The New Atlantis Study on Sexual Orientation and Gender Identity That's Not a Study

UPDATE: In a post out on 8/27/16, Adam Keiper, editor at The New Atlantis magazine responds to this post with a rebuttal to my points below. I urge you to go read it. I in turn respond to him. I also make a correction in my original post below based on his communication to me.
————————————————- (original post below)
Over the past year, hot discussions of sexual orientation have been pushed aside by controversies over gender identity and bathrooms. A new article from The New Atlantis shows that both topics have plenty of life. Yesterday, social media was buzzing about a new “study” of sexual orientation and gender identity by Lawrence Mayer and Paul McHugh. Actually, the article was not a study but a review and summary of empirical studies. As far as I can tell, it is being touted most by conservative leaning and anti-gay organizations.
The New Atlantis describes itself as a “Journal of Technology and Society.” However, the article did not receive peer review and it shows. Lawrence Mayer, the first author, is not well known in sexuality research circles but the second author is. Paul McHugh is retired from Johns Hopkins and was responsible for discontinuing the sex reassignment program there. He also was an advisor to the Repressed Memory Foundation in the 1990s.
Quickly, the National Organization for Marriage touted the paper as “Groundbreaking New Research.” Even calling the paper a new study isn’t accurate, there are no new studies in the paper. A bunch of old ones are missing as well.
In this post, I want to include some initial reactions and then some notes from Michael Bailey, professor at Northwestern, who was cited several times in TNA paper. I am going to focus on their points about sexual orientation and leave the gender identity points for a future post.
Here is their summary of research regarding sexual orientation:

● The understanding of sexual orientation as an innate, biologically fixed property of human beings — the idea that people are “born that way” — is not supported by scientific evidence.
● While there is evidence that biological factors such as genes and hormones are associated with sexual behaviors and attractions, there are no compelling causal biological explanations for human sexual orientation. While minor differences in the brain structures and brain activity between homosexual and heterosexual individuals have been identified by researchers, such neurobiological findings do not demonstrate whether these differences are innate or are the result of environmental and psychological factors.
● Longitudinal studies of adolescents suggest that sexual orientation may be quite fluid over the life course for some people, with one study estimating that as many as 80% of male adolescents who report same-sex attractions no longer do so as adults (although the extent to which this figure reflects actual changes in same-sex attractions and not just artifacts of the survey process has been contested by some researchers).
● Compared to heterosexuals, non-heterosexuals are about two to three times as likely to have experienced childhood sexual abuse.
● Compared to the general population, non-heterosexual subpopulations are at an elevated risk for a variety of adverse health and mental health outcomes.
● Members of the non-heterosexual population are estimated to have about 1.5 times higher risk of experiencing anxiety disorders than members of the heterosexual population, as well as roughly double the risk of depression, 1.5 times the risk of substance abuse, and nearly 2.5 times the risk of suicide.
● Members of the transgender population are also at higher risk of a variety of mental health problems compared to members of the non-transgender population. Especially alarmingly, the rate of lifetime suicide attempts across all ages of transgender individuals is estimated at 41%, compared to under 5% in the overall U.S. population.
● There is evidence, albeit limited, that social stressors such as discrimination and stigma contribute to the elevated risk of poor mental health outcomes for non-heterosexual and transgender populations. More high-quality longitudinal studies are necessary for the “social stress model” to be a useful tool for understanding public health concerns.

First, here is Michael Bailey’s quick reaction:

1. Their review of sexual orientation is not up to date (A major omission is that it neglects to cite our recent magnum opus on this topic: http://psi.sagepub.com/content/17/2/45.full.pdf+htmlf). The idea that sexual orientation is fluid has some plausibility for women, but not for men.
2. I agree with the authors that discrimination alone is unlikely to completely explain differences between heterosexual and homosexual people in mental health profiles, although it may contribute.
3. They are right on that the idea of innate, fixed gender identity is not consistent with empirical evidence. I differ from them, however, in believing that sex reassignment is still the best option for some individuals.
4. Most importantly, I agree that all of these issues should be openly discussed and researched. There is little government support for open-minded investigation for these controversial issues. That is unfortunate and exactly backwards. Support should be directed to resolve the most contentious issues.

As I reviewed the sexual orientations sections, I agree with Bailey. I especially agree that readers should read this major review of research on sexual orientation published earlier this year. Mayer and McHugh’s paper is missing any serious discussion of epigenetics, they overlook the new genetic linkage paper involving gay brothers, (they do address it, see the follow up post) as well as work on “gay rams.” The TNA authors minimize the neural differences between gays and straights, calling them “minor differences in brain structures.” How do these authors know what differences are minor and which are not? In fact, the differences in symmetry and brain activity are quite provocative and have not been accounted for by any environmental theory. Of course, we need more research with larger sample sizes but Mayer and McHugh just shrug these studies off as inconsequential.
Regarding sexual abuse, the authors review several studies which demonstrate higher rates of sexual abuse among GLB people as opposed to heterosexuals. For the most part, they report the relevant details but they failed to catch the mistakes in the Tomeo study and report it incorrectly (see this post for the problems with using Tomeo). Even though some who are touting the study miss this, the authors provide caution for those wanting to see homosexuality as the result of sexual abuse:

In short, while this study suggests that sexual abuse may sometimes be a causal contributor to having a non-heterosexual orientation, more research is needed to elucidate the biological or psychological mechanisms. Without such research, the idea that sexual abuse may be a causal factor in sexual orientation remains speculative.

They say “sometimes.” I would say infrequently or rarely and would add that we really don’t know. What we do know is that most people who are GLB were not abused. The TNA paper affirms that observation.
On the “born that way” claim, I find it contradictory that the authors express uncertainty about the causes of orientation but then say with great certainty that the “born that way” theory isn’t supported by scientific evidence. This line is apparently meant to hook the social conservatives which indeed it has. I mentioned the misleading “Groundbreaking New Research” headline from NOM, and then I just saw Liberty Counsel’s email which leads: “Scientific Research Debunks LGBT Propaganda.”
For readers wanting a more thorough review of the literature, please see the paper from Bailey and colleagues linked here.
 

Iowa Civil Rights Commission Releases Revised Sexual Orientation and Gender Identity Public Accommodations Brochure

This just in from the Iowa Civil Rights Commission:

Iowa Civil Rights Commission Releases Revised Sexual Orientation & Gender Identity Public Accommodations Brochure
The Iowa Civil Rights Commission announced today the publication of its Revised Sexual Orientation & Gender Identity Public Accommodations Brochure.  The revision replaces the previous version which had not been updated since 2008 and clarifies that religious activities by a church are exempt from the Iowa Civil Rights Act.
“The Iowa Civil Rights Commission has never considered a complaint against a church or other place of worship on this issue,” said director Kristin H. Johnson. “This statute was amended to add these protected classes (sexual orientation and gender identity) in 2007 and has been in effect since then. The Iowa Civil Rights Commission has not done anything to suggest it would be enforcing these laws against ministers in the pulpit, and there has been no new publication or statement from the ICRC raising the issue. The Commission regrets the confusion caused by the previous publication.”
The revised brochure may be found at this link: https://icrc.iowa.gov/sites/default/files/publications/2016/2016.sogi_.pa1_.pdf

This new language is more clear:

P L A C E S O F W O R S H I P
Places of worship (e.g. churches, synagogues, mosques, etc.) are generally exempt from the Iowa law’s prohibition of discrimination, unless the place of worship engages in non-religious activities which are open to the public. For example, the law may apply to an independent day care or polling place located on the premises of the place of worship.

By independent day care, the Commission means a day care renting or leasing a place of worship and not being conducted by the church as a part of the church’s ministry. Ms. Johnson clarified that to me earlier in the week.
For background on this issue see these posts: Link, link

Information and Misinformation on Gender Dysphoria from Wallbuilders and the American College of Pediatricians, Part One

Tuesday on Wallbuilders Live, Dr. Michelle Cretella represented tiny pediatric breakaway group the American College of Pediatricians. She briefly discussed the organization’s position paper on responding to gender identity issues. In doing so, she said something which caught my irony sensor. It also occurred to me, as it repeatedly has in the discussion of gender dysphoria, how difficult it is to avoid taking extreme positions.
Listen to her response to a question from host Rick Green about how much harm gender dysphoria is causing.

I want to address two claims that came up in this segment. In this post, I address the claim that 80% of gender dysphoric children will accept their biological sex with therapy. In a future post, I will write about the claim about suicide rates.
Cretella says:

They’re [advocates for transgender children] cooperating with, at least, mental confusion.  You know, initially, we know that there is psychiatric literature that shows if you work with these children one on one and with their families, the vast majority, over 80% will come to accept their biological sex after puberty before adulthood. So yes, to put these children to reaffirm their confused thinking, to put them on puberty blockers, and then cross-sex hormones to make them quote unquote the other gender, you are permanently sterilizing children. It’s insanity.

Cretella is correct that persistence rates are low (gender dysphoria continuing into adulthood) among gender dysphoric children, but this is not the case with adolescents who remain gender dysphoric or those who experience it with an adolescent onset. In their paper, ACP uses the American Psychiatric Association’s DSM-V as an authority. The section of the DSM-V cited by ACP supports the claim about persistence but does not fully support Cretella’s claim about the role of therapy.

Rates of persistence of gender dysphoria from childhood into adolescence or adulthood vary. In natal males, persistence has ranged from 2.2% to 30%. In natal females, persistence has ranged from 12% to 50%. Persistence of gender dysphoria is modestly correlated with dimensional measures of severity ascertained at the time of a childhood baseline assessment. In one sample of natal males, lower socioeconomic background was also modestly correlated with persistence. It is unclear if particular therapeutic approaches to gender dysphoria in children are related to rates of long-term persistence. Extant follow-up samples consisted of children receiving no formal therapeutic intervention or receiving therapeutic interventions of various types, ranging from active efforts to reduce gender dysphoria to a more neutral, “watchful waiting” approach. It is unclear if children “encouraged” or supported to live socially in the desired gender will show higher rates of persistence, since such children have not yet been followed longitudinally in a systematic manner. For both natal male and female children showing persistence, almost all are sexually attracted to individuals of their natal sex. For natal male children whose gender dysphoria does not persist, the majority are androphilic (sexually attracted to males) and often self-identify as gay or homosexual (ranging from 63% to 100%). In natal female children whose gender dysphoria does not persist, the percentage who are gynephilic (sexually attracted to females) and self-identify as lesbian is lower (ranging from 32% to 50%). (APA, DSM-V, p. 455)

To the DSM-V, I can add the description of persistence developed by the World Professional Association for Transgender Health (WPATH) in their standards of care.

An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood.V Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12–27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).
In contrast, the persistence of gender dysphoria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty-suppressing hormones, all continued with actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010).
Another difference between gender dysphoric children and adolescents is in the sex ratios for each age group. In clinically referred, gender dysphoric children under age 12, the male/female ratio ranges from 6:1 to 3:1 (Zucker, 2004). In clinically referred, gender dysphoric adolescents older than age 12, the male/female ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin, 2003). (WPATH, p. 11).

The irony of Cretella’s confidence in psychiatric intervention relates to the expulsion from ACP membership of George Rekers who was infamous for his own personal decline and his discredited treatment approach to what was then called gender identity disorder. In fact, we don’t know the role, if any, therapy plays in influencing the current persistence rates. While there is reason to think parental permission to transition in childhood might increase the persistence rates, there isn’t sufficient research to say for sure.
After listening to Cretella and reading the ACP paper, I wonder what the ACP recommends for the 10-20% of people with gender dysphoria persisting into the late teens. Do they favor reassignment for those persons? They focus on the data which make their point but don’t seem to have an answer for the rest of the people involved.
Another problem with ACP’s confidence in psychiatric interventions for gender dysphoria is that they also oppose a frequent end point in the trajectory of many gender dysphoric children: homosexuality (see image at the end of the post). One of the reasons George Rekers tried to re-orient gender dysphoria was to prevent homosexuality. Furthermore, one of the prime objectives of reparative therapists like Joseph Nicolosi is to prevent homosexuality via the alteration of parenting behaviors toward gender nonconforming children. ACP should stop pretending to sympathize with gender dysphoric children when they also write letters to school personnel promoting reparative change therapy for gay people.
Summary
Cretella is right that studies of gender dysphoric children (mostly with boys) find low rates of persistence of gender dysphoria into adulthood. However, she should have distinguished between prepubescent children and teens. The outcomes for these two groups do not appear to be the same. No doubt her listeners will not make that distinction.
Cretella was wrong to invoke psychiatric treatment as the reason for low persistence rates. If anything, some treatments have been shown to be harmful in some cases while others may not be harmful but may not cause a reduction in gender dysphoria. From her presentation, one could get the impression that advocates for gender dysphoric children know these treatments work but are motivated to undermine the natural family and therefore withhold appropriate medical care. While there is strong disagreement among experts and some advocates might oppose traditional families, it is simply not true that gender dysphoria could be easily treated if only activists would get out of the way.
Another important factor is that the treatment advocated by Cretella and the ACP is an outdated, discredited, psychoanalytically based approach which has not shown success. Even among those in the mainstream who are skeptical of puberty blocking drugs, the treatments advocated by ACP are rejected.
Gender Dysphoria After Childhood
The following image comes from a 2012 study by Devita Singh on gender dysphoric boys. Note the columns titled “sexual orientation in fantasy” and “sexual orientation in behavior.” By far, the most common end point for gender dysphoric children across studies is some level of same sex attraction. Gay advocates have in the past confided to me that they are ambivalent about supporting interruption of puberty because such interventions may interfere with a natural homosexual outcome. Please see this common sense article by Michael Bailey and Eric Vilain on the dilemma many parents of gender dysphoric children face.
Singh table

Top Ten Posts in 2015

The ten top posts during 2015 are as follows with the most popular first:
1. Open Letter to Gateway Church Pastor Robert Morris from a Former Member of Mars Hill Church – This was posted on November 2, 2014 but remained popular throughout 2015. Driscoll recently joined Jimmy Evans as a director to form The Trinity Church in Phoenix.
2. Former Chief Financial Officer at Turning Point Claims David Jeremiah Used Questionable Methods to Secure a Spot on Best Seller Lists – This story about David Jeremiah’s questionable tactics from a former insider was a scoop but not one which stuck to Jeremiah like  a similar scandal did to Mark Driscoll.
3. Hillsong’s Brian Houston Interviewed Mark and Grace Driscoll After All (VIDEO) (AUDIO) – First, he said he would interview Driscoll, then he said he wouldn’t, then Brian Houston aired an interview with Mark and Grace Driscoll. It was great theatre but didn’t draw good reviews from former Mars Hill leavers.
4. A major study of child abuse and homosexuality revisited – This post from 2009 is one of the most popular articles in the history of the blog. In it, I demonstrate a key mistake in a journal article often used to link homosexuality and child abuse.
5. Southern Baptists Say Enough to Perry Noble and NewSpring Church – I am surprised that this post got so much attention.
6. Gospel for Asia Faces Allegations of Misconduct; GFA Board Investigation Found No Wrongdoing – The GFA story received the most attention from me this year.
7. Pastor of Willow Creek Presbyterian Says Church Reaction to Hiring Tullian Tchividjian is “Overwhelmingly Positive” – I briefly covered Tullian Tchividjian’s comeback as a development minister at a PCA church in FL.
8. A Few Thoughts on The Village Church Controversy – Village Church’s leadership apologized for their response to a young woman who sought a divorce from her husband who had admitted having child porn.
9. Hillsong Founder Brian Houston Issues Statement On Mark Driscoll at the Hillsong 2015 Conference – Mark Driscoll’s return to the spotlight garnered much reader attention.
10. Gospel for Asia’s K.P. Yohannan and the Ring Kissing Ritual – While the financial scandals were of interest to readers, this article ranked higher than the money problems.
To fully capture activity on the blog, one should consider the Gospel for Asia scandals (Patheos considered my coverage as a part of one of their top ten Evangelical stories of 2015).
It has been a good year and I thank my readers and those who support the blog with their comments and regular visits.

Interview with Mark Yarhouse on SAMHSA Report Calling for an End to Sexual Orientation Change Efforts for Minors

On October 15, I linked to a report published by SAMHSA which called for an end to sexual orientation change efforts for LGBT minors. At the time, I wrote:

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth was released today by the Substance Abuse and Mental Health Services Administration. The report recommends the end of change therapies for minors via professional advocacy and legal strategies.

Mark Yarhouse, co-author with me of the Sexual Identity Therapy framework and professor at Regent University, was an evangelical presence on the panel of experts who produced the consensus statements.

I also said I hoped to have commentary from Mark. Today, I have an interview with him on his committee experience and his views of the consensus. Mark is professor of psychology at Regent University and Director of the Institute for the Study of Sexual Identity. He is co-author with me of the Sexual Identity Therapy Framework, which is a model for ethically and effectively helping clients with distress surrounding their sexual orientation and religious beliefs. For more on SITF, see the website which supports the framework. This will be cross–posted there.
This interview comes amid a bit of a controversy involving Mark and a speaking engagement in Canada. I hope those who assume they know Mark’s views will also read this and the SITF.

Warren Throckmorton: In general, what was your experience like being on the consensus committee? Did you feel the rest of the committee members took religious concerns seriously?
Mark Yarhouse: Overall, it was a good experience. I am always grateful for the opportunity to engage with others around complex issues, to learn from other experts, and to share from my own lines of research. We reviewed existing research and past policy statements, as well as shared from our professional experience working with children, adolescents, and families. In answer to your question about religious concerns, I think committee members wanted to take religious concerns seriously, although the primary focus was the well-being of minors who are navigating sexual identity and gender identity. As you know all too well, the beliefs and values of religious families are important considerations when working with families whose teen may be navigating gender identity or sexual identity concerns. In any case, my experience was that other committee members were interested in the experiences I’ve had – and others had – working with conventionally religious families.
WT: Even though the sexual identity therapy framework (SITF) wasn’t mentioned or cited, do you feel the report is supportive of the approach we take in the framework?
MY: Yes, I think so. We had the opportunity to review many documents, including the SITF and the 2009 APA task force report on appropriate therapeutic responses to sexual orientation, which, as you know, cited the SITF favorably. The kind of practice we saw as helpful would emphasize identity exploration without an a priori fixed outcome. I think the framework does that in the area of sexual identity. However, the framework does not address in much detail working with minors, and that may be something we consider if we offer a revision in the future.
WT: Do you have any comments, reservations about the consensus reported in the paper?
MY: As the SAMHSA report notes, we decided at the outset that we would define consensus as a reasonably high percentage of agreement rather than unanimous consensus. We all agreed to that, but that meant that what counted as consensus in at least a few occasions was not reflecting unanimity. We worked hard for unanimity in all cases, but that did not always happen. I at times found myself in disagreement with some of the wording, for example, but the threshold for consensus was met in those instances, and I understood and respected that process.
WT:It seems to me that the consensus surrounding sexual orientation is more settled than gender identity. How do you see that?
MY: There are fewer professional debates about sexual orientation, which likely reflects the consensus you are referring to. There seem to be more professional discussions about a range of clinical options with gender dysphoria. However, I was impressed by how little research is published on minors – particularly efforts to achieve congruence between gender identity and biological sex.  I was under the impression that more studies of higher quality had been published in some areas, and as the committee looked at them together, we found them lacking. Also, while research was one consideration, we drew on other sources, too, such as committee members’ professional experience and prior reports. In any case, I would have preferred to frame and word various aspects of the consensus report differently, but again that in some cases goes back to what counted as consensus. Without going into too much detail, you could imagine someone favoring the language of  ‘insufficient evidence’ in discussions of effectiveness and harm, to reflect how little published research is available in a given area of inquiry. Other topics, such as how to conceptualize sexual and gender identities and expressions in a diverse and pluralistic culture raise important philosophical and theological questions that were beyond the scope of the discussion.
WT: In general, do you support the recommendations of the paper (or asked another way). Is there anything in the recommendations you have concerns about?
MY: It is important to distinguish the consensus statement from the SAMHSA report. I did provide feedback on portions of the SAMHSA report, especially around family, community, and religious considerations, but it was written by designated persons from that agency. I think it reflects a little more regard for conventionally religious persons and families and provides for more resources than otherwise may have been available. But many committee members provided input and suggestions, and I imagine the author of the report had to balance various considerations in putting together the final document.
As far as concerns, I indicated at the outset that I did not think the government should be involved in legislating around the complexities of clinical practice in these two areas. I prefer to see government support the regulatory bodies that provide oversight to mental health professions in a given jurisdiction. I shared more of my thoughts on that in an interview with First Things. My opinion has not changed on that matter.

New SAMHSA Report Calls for End to Change Therapy for LGBT Youth

I may have more to say about this report in the coming days, hopefully with some commentary from Mark Yarhouse, but for now, I am going to link to it.
Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth was released today by the Substance Abuse and Mental Health Services Administration. The report recommends the end of change therapies for minors via professional advocacy and legal strategies.
Mark Yarhouse, co-author with me of the Sexual Identity Therapy framework and professor at Regent University, was an evangelical presence on the panel of experts who produced the consensus statements.
The most controversial parts of the report, in my opinion, deal with gender identity. I think most therapists now understand that sexual orientation is durable and rarely, if ever, changes dramatically as the result of change therapy. However, the recommendations on gender identity are more controversial. Despite the use of the word consensus, I question whether there is a consensus among professionals of all ideologies about how to respond therapeutically to youth dealing with stress over gender expression.
As for the goal of ending change therapy for youth, I am a supporter. Despite years of research and effort, no safe, effective and ethical approach to sexual orientation change has emerged. The very few people who still claim effectiveness are small operations with no research of their own methods. The anecdotes of harm are convincing and the candid admissions of people like Alan Chambers that the change they claimed didn’t happen is enough to cause significant skepticism. My own professional experience researching change efforts in clients and research participants informs me that any claimed change is unlikely to be lasting or complete. The biological research, while not conclusive, supports a very early establishment of sexual desires (especially for males). The available options for attempting change are often bizarre and carry potential to create psychological problems. Thus, limiting these efforts in a free society to adults seems like a reasonable professional position.
 

Southern Baptist Seminary Leaders Reject Reparative Therapy

Let me just say that I opposed reparative therapy before it was cool to oppose it.
Yesterday, Al Mohler and others articulated their position against reparative therapy, also known as sexual orientation change efforts.
Atlantic has an article on Alan Chambers’ new book and chronicles the demise of the ex-gay movement from Alan’s point of view.
Essentially, Mohler and colleagues believe changing orientation is not the Christian goal. Rather, avoidance of same-sex sexual relations is the objective in the narrow sense, and more broadly, pursuit of a spiritual life is what Christians should seek. Some same-sex attracted people are bisexual and others sometimes fall in love cross-orientation to form a mixed orientation marriage.
Although it is dated, I have a page on reparative therapy which demonstrates my approach to the issues in the professional sense.

SCOTUS Blog: We Probably Have Two More Opinion Days; No Same Sex Marriage Decision Today

I’ve been watching the Supreme Court blog a bit today. One of the bloggers there just wrote the following in response to this question “So – at the end of tomorrow’s session we’ll find out if there will be opinions or just orders on Monday?”

Tejinder
We’ll definitely know for sure then. But we predict already that there will be opinions on Monday. It’s customary, on the second-to-last opinion day of the Term, for the Chief Justice to announce that the remaining opinions are coming on the next day. He didn’t do that today, so we think we have 2 more opinion days.

So tomorrow or Monday, the news cycle will stop and focus on gay marriage. I intend to have a post on the decision as will nearly all other bloggers.
Many evangelicals have predicted doom and gloom if the Supreme Court issues a ruling in favor of gay marriage. However, I predict the sun will come up the next day and after a lot of weeping, wailing and gnashing of teeth, not much will change. Same-sex couples are getting married and divorced now in most states. Heterosexual couples are still doing that too and will do it no matter what the Supreme Court does. Ministers who don’t want to officiate at same-sex marriages won’t have to.
They are here and I am pretty much used to it.
 

What Kind of Woman is Caitlyn Jenner? Part Two of a Q&A on Autogynephilia with Michael Bailey

Yesterday, I posted part one of my interview with Michael Bailey on the topic of Caitlyn Jenner and autogynephilia. In that segment, Bailey covered the basics about autogynephilia and why he thinks Jenner manifests autogynephilic characteristics. In this segment, Bailey tackles what is known about outcomes for autogynephilic individuals, issues relating to minors with gender dysphoria and addresses critics of the concept. He also mentions one case where autogynephilia disappeared with the administration of leuprolide.
I also wrote GLAAD three times and asked for comment on autogynephilia generally and yesterday’s interview specifically with no response. GLAAD produces a tip sheet for journalists that doesn’t mention autogynephilia. Bailey addresses the media silence at the end of the interview.
I want to thank Michael for sharing his time and knowledge.

WT: What are the long term trajectories for autogynephilic individuals? What is the proper therapeutic response?
MB: Persons with autogynephilia often struggle, because of shame, lack of understanding, and the disapproval of others. Also, there is a real tension between achieving autogynephilic goals and maintaining conventional romantic relationships. Autogynephilic males who cross dress often go through binge-purge cycles, in which their cross dressing increases periodically, they get fed up and throw away their female clothing, and then later begin the cycle again. Some are fortunate to find partners (generally women) who accept their autogynephilia-driven behavior–some women even cooperate and participate. Some autogynephilic individuals never acquire partners, and they avoid the aforementioned struggle.
Some persons with autogynephilia are content to remain male. Those who get their gratification primarily from cross dressing are less likely to want to progress than those whose fantasies involve having female bodies, especially genitalia. Those, of course, can acquire female genitalia via surgery. Those who go that route generally undergo electrolysis and hormonal therapy prior to genital surgery.
As for “proper therapeutic response,” this is surely best considered at the individual level. But gender dysphoria due to autogynephilia doesn’t merely go away. Again, autogynephilia is like a sexual orientation, and that doesn’t change. I suspect that if there were more honesty about autogynephilia, then those who have it would understand themselves sooner, be less likely to commit to romantic interpersonal relationships, and would be more likely to pursue earlier sex reassignment. Evidence suggests they would be happier doing so, and there would be fewer wrecked families; quite parallel with the case of men hiding their homosexuality and getting heterosexually married.
WT: In your answer about proper therapeutic response, you said autogynephilia doesn’t change. Is this based on research or on the classification of autogynephilia as a sexual orientation? 
MB: Many men with autogynephilia would like not to have it. But I have never met a man who said his autogynephilia went away. Some transwomen say that it diminishes or vanishes after a sex change. Remember, the sex change also removes testosterone, which fuels male sex drive.
I should mention one other therapeutic approach that has not been widely used, to my knowledge. Still, I know one autogynephilic man who was on the verge of changing sex. He was, however, conflicted because he would have lost everything: his family fortune, his job, and his family. He was put on a course of leuprolide, a powerful drug that removes testosterone from the body. His desire to change sex virtually vanished. He’s happy and somehow able to have sex with his wife (viagra helps).
WT: I assume you are talking about adults. In other words, do you have different advice for minors? 
MB: The controversy over how and whether to treat preadolescent children experiencing gender dysphoria is irrelevant to controversies concerning autogynephilia. These preadolescent children are not autogynephilic. Autogynephilia almost never manifests in an obvious way before adolescence.
Lots of autogynephilic transsexuals wish they’d transitioned earlier. I can imagine this would have been better for them. If only people were more open about autogynephilia and people were more honest about it–and here I include journalists along with people with autogynephilia among those who have conspired to keep it secret–we could collect better data and ideally learn the optimal treatment for autogynephilic individuals of various subtypes.
I worry when autogynephilic transsexual activists (this includes all who were born male who have not always been exclusively attracted to men) advise families of preadolescent gender dysphoric children. The older activists have completely distinct conditions from the children, and the activists’ experiences are not an accurate guide to what the youngsters feel or how they will turn out. As we have argued, most preadolescent gender dysphoria does go away, and it is at least questionable whether it is in preadolescent children’s interests to change sex, socially (because this may lead to persistence requiring serious medical treatment).
WT: Why is there so little media coverage of the autogynephilia angle? 
MB: I think it’s a mixture of ignorance, political correctness, and fear. Most journalists know what they know from the media and from transgender activists — who do not mention autogynephilia. In fact, a few activists have managed to convince a lot of people that autogynephilia theory has been disproved (when in fact, it has substantial scientific support) and that anyone who agrees with it is anti-transgender (when in fact its major proponents, including me, have been quite supportive of transgender rights). As for fear, transgender activists (especially Lynn Conway, Andrea James, and Deirdre McCloskey) were so enraged by my writing about these ideas in my book that they tried to ruin my life. They were unsuccessful–their major success was to help Alice Dreger write a terrific article (and recently, a book) about the controversy–but I’m sure few people want to risk that. We will have made progress when Conway et al. are more ashamed of what they did to me than of autogynephilia.
WT: Is there anything else you would like to mention?
MB: I’ve noticed disapproval among some journalists–even Jon Stewart on the Daily Show went there–of the focus on Caitlyn Jenner’s attractive photographs in Vanity Fair. I can assure you (and Stewart): Caitlyn’s thrilled with that attention. It’s an autogynephilic fantasy.

Again, thanks to Michael for this information. Readers can leave follow up questions in the comments section which may form the basis for a return to the issue at a later time.

What Kind of Woman is Caitlyn Jenner? Part One of a Q&A on Autogynephilia with Michael Bailey

The transition of Bruce Jenner to Caitlyn Jenner has raised many questions about transgender issues. One that has not been widely discussed is autogynephilia as a trajectory for males who experience gender dysphoria. My impression of Jenner’s story is that she manifests aspects which are often associated with autogynephilia so it seems odd to me that the topic has not come up.
Michael Bailey is professor of psychology at Northwestern University and one of the more prolific sex researchers in the world. He kindly accepted my invitation to discuss autogynephilia in light of Caitlyn Jenner’s transition.

Throckmorton: What is autogynephilia? And how do autogynephilic individuals differ from androphilic men who become women?
Bailey: Before explaining what autogynephilia is, let me begin by explaining what it looks like. It occurs in natal males (those born male, regardless of whether they switch gender later), and it generally first manifests in adolescence, with the onset of puberty and sexual feelings. In the large majority of cases, it begins with erotic crossdressing. Generally, a boy discovers it’s sexually exciting to put in female clothing, especially lingerie, in private, look at himself in a mirror, and masturbate. People who know these boys don’t usually see them as feminine. Males like this usually are attracted to females, though some are not attracted to other people. A subset will discover other, related erotic fantasies, sometimes including the idea of having female anatomy (such as breasts and a vulva). If the anatomical fantasies predominate, then gender dysphoria is most likely to be intense. Males who eroticize the fantasy of having women’s bodies are most likely to get sex changes, for obvious reasons.
The phenomena I’ve talked about so far don’t make much sense if we take the conventional approach that these males have women’s brains. They make much more sense explained via autogynephilia. Autogynephilia might best be thought of as an unusual sexual orientation that occurs in natal males (those born male, no matter what they become). It’s very similar to male heterosexuality, because the erotic target is a woman. The difference is that in autogynephilia, the target is a self-constructed internal image–it’s like inwardly-turned heterosexuality. These males eroticize and fall in love with a woman they create within themselves
WT: Do you believe that Caitlyn Jenner is autogynephilic? If so, why?
MB: I believe it is very likely that Caitlyn Jenner’s transition was motivated by intense autogynephilia. I believe this because the best science suggests there are two completely different reasons why natal males become women: because they are feminine androphiles (lovers of men) or because they are autogynephilic. Jenner’s history shows none of the former and is very consistent with the latter. I refer specifically to his previous heterosexual marriages and secretive crossdressing.
WT. She says she always had gender dysphoria and that there was no erotic component. Would she say this if she were autogynephilic? Why?
MB: Autogynephilic individuals experience gender dysphoria, typically beginning in adolescence, when their intense erotic longing for female characteristics almost always begins. There is evidence (John Bancroft published an article long ago) showing that after changing sex, some show memory distortion. They begin to assert that their gender dysphoria began in early childhood and was far more overt than they had alleged before. They also deemphasize the erotic component, even if they admitted it before. I think they do this for at least two reasons: shame (because: sex is involved) and the desire to believe they really have the brains of women (as Jenner suggests she does–um, how does she know that?). I think also that Jenner (and others in the spotlight) likely enjoys the media spotlight, and the mainstream media loves the “was always a woman trapped in a man’s body” story and can’t deal with the “experienced intense sexual arousal when crossdressing or imagining I had a woman’s body” story.
WT: If Jenner doesn’t want people to think her transition was due to autogynephilia, why shouldn’t we just go along? 
MB: This inaccurate denial of autogynephilia is not for the good, because being honest could help lots of males struggling with their autogynephilia. (And there are lots who are.) It might help them understand themselves. It might help them accept themselves. It would at least say “Autogynephilia is nothing to be ashamed of.” I would say that people who admit and deal with their autogynephilia are even admirable.
Falsely misrepresenting one’s gender issues is also bad for science. It’s not good for people to believe false things merely because journalists don’t want to go certain places. Even among scientists, too many don’t bother to learn about the relevant literature and just listen to transgender people’s explanations (“I have the brain of a woman.”). This leads to bad scientific studies and ideas.
I think that Jenner’s brain has nothing more in common with the brain of a natal woman than mine does. She’s not that kind of woman. Her gender dysphoria was much more akin to times in my life when I had erotic and romantic longings for someone I couldn’t have.
WT: Do autogynephilic individuals have attraction to other people? 
MB: Usually, they are also attracted to women in the world (i.e., women besides their inner creation) as well. Some of these individuals marry–some tell their wives and some don’t. Wives who know often feel like they are married both to their husband and to the other woman. And the men (many–probably most–never become women) sometimes struggle between their love for their families and their desire to become women. This desire is like a typical man’s midlife crisis.
A subset of autogynephilic males report that they are bisexual, but knowledgeable scientists think this is not true bisexuality. Rather than attraction to men’s bodies, these individuals enjoy the fantasy of being courted by, desired by, or even engaging in sex with men, as women. This makes them feel quite feminine, and is thus exciting. Another subset identifies as asexual. These have plenty of sexual fantasies–it’s just that the sexual fantasies are all about the internal woman, and there’s nothing left for women in the world.
WT: What research support does this phenomenon have? 
MB: There is a great deal of support originating in Toronto in the important clinic formerly run by Ray Blanchard, the scientist most responsible for the study of autogynephilia. Blanchard observed that erotic arousal at the idea of having a female body was uncommon among natal male gender patients who said they were exclusively attracted to men (he referred to these as “homosexual” because with respect to their birth sex, that is their sexual orientation). In contrast, it was very common among natal male gender patients attracted to women, those who identified as bisexual, and those who identified as asexual–he referred to these three subtypes as “non homosexual” because they were not exclusively attracted to men. Homosexual natal male gender patients tended to have been extremely feminine since childhood. Nonhomosexual patients, not so much. (In follow up studies of preadolescent boys so feminine they wanted to be girls, not a single one was attracted to women as an adult.) Non homosexual natal male gender patients’ gender dysphoria is rarely evident in childhood but begins in adolescence. Homosexual patients request sex reassignment surgery much younger than non homosexual patients do–at least they have in the past. This partly reflects the fact that many non homosexual patients form families that delay them from pursuing such surgery.
A good resource summarizing this science (up to 2003) is the third section of my book (free pdf). A more scholarly and updated treatment is Anne Lawrence’s book.

Tomorrow, I will post the second part of my Q&A with Michael Bailey. In that part of the interview, Bailey opines about the proper therapeutic response to autogynephilic individuals, minors and transgender issues, media reporting about autogynephilia and his critics.
Part two of this Q&A is here.