open-minded. This was a three-year-old boy whose mother had brought him in to the clinic because of his cross-dressing, which she first observed at around age two. According to the mother, the boy wore her or his sisters' underwear, lingerie, slips, and nighties. The mother also reported that (at age three!) he got erections when looking at women's clothing in magazine advertisements, and he would demand that she buy the items he was viewing. His cross-dressing was sporadic, rather than continuous, and it did not appear to reflect early femininity-he did not say he wanted to be a girl or have other feminine interests, for example. The most fascinating development came when Zucker interviewed the father, who admitted that he had cross-dressed erotically since adolescence. There was no indication that the boy had ever seen his father do this or had any opportunity to learn the behavior from him. I predict (as does Zucker) that when he grows up, the boy is very likely to have some variety of autogynephilia. His early onset also smells biological, though as I stressed, early onset is not a necessary component of innate behavior.

Highly relevant to the nature-nurture question is whether autogynephilia has occurred in most cultures and times. In fact, there is only very limited evidence about its occurrence prior to Magnus Hirschfeld's classic work, Die Transvestiten, published in 1910. There are a few more-or-less definitive accounts, such as the AbbÈ de Choisy, who lived in France from 1644 until 1724. Although the historical record does not document Choisy's masturbatory habits (he was, after all, a cleric), it is clear that he was a heterosexual cross-dresser. He was romantically drawn to women, whom he preferred dressed as men. In fact, he once arranged a marriage ceremony in which he dressed as the bride, and the woman as the groom. He clearly experienced cross-dressing, and particularly being admired as a woman, as erotic. He had periods in which he felt guilty about his unusual preoccupation and purged, just as contemporary cross-dressers do.

The cross-cultural occurrence of autogynephilia has not been well established (in contrast to homosexual transsexualism, which has been). This is not surprising. It is probably rare, secretive, and poorly understood. On the other hand, I expect that it occurs everywhere. Blanchard has seen autogynephilic transsexualism in immigrants from Europe and Asia.

In order to progress scientifically toward the causes of autogynephilia, it will be useful to keep in mind that autogynephilia seems to be a type of paraphilia. Paraphilias comprise a set of unusual sexual preferences that include autogynephilia, masochism, sadism, exhibitionism (i.e., exposing one's genitals to strangers for sexual excitement), frotteurism (rubbing oneself against strangers, such as in a crowded bus, for sexual excitement), necrophilia, bestiality, and pedophilia. Because some of these preferences (especially pedophilia) are harmful, I hesitated to link them to autogynephilia, which is not harmful. But there are two reasons to think that these sexual preferences have some causes in common. First, all paraphilias occur exclusively (or nearly exclusively) in men. Second, paraphilias tend to go together. If a man has one paraphilia, then his chances of having any other paraphilia seem to be highly elevated. The best established link is between autogynephilia and masochism. There is a dangerous masochistic practice called "autoerotic asphyxia," in which a man strangles himself, usually by hanging, for sexual reasons. Although autoerotic asphyxiasts arrange an escape hatch-for example, a well placed stool they can stand on before it's too late-sometimes things go wrong. Perhaps 100 American men every per year die in this way. About one-fourth of the time, these men are found wearing some article of women's clothing, such as panties. There is no obvious reason why autoerotic asphyxia should require cross-dressing. Apparently, these men are both masochistic and autogynephilic. Cross-dressing has also been linked to sexual sadism-although most autogynephiles are not sexual sadists, they are more likely to be sadists compared with men who are not autogynephilic.

Paraphilias tend to seem bizarre to typical gay and straight people, whose sexual desires are primarily directed toward conventional sex acts with adults. Social explanations of paraphilias tend to be strained and unconvincing. What kind of experiences would make men risk their lives to become sexually aroused from being strangled while wearing panties? I'm betting on biology.

My gut feelings may say as much about my biases as they do about the evidence, which is admittedly scanty. Other people might look at the same evidence and reach the opposite conclusion. However, no one could honestly and competently say that we are anywhere close to understanding the causes of autogynephilia, or more generally, paraphilias.

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Suppose a man-let's assume he is a famous entertainer, a singer perhaps-has undergone a series of operations during his life to make himself look more feminine. Suppose that he comes off as feminine in some other respects as well, such as his speaking style. However, he denies being gay and, in fact, has been married several times. What might explain this man's behavior?

There are basically two possibilities. First, despite his protests to the contrary, hemight actually be gay. Surprisingly, many people continue to believe that being gay is still a liability in much of the entertainment industry, although Elton John has pulled it off nicely. But if this man were the member of a relatively anti-gay ethnic minority, say an African American, it might be especially hard to come out. In this case, his marriages would most likely be publicity stunts with cooperative women (as Doris Day was with Rock Hudson).

If this were the correct explanation, feminizing surgery would reflect homosexual transsexualism. Remember, homosexual transsexuals want to become women because they are innately feminine, but also because they want to become beautiful sexy women to attract men. They employ feminizing surgery across their entire bodies-hips, breasts, and if necessary, face-in very sexy, flattering ways. If surgery did not lead to a flattering appearance, and if it were restricted, say, to the face, this would not be the typical picture of a homosexual transsexual.

A homosexual transsexual would almost certainly have a series of sexual relationships with masculine straight men. These could be difficult to hide, depending on the tabloids' interest level.

The second likely possibility is that the singer is autogynephilic. Autogynephiles also are motivated by the desire to become more feminine. In contrast to homosexual transsexuals, however, they are not trying to become generally beautiful and sexy women in order to attract men. They create certain feminine traits in themselves to fulfill their own sexual desires. Although some autogynephiles want everything, others are content with very limited feminizing steps. Autogynephiles frequently have very specific desires-to have breasts, for example, or to have a vagina, or to have a feminine face, or to wear a garter belt. This would never be true of a homosexual transsexual. If the entertainer were autogynephilic, his marriages might well have been real sexual relationships, although autogynephilia might tend eventually to strain them.

Information that could help decide what was motivating our entertainer would include stories from childhood and adolescence. If the entertainer is a homosexual transsexual, then he was almost certainly a markedly feminine boy. Anyone who knew him well during childhood would know that he enjoyed playing with dolls, for example, or dressing up like a girl. If he were an autogynephile, his childhood would not have been remarkable in this way. His adolescence probably would have been unusual. If the entertainer is an autogynephile, then most likely as a teenage boy, he cross-dressed fetishistically-put on women's lingerie in private and masturbated while looking at himself in the mirror. Although many autogynephiles have traumatic stories of being discovered while cross-dressing, many successfully hid their secret. So even if the singer is autogynephilic, relevant information on adolescence might never surface.

Other relevant information would include knowledge about his other sexual proclivities. For example, if the singer liked to cross-dress during sex with his wife, that would be a sure sign of autogynephilia. Also, remember that autogynephilia is a paraphilia, and paraphilias often run together. If we knew that the singer had another paraphilia, this would increase our confidence in a paraphilic interpretation of his behavior. This would be particularly true if he was a masochist, for example, because the link between autogynephilia and masochism has been clearly drawn in research studies. But I think that even if he had a paraphilia that no one has yet linked to autogynephilia-pedophilia for example-we should still move toward autogynephilia. No multimillionaire homosexual transsexual would waste his time and money and risk everything to have sex with a prepubertal or pubescent child, even a boy. Like other males, homosexual transsexuals favor youthful sex partners, but their prototypal Adonis is a 20-year-old man. Knowing that our singer had sexual interest in children would certainly sway me in favor of autogynephilia. (I note here that Anne Lawrence disagrees with me. And even if I am correct, the vast majority of autogynephiles have no sexual interest in children.)

Privacy might prevent us from ever knowing the truth, but these are the kinds of things we would want to know.

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"Most gender patients lie," says Maxine Petersen, the ace gender clinician at the Clarke. One common lie among autogynephiles, according to Petersen, is that they are homosexual rather than heterosexual. The motivation for that lie is probably the fear that a gender clinic will deny them a sex change if they are determined to be heterosexual. And indeed, some psychiatrists have taken the position that nonhomosexual transsexuals are uniquely inappropriate for sex reassignment because they are not "true" transsexuals. (The Clarke Institute does not discriminate against autogynephiles and indeed, Blanchard wrote an uncharacteristically impassioned passage in one article urging readers not to use his findings to justify such discrimination. However, as recently as 1989, Blanchard and his colleagues from the Clarke opined that "heterosexual applicants for sex reassignment should be evaluated with particular caution" because of an increased likelihood of postoperative regret.) Autogynephiles who claimed to be homosexual transsexuals could account for the apparent cases of homosexual transsexuals who practiced erotic cross-dressing. Other common lies, according to Petersen and others, include an exaggeration of early femininity. This might in some cases have the same motivation.

The most common way that autogynephiles mislead others is by denying the erotic component of their gender bending. For example, when Stephanie Braverman lectures to my human sexuality class, she does not even mention her history of masturbating while cross-dressed. When I spoke at a meeting of Chicago cross-dressers, the men became clearly uncomfortable when I brought up the erotic component of their activity, preferring instead to attribute it to their inner femininity. When I pointed this out, one cross-dresser said "I wear feminine clothing because I feel feminine, and I can't help getting aroused because the clothes are sexy. Any man would." I don't think so. But you can judge. Here is one of the passages that aroused the cross-dressers in Blanchard's study. See if you think it is sexy.

"You have plenty of time to dress this evening. You slip your panties over your ankles and pull them up too your waist. Sitting on the edge of your bed, you put on a pair of sheer nylon stockings. You fasten the stockings with the snaps of your lacy garter belt. You slip your arms through the straps of your brassiere and reach behind you to fasten it. You put on your eye shadow, mascara, and lipstick. Lying on your bed, you look up at your reflection in the large mirror on the ceiling."

Why do some autogynephiles deny the sexual component of their condition? One reason, again, is the real or imagined treatment implications. Some psychiatrists refuse to recommend for sex reassignment any man who has had even one incident of erotic cross-dressing. But this fear surely cannot explain the resistance of Stephanie Braverman and the cross-dressers at the meeting-they are not trying to become women.

Perhaps the major reason is shame and assumed social reaction. The physician Harry Benjamin, who popularized the word "transsexual," noticed early on that cross-dressers, and especially cross-dressers in organizations trying to influence the public, tend to de-emphasize the erotic element. He suggested that they do this in order to be more accepted by others. Today, public statements by those who call themselves "transgendered" (who are almost all autogynephiles rather than homosexual transsexuals) rarely acknowledge any erotic component of "transgenderism."

There is also a more personal motivation to deny the erotic component of autogynephilia. Anne Lawrence put it this way:

I imagine most men would be humiliated to admit that dressing in women's clothing is a sexual kick, and even more humiliated to admit that doing so, or fantasizing doing so, is obligatory for climax some or all of the time. Just dressing in women's clothing is shameful enough; but having one's sexual potency contingent upon such an unmanly, "ridiculous" crutch would be almost impossible to admit. Moreover, for anyone who thinks about it, the whole experience of reliance on paraphilic behavior or fantasy for arousal is rather tragic and lonely: it cuts one off from intimate contact during partnered sex, because one is (at least mentally) often making love to oneself rather than to one's partner. Better not to admit this to anyone--especially to one's wife. I think that if the wives of heterosexual cross-dressers knew what their husbands were really thinking about at the moment of climax, they would be appalled. (Of course, this might apply to the wives of other straight men as well; but it's one thing to learn he's fantasizing about making love to Claudia Schiffer, and another to learn he's fantasizing about being forced to wear a French maid's outfit.) On the other hand, to attribute one's cross-dressing to a desire to express one's "feminine side" is much more acceptable. Though the behavior may still appear ridiculous, the putative rationale allows the cross-dresser to portray himself as multi-faceted, courageous, and even empathic with his spouse. That's a far easier script for most men to follow.

In my experience, most lay people are happy to accept the "I'm a woman in a man's body" narrative, and don't really want to know about autogynephilia-even though the preferred narrative is misleading and it is impossible to understand nonhomosexual transsexualism without autogynephilia. When I have tried to educate journalists who have called me as an expert on transsexualism, they have reacted uncomfortably. One said: "We just can't put that into a family newspaper." Perhaps not, but then, they can't print the truth.

There is one more reason why many autogynephiles provide misleading information about themselves that is different than outright lying. It has to do with obsession. Something about autogynephilia creates a need not only to enact a feminine self, but also to actually believe in her. It seems important to them to emphasize the permanence of the feminine self as well as her primacy: "I was always feminine, I just managed to hide it. I became a Green Beret as a defensive response to my femininity." In such accounts, the feminine self is the real self; the masculine self is the creation. (I have been arguing that the opposite is closer to the truth.) Intersexuality refers to congenital conditions in which biological sex is ambiguous, usually due to hormonal or genetic problems. Cheryl Chase, the intersex activist, told me that transsexuals frequently join intersex groups because they are convinced that they are also intersexual. In most cases, they are not. I assume that these are autogynephilic transsexuals who want to believe that there is a real biological woman inside them as well as a real psychological woman.

The self-presentational deceptiveness of some autogynephiles is a main reason why autogynephilia was not understood until recently. Many clinicians-even some who write books-have taken the information that transsexuals tell them at face value. I recently attended a talk by a well-known psychologist at an academic sex conference in which she presented a case that was clearly autogynephilic (he'd been married and was in his late 40s, among other signs). However, she spoke not one word about her patient's sexual fantasies, dwelling instead on the usual "woman trapped in man's body" story. Blanchard's ideas have not yet received the widespread attention they deserve, in large part because sex researchers are not as scholarly as they should be and so don't know read the current scientific journals.

And although Blanchard's ideas are fundamental to an understanding of transsexualism, they might not matter that much for helping transsexuals, which most clinicians have as their first priority. With luck, the next revision of the DSM will distinguish "homosexual" from "autogynephilic" transsexualism. But will popular features on "the transgendered" begin to mention the teenage masturbatory cross-dressing? Will "The Cher Mondavi Story" become a made-for-television movie co-starring "Robot Man?" Probably not, and it is a pity. True acceptance of the transgendered requires that we truly understand who they are.