Causes of transsexuality
The study of the causes of transsexuality investigates gender identity formation of transgender people, especially those who are transsexual. Transsexual people have a gender identity that does not match their assigned sex, often resulting in gender dysphoria. The causes of transsexuality have been studied for decades.
The most studied factors are biological. Studies beginning with Zhou in 1995 have found that trans women's brain structure (volume and density of neurons) is similar to cisgender (cis) women's and unlike cis men's, and trans men's is similar to cis men's, even when controlling for hormone use. A 2002 study by Chung suggested significant sexual dimorphism in the BSTc did not become established until adulthood, theorizing that either changes in fetal hormone levels produce changes in BSTc synaptic density and other factors which later lead to the observed differences in BSTc, or the differences are affected by the generation of a gender identity inconsistent with assigned sex. Studies in 2004 (Swaab), 2006 (Gooran) and 2008 (Garcia-Falgueras) confirmed earlier research finding that gender identity is influenced by brain structure. (Brain structure differences have also been noted between gay and heterosexual men, and lesbian and heterosexual women.) Studies have also found that both androphilic and gynephilic trans women's brain function and responses are like cis women's and unlike cis men's, or are intermediate between the two. Likewise, studies have found that gynephilic trans men have male-like white matter patterns (even before using hormones).
With regard to genetic factors, a study by Hare reported that trans women have a longer androgen receptor gene than cis men, which is less effective at binding testosterone, potentially preventing complete masculinization of the brain. (Prenatal androgen exposure or sensitivity, or lack thereof, is often cited mechanisms to explain observed brain-structure differences.) A study by Bentz found that trans men have a CYP17 allele distribution like cis men and unlike cis women. A twin study found that 33% of pairs of identical twins were both trans, compared to only 2.6% of non-identical twins who were raised in the same family at the same time, but were not genetically identical.
Psychological factors have also been proposed. The failure of an attempt to raise David Reimer from infancy through adolescence as a girl after his genitals were accidentally mutilated is cited as disproving the theory that gender identity is determined by parenting. Ray Blanchard developed a taxonomy of male-to-female transsexuality that assumes transsexuals are either homosexual or autogynephilic, but it is controversial; J. Michael Bailey, Anne Lawrence, James Cantor and others support it, but Charles Allen Moser, Larry Nuttbrock, Julia Serano, the World Professional Association for Transgender Health and others argue it is poorly representative, non-instructive, and lacks empirical evidence, because the experiments behind it are poorly controlled and/or contradicted by other data.
- 1 Biological factors
- 2 Psychological factors and theories
- 3 See also
- 4 References
A 2008 study compared 112 male-to-female transsexuals (both androphilic and gynephilic), mostly already undergoing hormone treatment, with 258 cisgender male controls. Male-to-female transsexuals were more likely than cisgender males to have a longer version of a receptor gene (longer repetitions of the gene) for the sex hormone androgen or testosterone, which reduced its effectiveness at binding testosterone. The androgen receptor (NR3C4) is activated by the binding of testosterone or dihydrotestosterone, where it plays a critical role in the forming of primary and secondary male sex characteristics. The research suggests reduced androgen and androgen signaling contributes to the female gender identity of male to female transsexuals. The authors say that a decrease in testosterone levels in the brain during development might prevent complete masculinization of the brain in male to female transsexuals and thereby cause a more feminized brain and a female gender identity.
A variant genotype for a gene called CYP17, which acts on the sex hormones pregnenolone and progesterone, has been found to be linked to female-to-male transsexuality but not MTF transsexuality. Most notably, the FTM subjects not only had the variant genotype more frequently, but had an allele distribution equivalent to male controls, unlike the female controls. The paper concluded that the loss of a female-specific CYP17 T -34C allele distribution pattern is associated with FTM transsexuality.
Transsexuality among twins
In 2013, a twin study combined a survey of pairs of twins where one or both had undergone, or had plans and medical approval to undergo, gender transition, with a literature review of published reports of transgender twins. The study found that one third of identical twin pairs in the sample were both transgender: 13 of 39 (33%) monozygotic or identical pairs of assigned males and 8 of 25 (22.5%) pairs of assigned females. Among dizygotic or non-identical twin pairs, there was only 1 of 38 (2.6%) pairs where both twins were trans. The significant percent of identical twin pairs where both twins are trans, and the virtual absence of dizygotic twins (raised in the same family at the same time, but not genetically identical) where both were trans, provides evidence that transgender identity is significantly influenced by genetics.
Several studies have found a correlation between gender identity and brain structure. A first-of-its-kind study by Zhou et al. (1995) found that in a region of the brain called the bed nucleus of the stria terminalis (BSTc), a region which is known for sex and anxiety responses (and which is affected by prenatal androgens), male-to-female trans women had a female-normal BTSc size (like cisgender women) and female-to-male trans men had a male-normal size. While the transsexuals studied had taken hormones, this was accounted for by including non-transsexual male and female controls who, for a variety of medical reasons, had experienced hormone reversal. The controls still had sizes typical for their gender. No relationship to sexual orientation was found.
In a follow-up study, Kruijver et al. (2000) looked at the number of neurons in BSTc instead of volumes. They found the same results as Zhou et al. (1995), but with even more dramatic differences. One MTF subject who had never gone on hormones was also included, and who matched up with the female neuron counts nonetheless.
In 2002, a follow-up study by Chung et al. found that significant sexual dimorphism (variation between sexes) in BSTc did not become established until adulthood. Chung et al. theorized that either changes in fetal hormone levels produce changes in BSTc synaptic density, neuronal activity, or neurochemical content which later lead to size and neuron count changes in BSTc, or that the size of BSTc is affected by the generation of a gender identity inconsistent with one's assigned sex.
In a review of the evidence in 2006, Gooren confirmed the earlier research as supporting the concept of transsexuality as a sexual differentiation disorder of the sex dimorphic brain. Dick Swaab (2004) concurs.
In 2008, a new region with properties similar to that of BSTc in regards to transsexuality was found by Garcia-Falgueras and Swaab: the interstitial nucleus of the anterior hypothalamus (INAH3), part of the hypothalamic uncinate nucleus. The same method of controlling for hormone usage was used as in Zhou et al. (1995) and Kruijver et al. (2000). The differences were even more pronounced than with BSTc; control males averaged 1.9 times the volume and 2.3 times the neurons as control females, yet once again, regardless of hormone exposure, MTF transsexuals lay within the female range and the FTM transsexual within the male range.
A 2009 MRI study by Luders et al. of 24 MTF transsexuals not yet treated with cross-sex hormones found that regional gray matter concentrations were more similar to men than women, but there was a significantly larger volume of gray matter in the right putamen compared to men. Like earlier studies, it concluded that transsexuality was associated with a distinct cerebral pattern. (MRI allows easier study of larger brain structures, but independent nuclei are not visible due to lack of contrast between different neurological tissue types, hence other studies on e.g. BSTC were done by dissecting brains postmortem.)
An additional feature was studied in a group of FTM transsexuals who had not yet received cross-sex hormones: fractional anisotropy values for white matter in the medial and posterior parts of the right superior longitudinal fasciculus (SLF), the forceps minor, and the corticospinal tract. Rametti et al. (2010) discovered that, "Compared to control females, FtM showed higher FA values in posterior part of the right SLF, the forceps minor and corticospinal tract. Compared to control males, FtM showed only lower FA values in the corticospinal tract."
Hulshoff Pol et al. (2006) studied the gross brain volume of 8 male-to-female transsexuals and in 6 female-to-male transsexuals undergoing hormone treatment. They found that hormones changed the sizes of the hypothalamus in a gender consistent manner: treatment with male hormones shifted the hypothalamus towards the male direction in the same way as in male controls, and treatment with female hormones shifted the hypothalamus towards the female direction in the same way as female controls. They concluded: "The findings suggest that, throughout life, gonadal hormones remain essential for maintaining aspects of sex-specific differences in the human brain."
Brain-based research has repeatedly shown that female-to-male transsexuals have several male-like characteristics in neuroanatomy. In 2010, a team of neuroscientists compared 18 female-to-male transsexuals with 24 male and 19 female gynephilic controls, using an MRI technique called diffusion tensor imaging or DTI. DTI is a specialized technique for visualizing white matter of the brain, and white matter structure is one of the differences in neuroanatomy between men and women. The study found that the white matter pattern in female-to-male transsexuals was shifted in the direction of biological males, even before the female-to-male transsexuals started taking male hormones (which can also modify brain structure).
Similar brain structure differences have been noted between gay and heterosexual men, and between lesbian and heterosexual women. Studies have also found that circumstance and repeated activities such as meditation modify brain structures in a process called brain plasticity or neuroplasticity. In May 2014, the Proceedings of the National Academy of Sciences reported that parenting "rewires the male brain" for fathers.
Androphilic male-to-female transsexuals
Studies have shown that androphilic male-to-female transsexuals (sometimes called homosexual MtF transsexuals) show a shift towards the female direction in brain anatomy. In 2009, a German team of radiologists led by Gizewski compared 12 androphilic transsexuals with 12 cisgender males and 12 cisgender females. Using functional magnetic resonance imaging (fMRI), they found that when shown erotica, the cisgender men responded in several brain regions that the cisgender women did not, and that the sample of androphilic transsexuals was shifted towards the female direction in brain responses.
In another study, Rametti and colleagues used diffusion tensor imaging (DTI) to compare 18 androphilic male-to-female transsexuals with 19 gynephilic males and 19 androphilic cisgender females. The androphilic transsexuals differed from both control groups in multiple brain areas, including the superior longitudinal fasciculus, the right anterior cingulum, the right forceps minor, and the right corticospinal tract. The study authors concluded that androphilic transsexuals were halfway between the patterns exhibited by male and female controls.
Gynephilic male-to-female transsexuals
Gynephilic male-to-female transsexuals also show differences in the brain from non-transsexuals, in a pattern intermediate between male or female, or more female than male. Researchers of the Karolinska Institute of Stockholm used MRI to compare 24 gynephilic male-to-female transsexuals with 24 cisgender male and 24 cisgender female controls. None of the study participants were on hormone treatment. The researchers found sex-typical differentiation between the MtF transsexuals and cisgender males, and the cisgender females; but the gynephilic transsexuals "displayed also singular features and differed from both control groups by having reduced thalamus and putamen volumes and elevated GM volumes in the right insular and inferior frontal cortex and an area covering the right angular gyrus."
These researchers concluded that:
Contrary to the primary hypothesis, no sex-atypical features with signs of 'feminization' were detected in the transsexual group....The present study does not support the dogma that [male-to-female transsexuals] have atypical sex dimorphism in the brain but confirms the previously reported sex differences. The observed differences between MtF-TR and controls raise the question as to whether gender dysphoria may be associated with changes in multiple structures and involve a network (rather than a single nodal area).
Berglund et al. (2008) tested the response of gynephilic MTF transsexuals to two sex pheromones: the progestin-like 4,16-androstadien-3-one (AND) and the estrogen-like 1,3,5(10),16-tetraen-3-ol (EST). Despite the difference in sexuality, the MTFs' hypothalamic networks activated in response to the AND pheromone, like the androphilic female control groups. Both groups experienced amygdala activation in response to EST. Male control groups (gynephilic) experienced hypothalamic activation in response to EST. However, the MTF subjects also experienced limited hypothalamic activation to EST. The researchers concluded that in terms of pheromone activation, MTFs occupy an intermediate position with predominantly female features. The MTF transsexual subjects had not undergone any hormonal treatment at the time of the study, according to their own declaration beforehand, and confirmed by repeated tests of hormonal levels.
Gynephilic female-to-male transsexuals
Another team of neuroscientists, led by Nawata in Japan, used a technique called single-photon emission computed tomography (SPECT) compare the regional cerebral blood flow (rCBF) of 11 female-to-male transsexuals (attracted to women) with that of 9 biological females (attracted to men). Although the study did not include a sample of biological males so that a conclusion of "male shift" could be made, the study did reveal that the female-to-male transsexuals showed significant decrease in blood flow in the left anterior cingulate cortex and a significant increase in the right insula, two brain regions known to respond during sexual arousal.
Phantom limb syndrome
Phantom limb syndrome is a common, often painful experience after the loss of an external organ. Ramachandran (2008) found that while nearly two thirds of non-transsexual males who have a penis surgically removed experience the sensation of a phantom penis, only one third of MTF transsexuals do so after sex reassignment surgery. However, this study overlooks differences between an amputation, where nerves connecting the penis and brain are severed, and reassignment surgery, where some of the penis and scrotum may be reused to create a vaginal canal, labia and a clitoris. In this case, some nerves connecting the genitalia to the brain remain intact. Two-thirds of FTM transsexuals reported the sensation of a phantom penis from childhood onwards, complete with phantom erections and other phenomena.
Prenatal androgen exposure
Prenatal androgen exposure, the lack thereof, or poor sensitivity to prenatal androgens are commonly cited mechanisms to explain the above discoveries. Schneider, Pickel, and Stalla (2006) found a correlation between digit ratio (a generally accepted marker for prenatal androgen exposure) and male to female transsexuality. MTF transsexuals were found to have a higher digit ratio than control males, but one that was comparable to control females.
Congenital adrenal hyperplasia in persons with XX sex chromosomes results in what is considered to be excess exposure to prenatal androgens, resulting in masculinization of the genitalia and, typically, in controversial prenatal hormone treatment and postnatal surgical interventions. Individuals with CAH are usually raised as girls and tend to have similar cognitive abilities to the typical female, including spatial ability, verbal ability, language lateralization, handedness and aggression. Research has shown that people with CAH and XX chromosomes will be more likely to be same sex attracted, and at least 5.2% of these females develop serious gender dysphoria.
In males with 5-alpha-reductase deficiency, conversion of testosterone to dihydrotestosterone is disrupted, decreasing the masculinization of genitalia. Individuals with this condition are typically raised as females due to their feminine appearance at a young age. However, more than half of males with this condition raised as females become males later in their life. Scientists speculate that the definition of masculine characteristics during puberty and the increased social status afforded to men are two possible motivations for a female-to-male transition.
Psychological factors and theories
For many years, people such as psychiatrist and sexologist David Oliver Cauldwell and Harry Benjamin argued that transsexuality was a psychological/emotional disorder caused by psychological and environmental factors and personality conflicts. The failure of an attempt to raise David Reimer from infancy through adolescence as a girl after his genitals were accidentally mutilated is cited as disproving this theory that gender identity is determined by parenting. However, no studies have been able to demonstrate this at a large scale, in part due to widespread agreement among scholars that the Reimer study's methodology was unethical. Reimer's case is used by organizations such as The Intersex Society of North America to caution against needlessly modifying the genitals of unconsenting minors.
Blanchard's theories about sexuality
Ray Blanchard has developed a taxonomy of male-to-female transsexualism built upon the work of his colleague Kurt Freund, which assumes that trans women have one of two motivations for transition. Blanchard theorizes that "homosexual transsexuals" transition because they are attracted to men, and characterizes them as displaying overt and obvious femininity since childhood; he then characterizes "non-homosexual transsexuals" as transitioning because they are autogynephilic (sexually aroused by the thought or image of themselves as a woman), and as being attracted to women, attracted to both women and men, or asexual.
The theory has gained support from J. Michael Bailey, Anne Lawrence, James Cantor, and others who argue that there are significant differences between the two groups, including sexuality, age of transition, ethnicity, IQ, fetishism, and quality of adjustment. However, the theory has been criticized in papers from Veale, Nuttbrock, Moser, and others who argue that it is poorly representative of MTF transsexuals and non-instructive, and that the experiments behind it are poorly controlled and/or contradicted by other data. Many authorities, including some supporters of the theory, criticize Blanchard's choice of wording as confusing or degrading. Transsexuals themselves overwhelming reject the theory, with evolutionary biologist and trans woman Julia Serano writing that "Blanchard's controversial theory is built upon a number of incorrect and unfounded assumptions, and there are many methodological flaws in the data he offers to support it." Blanchard's ideas about trans women have also been rejected by the World Professional Association for Transgender Health (WPATH), the largest association of medical professionals who provides care for transgender people, as lacking empirical evidence and for stigmatizing behavior instead of focusing on treating distress.
The DSM-5 Sexual and Gender Identity Disorders workgroup, of which Blanchard is a member, has said:
In contemporary clinical practice, sexual orientation per se plays only a minor role in treatment protocols or decisions. Also, changes as to the preferred gender of sex partner occur during or after treatment (DeCuypere, Janes, & Rubens, 2005; Lawrence, 2005; Schroder & Carroll, 1999). It can be difficult to assess sexual orientation in individuals with a GI diagnosis, as they preoperatively might give incorrect information in order to be approved for hormonal and surgical treatment (Lawrence, 1999). Because sexual orientation subtyping is of interest to researchers in the field, it is recommended that reference to it be addressed in the text, but not as a specifier. It should also be assessed as a dimensional construct.
- Curtis, R.; et al. (March 2009). "Transgender experiences – Information and support" (PDF). NHS. p. 12. Retrieved 2012-07-01.
- Bentz, E; Hefler, L; Kaufmann, U; Huber, J; Kolbus, A; Tempfer, C (2008). "A polymorphism of the CYP17 gene related to sex steroid metabolism is associated with female-to-male but not male-to-female transsexualism". Fertility and Sterility. 90 (1): 56–9. doi:10.1016/j.fertnstert.2007.05.056. PMID 17765230.
- Diamond, Milton (May 2013). "Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation". International Journal of Transgenderism. Retrieved 14 June 2015.
- Hare, L; Bernard, P; Sanchez, F; Baird, P; Vilain, E; Kennedy, T; Harley, V (2009). "Androgen Receptor Repeat Length Polymorphism Associated with Male-to-Female Transsexualism" (PDF). Biological Psychiatry. 65 (1): 93–6. doi:10.1016/j.biopsych.2008.08.033. PMC . PMID 18962445.
- "Transsexual study reveals genetic link". abc.net.au.
- For a survey, see Swaab, Dick F.; Castellanos-Cruz, L.; Bao, A.-M. "The Human Brain and Gender: Sexual Differentiation of Our Brains." In: Schreiber, Gerhard. Transsexuality in Theology and Neuroscience. Findings, Controversies, and Perspectives. Berlin and Boston: Walter de Gruyter 2016 (ISBN 978-3-11-044080-5), pp. 23-42.
- Psychology The Science Of Behaviour, pg 418, Pearson Education, Neil R.Carlson
- Zhou, Jiang-Ning; Hofman, Michel A.; Gooren, Louis J. G.; Swaab, Dick F. (1995). "A sex difference in the human brain and its relation to transsexuality". Nature. 378 (6552): 68–70. doi:10.1038/378068a0. PMID 7477289.
- Kruijver, F. P. M.; Zhou, JN; Pool, CW; Hofman, MA; Gooren, LJ; Swaab, DF (2000). "Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus". Journal of Clinical Endocrinology & Metabolism. 85 (5): 2034–41. doi:10.1210/jcem.85.5.6564. PMID 10843193.
- Chung, WC; De Vries, GJ; Swaab, DF (2002). "Sexual differentiation of the bed nucleus of the stria terminalis in humans may extend into adulthood". Journal of Neuroscience. 22 (3): 1027–33. PMID 11826131.
- Gooren, L (2006). "The biology of human psychosexual differentiation". Hormones and Behavior. 50 (4): 589–601. doi:10.1016/j.yhbeh.2006.06.011. PMID 16870186.
- Swaab, DF (2004). "Sexual differentiation of the human brain: relevance for gender identity, transsexualism and sexual orientation". Gynecological Endocrinology. 19 (6): 301–12. doi:10.1080/09513590400018231. PMID 15724806.
- Garcia-Falgueras, A.; Swaab, D. F. (2008). "A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity". Brain. 131 (Pt 12): 3132–46. doi:10.1093/brain/awn276. PMID 18980961.
- Luders, Eileen; Sánchez, Francisco J.; Gaser, Christian; Toga, Arthur W.; Narr, Katherine L.; Hamilton, Liberty S.; Vilain, Eric (2009). "Regional gray matter variation in male-to-female transsexualism". NeuroImage. 46 (4): 904–7. doi:10.1016/j.neuroimage.2009.03.048. PMC . PMID 19341803.
- Rametti, G; Carrillo, B; Gómez-Gil, E; Junque, C; Segovia, S; Gomez, A; Guillamon, A (2010). "White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study". Journal of Psychiatric Research. 45 (2): 199–204. doi:10.1016/j.jpsychires.2010.05.006. PMID 20562024.
- Pol, H. E H.; Cohen-Kettenis, P. T; Van Haren, N. E M; Peper, J. S; Brans, R. G H; Cahn, W.; Schnack, H. G; Gooren, L. J G; Kahn, R. S (2006). "Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure". European Journal of Endocrinology. 155: S107–S114. doi:10.1530/eje.1.02248.
- Rametti, G.; Carrillo, B.; Gómez-Gil, E.; Junque, C.; Zubiarre-Elorza, L.; Segovia, S.; Gomez, Á; Guillamon, A. (2011). "White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study". Journal of Psychiatric Research. 45: 199–204. doi:10.1016/j.jpsychires.2010.05.006. PMID 20562024.
- LeVay S (August 1991). "A difference in hypothalamic structure between heterosexual and homosexual men". Science. 253 (5023): 1034–7. doi:10.1126/science.1887219. PMID 1887219.
- Byne W, Tobet S, Mattiace LA, et al. (September 2001). "The interstitial nuclei of the human anterior hypothalamus: an investigation of variation with sex, sexual orientation, and HIV status". Horm Behav. 40 (2): 86–92. doi:10.1006/hbeh.2001.1680. PMID 11534967.
- Eyal Abraham; Talma Hendler; Irit Shapira-Lichter; Yaniv Kanat-Maymon; Orna Zagoory-Sharon; Ruth Feldman (May 2014). "Father's brain is sensitive to childcare experiences". Proceedings of the National Academy of Sciences. 111 (27): 9792–9797. doi:10.1073/pnas.1402569111.
- Gizewski, E. R.; Krause, E.; Schlamann, M.; Happich, F.; Ladd, M. E.; Forsting, M.; Senf, W. (2009). "Specific cerebral activation due to visual erotic stimuli in male-to-female transsexuals compared with male and female controls: An fMRI study". Journal of Sexual Medicine. 6: 440–448. doi:10.1111/j.1743-6109.2008.00981.x.
- Rametti, G.; Carrillo, B.; Gómez-Gil, E.; Junque, C.; Zubiarre-Elorza, L.; Segovia, S.; Gomez, Á.; Guillamon, A. (2010). "The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment: A DTI study". Journal of Psychiatric Research. 45: 949–954. doi:10.1016/j.jpsychires.2010.11.007.
- Savic, I.; Arver, S. (2011). "Sex dimorphism of the brain in male-to-female transsexuals". Cerebral Cortex. 21: 2525–2533. doi:10.1093/cercor/bhr032.
- Berglund, H.; Lindstrom, P.; Dhejne-Helmy, C.; Savic, I. (2007). "Male-to-Female Transsexuals Show Sex-Atypical Hypothalamus Activation When Smelling Odorous Steroids". Cerebral Cortex. 18 (8): 1900–8. doi:10.1093/cercor/bhm216. PMID 18056697.
- Male-to-Female Transsexuals Show Sex-Atypical Hypothalamus Activation When Smelling Odorous Steroids (full article)
- Nawata, H.; Ogomori, K.; Tanaka, M.; Nishimura, R.; Urashima, H.; Yano, R.; Takano, K.; Kuwabara, Y. (2010). "Regional cerebral blook flow changes in female to male gender identity disorder". Psychiatry and Clinical Neurosciences. 64: 157–161. doi:10.1111/j.1440-1819.2009.02059.x.
- Ramachandran, V. S. (2008). "Phantom Penises In Transsexuals". Journal of Consciousness Studies. 15 (1): 5–16.
- Schneider, H; Pickel, J; Stalla, G (2006). "Typical female 2nd–4th finger length (2D:4D) ratios in male-to-female transsexuals—possible implications for prenatal androgen exposure". Psychoneuroendocrinology. 31 (2): 265–9. doi:10.1016/j.psyneuen.2005.07.005. PMID 16140461.
- Dreger, Alice; Feder, Ellen K.; Tamar-Mattis, Anne (September 2012). "Prenatal Dexamethasone for Congenital Adrenal Hyperplasia: An Ethics Canary in the Modern Medical Mine". Journal of Bioethical Inquiry. 9 (3): 277–294. doi:10.1007/s11673-012-9384-9. ISSN 1176-7529. Retrieved 2016-05-31.
- Clayton, Peter E.; Miller, Walter L.; Oberfield, Sharon E.; Ritzén, E. Martin; Sippell, Wolfgang G.; Speiser, Phyllis W.; ESPE/ LWPES CAH Working Group (2002). "Consensus statement on 21-hydroxylase deficiency from the European Society for Paediatric Endocrinology and the Lawson Wilkins Pediatric Endocrine Society" (PDF). Hormone Research. 58 (4): 188–195. doi:10.1159/000065490. ISSN 0301-0163. PMID 12324718.
- Erickson-Schroth, Laura (2013). "Update on the Biology of Transgender Identity". Journal of Gay & Lesbian Mental Health. 17: 150–74. doi:10.1080/19359705.2013.753393.
- Desire for Surgical Sex Transmutation: An Insane Fancy of Near Males. D.O. Cauldwell. 2001 reprint in the International Journal of Transgenderism Vol. 5 Number 2 of a paper published in 1947.
- Benjamin, H. (1966). The transsexual phenomenon. New York: Julian Press, page 85.
- "David Reimer, subject of 'sex reassignment,' dead at 38".
- Colapinto, J (2001). As Nature Made Him: The Boy Who Was Raised as a Girl. Harper Perennial. ISBN 0-06-092959-6. Revised in 2006
- Intersex Society of North America | A world free of shame, secrecy, and unwanted genital surgery
- Blanchard, RAY (1989). "The Concept of Autogynephilia and the Typology of Male Gender Dysphoria". The Journal of Nervous and Mental Disease. 177 (10): 616–23. doi:10.1097/00005053-198910000-00004. PMID 2794988.
- Freund, Kurt; Steiner, Betty W.; Chan, Samuel (1982). "Two types of cross-gender identity". Archives of Sexual Behavior. 11 (1): 49–63. doi:10.1007/BF01541365. PMID 7073469.
- Bailey, J. M. (2003). The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. Joseph Henry Press, ISBN 0-309-08418-0, ISBN 978-0-309-08418-5
- Blanchard, R. (2005) "...Since the beginning of the last century, clinical observers have described the propensity of certain males to be erotically aroused by the thought or image of themselves as women..." in Early History of the Concept of Autogynephilia from the Archives of Sexual Behavior, Volume 34, Number 4, pages 439-446. Retrieved on 2007-09-22.
- Smith, Y.L.S., van Goozen, S.H.M., Kuiper, A.J., Cohen-Kettenis, P.T.. (2005) "...The present study was designed to investigate whether transsexuals can be validly subdivided into subtypes on the basis of sexual orientation..." in Transsexual subtypes: Clinical and theoretical significance from Psychiatry Research, Volume 137, Issue 3, pages 151-160. Retrieved on 2007-09-22.
- Blanchard, Ray (1989). "The classification and labeling of nonhomosexual gender dysphorias". Archives of Sexual Behavior. 18 (4): 315–34. doi:10.1007/BF01541951. PMID 2673136.
- Blanchard, Ray (1988). "Nonhomosexual gender dysphoria". Journal of Sex Research. 24 (1): 188–93. doi:10.1080/00224498809551410. PMID 22375647.
- Blanchard, R (1989). "The concept of autogynephilia and the typology of male gender dysphoria". The Journal of Nervous and Mental Disease. 177 (10): 616–23. doi:10.1097/00005053-198910000-00004. PMID 2794988.
- Blancard, Ray (Winter 1991). "Clinical observations and systematic studies of autogynephilia". Journal of Sex & Marital Therapy. 17 (4): 235–51. doi:10.1080/00926239108404348. PMID 1815090.
- Bailey, J. M. (2003). The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. Joseph Henry Press. ISBN 0-309-08418-0.[page needed]
- Veale, Jaimie F.; Clarke, Dave E.; Lomax, Terri C. (2008). "Sexuality of Male-to-Female Transsexuals". Archives of Sexual Behavior. 37 (4): 586–597. doi:10.1007/s10508-007-9306-9. PMID 18299976.
- Moser, Charles (2009). "Autogynephilia in Women". Journal of Homosexuality. 56 (5): 539–547. doi:10.1080/00918360903005212. PMID 19591032.
- Moser, Charles (2010). "Blanchard's Autogynephilia Theory: A Critique". Journal of Homosexuality. 57 (6): 790–809. doi:10.1080/00918369.2010.486241. PMID 20582803.
- Nuttbrock, L; Bockting, W; Mason, M; Hwahng, S; Rosenblum, A; Macri, M; Becker, J (2010). "A Further Assessment of Blanchard's Typology of Homosexual Versus Non-Homosexual or Autogynephilic Gender Dysphoria". Archives of Sexual Behavior. 40 (2): 247–257. doi:10.1007/s10508-009-9579-2. PMC . PMID 20039113.
- Dreger, A. D. (2008). "The Controversy Surrounding the Man Who Would Be Queen: A Case History of the Politics of Science, Identity, and Sex in the Internet Age". Archives of Sexual Behavior. 37 (3): 366–421. doi:10.1007/s10508-007-9301-1. PMC . PMID 18431641.
- Serano, Julia (2007). Whipping girl: a transsexual woman on sexism and the scapegoating of femininity. Seal Press. p. 178. ISBN 978-1-58005-154-5.
While Blanchard's controversial theory is built upon a number of incorrect and unfounded assumptions, and there are many methodological flaws in the data he offers to support it, it has garnered some acceptance in the psychiatric literature...
- Gijs, L.; Carroll, R. A. (2011). "Should Transvestic Fetishism Be Classified inDSM 5? Recommendations from the WPATH Consensus Process for Revision of the Diagnosis of Transvestic Fetishism". International Journal of Transgenderism. 12 (4): 189–197. doi:10.1080/15532739.2010.550766.
- Knudson, G.; De Cuypere, G.; Bockting, W. (2011). "Second Response of the World Professional Association for Transgender Health to the Proposed Revision of the Diagnosis of Transvestic Disorder forDSM5". International Journal of Transgenderism. 13: 9–12. doi:10.1080/15532739.2011.606195.
- from DSM5.org rationale bullet 18. bullet 18 under rationale