Transsexualism and transgender: links

This page collates links to scientific papers on the subject of transsexualism and transgender. Where non scientific papers have been included, eg Veale, it is because the author or the paper has achieved prominence in the debate. I accept suggestions for new links to include: please use the Contact Form below.

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The American Psychiatric Association’s Diagnostic and Statistical Manual (Fifth Edition) chapter on Gender Dysphoria (PDF download)The APA on Gender Dysphoria

Published Papers


Ainsworth TA. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. 2010.



To determine the self-reported quality of life of male-to-female (MTF) transgendered individuals and how this quality of life is influenced by facial feminization and gender reassignment surgery.


Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

Auer M K. Transgender Transitioning and Change of Self-Reported Sexual Orientation.


Bakker A The prevalence of transsexualism in The Netherlands. 1993.


The prevalence of transsexualism in the Netherlands was estimated by counting all the subjects who were diagnosed as transsexuals by psychiatrists or psychologists and were subsequently hormonally treated and generally underwent sex-reassignment surgery. At the end of 1990, 713 Dutch-born transsexuals received treatment (507 men, 206 women). This amounts to a prevalence of 1:11,900 for male-to-female transsexualism and 1:30,400 for female-to-male transsexualism (population age 15 and above in both groups). The sex ratio was about 2.5 men to 1 woman. The most important reason for this relatively high prevalence seems to be the benevolent climate for the treatment of transsexualism in the Netherlands.

Barboza et al. Physical victimization, gender identity and suicide risk among transgender men and women. 2016.



We investigated whether being attacked physically due to one’s gender identity or expression was associated with suicide risk among trans men and women living in Virginia. The sample consisted of 350 transgender men and women who participated in the Virginia Transgender Health Initiative Survey (THIS). Multivariate multinomial logistic regression was used to explore the competing outcomes associated with suicidal risk. Thirty-seven percent of trans men and women experienced at least one physical attack since the age of 13. On average, individuals experienced 3.97 (SD = 2.86) physical attacks; among these about half were attributed to one’s gender identity or expression (mean = 2.08, SD = 1.96). In the multivariate multinomial regression, compared to those with no risk, being physically attacked increased the odds of both attempting and contemplating suicide regardless of gender attribution. Nevertheless, the relative impact of physical victimization on suicidal behavior was higher among those who were targeted on the basis of their gender identity or expression. Finally, no significant association was found between multiple measures of institutional discrimination and suicide risk once discriminatory and non-discriminatory physical victimization was taken into account. Trans men and women experience high levels of physical abuse and face multiple forms of discrimination. They are also at an increased risk for suicidal tendencies. Interventions that help transindividuals cope with discrimination and physical victimization simultaneously may be more effective in saving lives.

Beemyn & Rankin. Understanding Transgender Lives

Bentler, P. A typology of transsexualism: Gender identity theory and data.

This paper pre-dates Blanchard and in it the authors describe three types of transsexual: homosexual, asexual and heterosexual. Blanchard was able to reconcile the two latter groups into one, autogynephilic.

Blanchard, R. Heterosexual and homosexual gender dysphoria


This study investigated why more males than females complain of dissatisfaction with their anatomical sex (gender dysphoria). New referrals to a university gender identity clinic were dichotomously classified as heterosexual or homosexual. There were 73 heterosexual and 52 homosexual males; 1 heterosexual and 71 homosexual females. The average heterosexual male was 8 years older at inception than the homosexual groups. The heterosexual males reported that their first cross-gender wishes occurred around the time they first cross-dressed, whereas the homosexual groups reported that cross-gender wishes preceded cross-dressing by 3–4 years. Some history of fetishistic arousal was acknowledged by over 80% of the heterosexual males, compared to fewer than 10% of homosexual males and no homosexual females. The results suggest that males are not differentially susceptible to gender dysphoria per se, but rather that they are differentially susceptible to one of the predisposing conditions, namely, fetishistic transvestism.

Blanchard, R, The Concept of Autogynephilia and the Typology of Male Gender Dysphoria.

This is paper sets out the basis of Blanchard’s typology. The appendix contains his questionnaires. One of the most important sentences in it is this:

‘the central prediction of the present study, namely, that autogynephilic behavior will be reported more frequently by non-homosexual than by homosexual gender dysphorics.’ (My emphasis.)

It has been the consistent attempt of Western autogynephilic activists to attack Blanchard for making what they call ‘generalisations’. That is a straw man. Blanchard, in all his  papers, is careful not to go beyond the science. This is demonstrated here.

Blanchard, R The Classification and labeling of no nonhomosexual gender dysphorias. 1989 (pdf)

Perhaps the definitive paper by Blanchard on non-homosexual gender dysphoria, otherwise known as Autogynephilia.

Blanchard, R. A History of Autogynephilia (pdf) Blanchard- History of Autogynephilia

Blanchard, R. Typology of male-to-female transsexualism

Blanchard, R. The classification and labeling of nonhomosexual gender dysphorias

Blanchard R, Collins PI., “Men with sexual interest in transvestites, transsexuals, and she-males”

Blanchard R., “The she-male phenomenon and the concept of partial autogynephilia”

Blanchard R,et al. Comparison of height and weight in homosexual versus nonhomosexual male gender dysphorics.

Blanchard, R. Fraternal Birth Order and the Maternal Immune Hypothesis of Male Homosexuality. 2001. (pdf)

Blanchard, R. Review and theory of handedness, birth order, and homosexuality in men. 2008.


Research has repeatedly shown that older brothers increase the odds of homosexuality in later-born males. This phenomenon has been called the fraternal birth order effect. The most highly developed explanation of this phenomenon is the maternal immune hypothesis, which proposes that the fraternal birth order effect reflects the progressive immunisation of some mothers to male-specific antigens by each succeeding male foetus and the concomitantly increasing effects of anti-male antibodies on the sexual differentiation of the brain in each succeeding male foetus. Recent studies indicate that older brothers increase the odds of homosexuality in right-handed males but not in non-right-handed males. The present article explores how the maternal immune hypothesis might be extended or modified to account for the apparent interaction of older brothers and handedness. Two possibilities are considered: (1) non-right-handed foetuses are insensitive to the presence of maternal anti-male antibodies, and (2) mothers of non-right-handed foetuses do not produce anti-male antibodies.

Review and theory of handedness, birth order, and homosexuality in men (PDF Download Available). Available from:

Blanchard R, et al. Sexual Attraction to Others: A Comparison of Two Models of Alloerotic Responding in Men 2010


The penile response profiles of homosexual and heterosexual pedophiles, hebephiles, and teleiophiles to laboratory stimuli depicting male and female children and adults may be conceptualized as a series of overlapping stimulus generalization gradients. This study used such profile data to compare two models of alloerotic responding (sexual responding to other people) in men. The first model was based on the notion that men respond to a potential sexual object as a compound stimulus made up of an age component and a gender component. The second model was based on the notion that men respond to a potential sexual object as a gestalt, which they evaluate in terms of global similarity to other potential sexual objects. The analytic strategy was to compare the accuracy of these models in predicting a man’s penile response to each of his less arousing (nonpreferred) stimulus categories from his response to his most arousing (preferred) stimulus category. Both models based their predictions on the degree of dissimilarity between the preferred stimulus category and a given nonpreferred stimulus category, but each model used its own measure of dissimilarity. According to the first model (“summation model”), penile response should vary inversely as the sum of stimulus differences on separate dimensions of age and gender. According to the second model (“bipolar model”), penile response should vary inversely as the distance between stimulus categories on a single, bipolar dimension of morphological similarity-a dimension on which children are located near the middle, and adult men and women are located at opposite ends. The subjects were 2,278 male patients referred to a specialty clinic for phallometric assessment of their erotic preferences. Comparisons of goodness of fit to the observed data favored the unidimensional bipolar model.

Blanchard, R. Fraternal Birth Order, Family Size, and Male Homosexuality: Meta-Analysis of Studies Spanning 25 Years. 2018. Archives of Sexual Behavior


The fraternal birth order effect is the tendency for older brothers to increase the odds of homosexuality in later-born males. This study compared the strength of the effect in subjects from small versus large families and in homosexual subjects with masculine versus feminine gender identities. Meta-analyses were conducted on 30 homosexual and 30 heterosexual groups from 26 studies, totaling 7140 homosexual and 12,837 heterosexual males. The magnitude of the fraternal birth order effect was measured with a novel variable, the Older Brothers Odds Ratio, computed as (homosexuals’ older brothers ÷ homosexuals’ other siblings) ÷ (heterosexuals’ older brothers ÷ heterosexuals’ other siblings), where other siblings = older sisters + younger brothers + younger sisters. An Older Brothers Odds Ratio of 1.00 represents no effect of sexual orientation; values over 1.00 are positive evidence for the fraternal birth order effect. Evidence for the reliability of the effect was consistent. The Older Brothers Odds Ratio was significantly >1.00 in 20 instances, >1.00 although not significantly in nine instances, and nonsignificantly <1.00 in 1 instance. The pooled Older Brothers Odds Ratio for all samples was 1.47, p < .00001. Subgroups analyses showed that the magnitude of the effect was significantly greater in the 12 feminine or transgender homosexual groups than in the other 18 homosexual groups. There was no evidence that the magnitude of the effect differs according to family size.

Dr Ray Blanchard remains one of the most interesting researchers into sex and sexuality, after a career of over 40 years.  He is generous of his time and will respond to requests for full pdf versions of papers not already available as such, for those who lack academic access to them. He can be contacted through his Researchgate page here:

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Bockting et al. Gay and bisexual identity development among female-to-male transsexuals in North America: emergence of a transgender sexuality.

Bogaert, Anthony F. The prevalence of male homosexuality: the effect of fraternal birth order and variations in family size 2004

Bullough, Vern L. Transgenderism and the Concept of Gender

Burke, S et al. Structural connections in the brain in relation to gender identity and sexual orientation 2017


Both transgenderism and homosexuality are facets of human biology, believed to derive from different sexual differentiation of the brain. The two phenomena are, however, fundamentally unalike, despite an increased prevalence of homosexuality among transgender populations. Transgenderism is associated with strong feelings of incongruence between one’s physical sex and experienced gender, not reported in homosexual persons. The present study searches to find neural correlates for the respective conditions, using fractional anisotropy (FA) as a measure of white matter connections that has consistently shown sex differences. We compared FA in 40 transgender men (female birth-assigned sex) and 27 transgender women (male birth-assigned sex), with both homosexual (29 male, 30 female) and heterosexual (40 male, 40 female) cisgender controls. Previously reported sex differences in FA were reproduced in cis-heterosexual groups, but were not found among the cis-homosexual groups. After controlling for sexual orientation, the transgender groups showed sex-typical FA-values. The only exception was the right inferior fronto-occipital tract, connecting parietal and frontal brain areas that mediate own body perception. Our findings suggest that the neuroanatomical signature of transgenderism is related to brain areas processing the perception of self and body ownership, whereas homosexuality seems to be associated with less cerebral sexual differentiation.

Comment: On a number of parameters, this study conflicts with Rametti. The authors acknowledge this anomaly but do not explain it.


Campbell, Natalie M.  Nuclear family dynamics: Predictors of childhood crushes and adult sexual orientation 2015

Cantor, J M. New MRI Studies Support the Blanchard Typology of Male-to-Female Transsexualism. 2011.

Full Article

Two independent empirical articles have recently appeared in the literature that, taken together, bear out an hypothesis Blanchard (2008) postulated in the Archives about brain development in transsexualism:

[T]he brains of both homosexual and heterosexual male-to-female transsexuals probably differ from the brains of typical heterosexual men, but in different ways. In homosexual male-to-female transsexuals, the difference does involve sex-dimorphic structures, and the nature of the difference is a shift in the female-typical direction. If there is any neuroanatomic intersexuality, it is in the homosexual group. In heterosexual male-to-female transsexuals, the difference may not involve sex-dimorphic structures at all, and the nature of the structural difference is not necessarily along the male–female dimension. (p. 437)

Blanchard’s prediction follows from studies that have repeatedly shown that the homosexual male-to-female transsexuals are “female-shifted” in multiple, sexually dimorphic characteristics, whereas the heterosexual male-to-female transsexuals are not (Blanchard, 1989a1989b). For example, homosexual male-to-female transsexuals are sexually attracted to natal males, express greater interest in female-typical activities (even in childhood), and are naturally effeminate in mannerism. In contrast, heterosexual male-to-female transsexuals are indistinguishable from nontranssexual natal males on these variables. The heterosexual transsexuals are still distinct from typical males in other ways, however, such as by manifesting “autogynephilia”—the erotic interest in or sexual arousal in response to being or seeming female. The consistent detection of cross-sex features among homosexual male-to-female transsexuals, but not among heterosexual male-to-female transsexuals, led Blanchard to predict that the cross-sex pattern would also emerge at the level of brain anatomy and be limited to the homosexual male-to-female transsexuals. That prediction now appears to be the case, with Rametti et al. (2010) supporting his prediction for the homosexual transsexuals, and Savic and Arver (2010), for the heterosexual transsexuals.

The Rametti team used an MRI technique called Diffusion Tensor Imaging to compare homosexual male-to-female transsexuals (n = 18) with nontranssexual, heterosexual control males (n = 19) and with nontranssexual, heterosexual control females (n = 19). They contrasted the male controls with the female controls to identify the sex-dimorphic portions of the brain and then contrasted the homosexual transsexuals with each of the control groups on the dimorphic brain regions so identified. The initial contrasts identified six sex-dimorphic brain regions. The homosexual transsexual sample was intermediate in volume on all six brain structures, significantly different from the male controls on five of the six (and significantly different from the female controls on all six). That is, these male-to-female transsexuals were different from the control males, shifted towards the female direction on all parameters.

Savic and Arver (2010) applied anatomical MRIs with an analogous research design, identifying the sex-dimorphic portions of the brain and contrasting the (this time) heterosexual transsexual sample (n = 24) with each control sample (n’s = 24 each) on the sex-dimorphic brain regions. Of the eight brain regions that distinguished male from female brains, the heterosexual transsexual sample differed from the male controls on none (Savic & Arver, 2010, Table 3). Of the four brain regions that distinguished these heterosexual transsexuals from the male controls, sex-dimorphism was present in none (Savic & Arver, 2010, Table 3). As Savic and Arver themselves emphasized, “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” although that statement should have been restricted to refer to heterosexual male-to-female transsexuals only.

Also meriting emphasis is that—although these data disconfirm that the heterosexual type has a feminized brain pattern—the data nonetheless confirm that heterosexual transsexuals have a brain structure distinct from that of typical (nontranssexual) persons. Their gender identity is not a transient or ephemeral characteristic, but a likely innate and immutable characteristic, emerging from their particular brain structure.

Clemens, B. Male‐to‐female gender dysphoria: Gender‐specific differences in resting‐state networks 2017 (full)



Recent research found gender‐related differences in resting‐state functional connectivity (rs‐FC) measured by functional magnetic resonance imaging (fMRI). To the best of our knowledge, there are no studies examining the differences in rs‐FC between men, women, and individuals who report a discrepancy between their anatomical sex and their gender identity, i.e. gender dysphoria (GD).


Our results provide first evidence that MtFs exhibit patterns of rs‐FC which are different from both their assigned and their aspired gender, indicating an intermediate position between the two sexes. We suggest that the present study constitutes a starting point for future research designed to clarify whether the brains of individuals with GD are more similar to their assigned or their aspired gender.


De Vries et al. Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach 2012.


The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth’s functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.

Del Giudice, M. Joel et al.’s method systematically fails to detect large, consistent sex differences (in human brains.) 2016. (Letter)

Dhejne, C et al: Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden 2011



The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person’s body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment.


To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons.


Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.



This study is limited in its usefulness because it does not control for the homosexual/non-homosexual variable. This results in two markedly different expressions, Homosexual transsexualism (HSTS) and Autogynephilic transvestism (AGP). The study method makes no attempt to account for this dichotomy, indeed it does not even mention it. Since the different types are so disparate, this renders it in essence useless, although it does illustrate that Gender Reconstruction Surgery is not the panacea for Gender Dysphoria that advocates claim it is. However, whether the negative effects are spread evenly across HSTS and AGP types is not analysed in the study.

This methodological failure should serve to indicate that research into Gender Dysphorias and the treatments of them must take into account and control for the four different types, male HS, male non-HS (AGP), female HS and female non-HS.

Dhejne, C. An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960-2010: Prevalence, Incidence, and Regrets. 2014. (pdf)

Dreger, Alice D. The Controversy Surrounding The Man Who Would Be Queen: A Case History of the Politics of Science, Identity, and Sex in the Internet Age 2008



 Fortenberry, JD Puberty and Adolescent Sexuality 2014

Freund, K.Cross-Gender Identity in a Broader Context


This chapter is a review of clinical and experimental studies that may suggest questions useful in research on the etiology of cross-gender identity (which is here conceived as an extreme form of masculine gender identity in females or feminine gender identity in males). The first section addresses itself to the typology of cross-gender identity and demonstrates that there are two main types, one occurring in homosexual, the other in heterosexual (or just nonhomosexual) persons. Next, the relationships among androphilia (an erotic preference for physically mature males), homosexual-type cross-gender identity, and feminine gender identity (in males) in general are explored. The second section investigates the feasibility of physiological hypotheses of homosexual cross-gender identity and discusses, in this context, relevant work on the development of gender identity in intersexes. The third section explores the relevance of animal studies to the problem of gender identity.

Freund K et al. Two types of cross-gender identity. 1982


A revision of the typology of male cross-gender identity was carried out by means of formalized, easily replicable methods. The results suggest (1) that there are two discrete types of cross-gender identity, one heterosexual, the other homosexual; (2) that transvestism, and closely related conditions of cross-gender identity, occur exclusively or almost exclusively in heterosexuals; (3) that of the two types of transsexualism distinguished in this study, type A is, in heterosexuals, very rare or completely nonexistent; (4) that (in the course of time) transvestites or borderline transsexuals (defined below) may develop sustained cross-gender identity, as observed by Stoller (1971); (5) that although, according to Hoenig and Kenna (1974), transsexualism by itself is not an anomalous erotic preference, it is (virtually) always either preceded by transvestism or accompanied by homosexuality or cross-gender fetishism.

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Galis, Frietson. Sexual Dimorphism in the Prenatal Digit Ratio (2D:4D)

Green et al. Specific cross-gender behaviour in boyhood and later homosexual orientation.

Green, R. Gender Identity in Childhood and Later Sexual Orientation: Follow-Up of 78 Males (1983) (abstract)

Guillamon, A, et al. A Review of the Status of Brain Structure Research in Transsexualism

Gurven, M and Hill, K. Why Do Men Hunt? A Reevaluation of “Man the Hunter” and the Sexual Division of Labor


Hahn, al Structural Connectivity Networks of Transgender People 2015   Full paper

Hare et al. Androgen receptor repeat length polymorphism associated with male-to-female transsexualism.



There is a likely genetic component to transsexualism, and genes involved in sex steroidogenesis are good candidates. We explored the specific hypothesis that male-to-female transsexualism is associated with gene variants responsible for undermasculinization and/or feminization. Specifically, we assessed the role of disease-associated repeat length polymorphisms in the androgen receptor (AR), estrogen receptor β (ERβ), and aromatase (CYP19) genes.


A significant association was identified between transsexualism and the AR allele, with transsexuals having longer AR repeat lengths than non-transsexual male control subjects (p = .04). No associations for transsexualism were evident in repeat lengths for CYP19 or ERβ genes. Individuals were then classified as short or long for each gene polymorphism on the basis of control median polymorphism lengths in order to further elucidate possible combined effects. No interaction associations between the three genes and transsexualism were identified.

Hilleke E Hulshoff Pol,  Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure 2006


Objective: Sex hormones are not only involved in the formation of reproductive organs, but also induce sexually-dimorphic brain development and organization. Cross-sex hormone administration to transsexuals provides a unique possibility to study the effects of sex steroids on brain morphology in young adulthood.

Methods: Magnetic resonance brain images were made prior to, and during, cross-sex hormone treatment to study the influence of anti-androgen + estrogen treatment on brain morphology in eight young adult male-to-female transsexual human subjects and of androgen treatment in six female-to-male transsexuals.

Results: Compared with controls, anti-androgen + estrogen treatment decreased brain volumes of male-to-female subjects towards female proportions, while androgen treatment in female-to-male subjects increased total brain and hypothalamus volumes towards male proportions.

Conclusions: The findings suggest that, throughout life, gonadal hormones remain essential for maintaining aspects of sex-specific differences in the human brain.

Hockenberry et al. Sexual orientation and boyhood gender conformity: development of the Boyhood Gender Conformity Scale (BGCS) 1987




Two hundred twenty-five [corrected] respondents (109 [corrected] heterosexuals and 116 [corrected] homosexuals) completed a survey containing a 20-item Boyhood Gender Conformity Scale (BGCS). This scale was largely composed of edited and abridged gender items from Part A of Freund et al.’s Feminine Gender Identity Scale (FGIS-A) and Whitam’s “childhood indicators.” The combined scale was developed in an attempt to obtain a reliable, valid, and potent discriminating instrument for accurately classifying adult male respondents for sexual orientation on the basis of their reported boyhood gender conformity or nonconforming behavior and identity. In addition, 33% of these respondents were administered the original FGIS-A and Whitam inventory during a 2-week test-retest analysis conducted to determine the validity and reliability of the new instrument. All the original items significantly discriminated between heterosexual and homosexual respondents. From these a 13-item function and a 5-item function proved to be the most powerful discriminators between the two groups. Significant correlations between each of the three scales and a very high test-retest correlation coefficient supported the reliability and validity assumption for the BGCS. The conclusion was made that the five-item function (playing with boys, preferring [corrected] boys’ games, imagining self as sports figure, reading adventure and sports stories, considered a “sissy”) was the most potent and parsimonious discriminator among adult males for sexual orientation. It was similarly noted that the absence of masculine behaviors and traits appeared to be a more powerful predictor of later homosexual orientation than the traditionally feminine or cross-sexed traits and behaviors.

Hsu,  Rosenthal, Miller and Bailey, “Who are gynandromorphophilic men? Characterizing men with sexual interest in transgender women

Hsu, Rosenthal, Miller, & Bailey 2015  Who are gynandromorphophilic men? Characterizing men with sexual interest in transgender women. 2015


Italiano, M. Postsurgical Changes in the Neovagina. 1998.Transgender Treatment Bulletin.


Junger, J, et al More than Just Two Sexes: The Neural Correlates of Voice Gender Perception in Gender Dysphoria 2013


Compared to men and women, MtFs showed differences in a neural network including the medial prefrontal gyrus, the insula, and the precuneus when responding to male vs. female voices. With increased voice morphing men recruited more prefrontal areas compared to women and MtFs, while MtFs revealed a pattern more similar to women. On a behavioral and neuronal level, our results support the feeling of MtFs reporting they cannot identify with their assigned sex.

Link to full article:



Kulick, D. The Gender of Brazilian Transgender Prostitutes.1997

Note: This is an anthropological study of travestis, trans prostitutes. This, and Kulick’s other work on the subject is the most important body of information available on this subject. A great many of the observations that Kulick makes are found in other trans populations both in the West and elsewhere. Familiarity with the concepts discussed in this work will make it far easier to understand the nature of homosexuality and HSTS everywhere. (pdf download available.)

Karwowsk, Maciej Greater male variability in creativity: A latent variables approach 2016


Lagos et al. Regional Grey Matter Structure Differences between Transsexuals and Healthy Controls—A Voxel Based Morphometry Study. 2013.

Study of homosexual transsexuals, both MtF and FtM. Non-homosexual subjects were screened out. Results consistent with Rametti 2011.

Full text link:

Landén M, et al. Prevalence, incidence and sex ratio of transsexualism.1996.

Abstract: Frequency figures for transsexualism, concerning incidence, prevalence and sex ratio calculated in the 1960s and 1970s, were compared with recent reports. The incidence figures remained constant over time, whereas the prevalence figures tended to increase during the review period. The incidence was found to be of the same magnitude in men and women, while the corresponding ratio for prevalence figures was 3:1. It is suggested that men seeking sex reassignment represent a more heterogeneous group than women, and that the reported male predominance to date is due to a lack of categorical studies of primary/ genuine transsexualism. It would appear that genuine transsexualism is, on the whole, insensitive to societal changes. The fundamental disturbance underlying this psychosexual identity disorder is suggested to be neurobiological in origin.

Note: it is not clear what the author means by ‘primary/ genuine transsexualism‘ but we assume he means HSTS, given the subsequent comments.

Lawrence, Dr A. Anatomic Autoandrophilia in an Adult Male. 2009




Some men are sexually aroused by impersonating the individuals to whom they are sexually attracted, or by permanently changing their bodies to become facsimiles of such individuals. Blanchard (J Sex Marital Ther 17:235–251, 1991) suggested that these paraphilic sexual interests, along with fetishism, represented erotic target location errors, i.e., developmental errors in locating erotic targets in the environment. Because the desire to impersonate or become a facsimile of the kind of person to whom one is attracted can have significant implications for identity, Freund and Blanchard (Br J Psychiatry 162:558–563, 1993) coined the term erotic target identity inversion to describe this type of erotic target location error. The best-known examples of erotic target identity inversions occur in men who are sexually attracted to women and who are also sexually aroused by the idea of impersonating or becoming women; these paraphilic interests manifest as transvestic fetishism and as one type of male-to-female transsexualism. Analogous erotic target identity inversions have been described in men who are sexually attracted to children and to female amputees. In theory, erotic target identity inversions should also occur in men who are sexually attracted to men. There have been no unambiguous descriptions, however, of men who are sexually attracted to men and also sexually aroused by the idea of changing their bodies to become more sexually attractive men. This report describes such a man, whose paraphilic interest would appropriately be called anatomic autoandrophilia. The demonstration that anatomic autoandrophilia exists in men is consistent with the theory that erotic target location errors constitute an independent paraphilic dimension.

Lawrence, Dr A. Do Some Men Who Desire Sex Reassignment Have a Mental Disorder? Comment on Meyer-Bahlburg (2010) 2011

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Lawrence, A. Autogynephilia: A Paraphilic Model of Gender Identity Disorder.,_a_paraphilic_model_of_GID.pdf

Lawrence, Anne A. Autogynephilia and Heterosexuality 2012

Lawrence, A. Further Validation of Blanchard’s Typology: A Reply to Nuttbrock, Bockting, Rosenblum, Mason, and Hwahng (2010)’s_Typology_A_Reply_to_Nuttbrock_Bockting_Rosenblum_Mason_and_Hwahng_2010

Lawrence, Anne A. Clinical and Theoretical Parallels Between Desire for Limb Amputation and Gender Identity Disorder 2006

Lawrence Anne A  A Critique of the Brain-Sex Theory of Transsexualism (2007) pdf download

Lawrence Anne A. Erotic Target Location Errors: An Underappreciated Paraphilic Dimension


Based on studies of heterosexual male fetishists, transvestites, and transsexuals, Blanchard (1991) proposed the existence of a hitherto unrecognized paraphilic dimension, erotic target location errors (ETLEs), involving the erroneous location of erotic targets in the environment. ETLEs can involve preferential attention to a peripheral or inessential part of an erotic target, manifesting as fetishism, or mislocation of an erotic target in one’s own body, manifesting as the desire to impersonate or become a facsimile of the erotic target (e.g., transvestism or transsexualism). Despite its potential clinical and heuristic value, the concept that ETLEs define a paraphilic dimension is underappreciated. This review summarizes the studies leading to the concept of ETLEs and describes how ETLEs are believed to manifest in men whose preferred erotic targets are women, children, men, amputees, plush animals, and real animals. This review also describes ETLEs in women; discusses possible etiologies of ETLEs; considers the implications of the ETLE concept for psychoanalytic theories of transvestism and male-to-female transsexualism, as well as for the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; suggests reasons why the concept of ETLEs has been underappreciated; and describes what might result if the concept were more widely appreciated.

Lawrence, Dr Anne A. Erotic Target Location Errors are Easy to Mischaracterize: A Reply to Moser. 2009

Lawrence, Dr Anne. Autogynephilia and the Typology of Male-to-Female Transsexualism: Concepts and Controversies. 2017.


Abstract: Sexual scientists have recognized for over a century that biologic males who seek sex reassignment – male-to-female (MtF) transsexuals – are not a homogeneous clinical population but comprise two or more distinct subtypes with different symptoms and developmental trajectories. The most widely used typologies of MtF transsexualism have been based on sexual orientation and have distinguished between persons who are androphilic (exclusively sexually attracted to males) and those who are nonandrophilic (sexually attracted to females, both males and females, or neither gender). In 1989, psychologist Ray Blanchard proposed that most nonandrophilic MtF transsexuals display a paraphilic sexual orientation called autogynephilia, defined as the propensity to be sexually aroused by the thought or image of oneself as a woman. Studies conducted by Blanchard and colleagues provided empirical support for this proposal, leading to the hypothesis that almost all nonandrophilic MtF transsexuals are autogynephilic, whereas almost all androphilic MtF transsexuals are not. Blanchard’s ideas received increased attention in 2003 after they were discussed in a book by psychologist J. Michael Bailey. The concept of autogynephilia subsequently became intensely controversial among researchers, clinicians, and MtF transsexuals themselves, causing widespread repercussions. This article reviews the theory of autogynephilia, the evidence supporting it, the objections raised by its critics, and the implications of the resulting controversy for research and clinical care.

Li et al. Childhood Gender-Typed Behavior and Adolescent Sexual Orientation: A Longitudinal Population-Based Study. 2016.

Little A C. Women’s preferences for masculinity in male faces are highest during reproductive age range and lower around puberty and post-menopause 2010

Littman, L Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports 2018

Full paper available online, printable version

Rapid-onset gender dysphoria in adolesc..

Below is the GD working group’s response to Julia Serano’s ‘critique’ of the above paper. It is worth reading.

Response to Julia Serano’s critique of … Parental Reports – gdworkinggroup


Lonsdor, Elizabeth V. Sex differences in nonhuman primate behavioral development


Sex differences in behavior and developmental trajectories in human children are of great interest to researchers in a variety of fields, and a persistent topic of discussion and debate is the relative contribution of biological vs. social influences to such differences. Given the potentially large effects of cultural and social influences on human child development, nonhuman primates are important model species for investigating the biological and evolutionary roots of sex differences in human development. This Mini-Review briefly summarizes the existing literature on sex-biased behavior toward infant nonhuman primates by mothers and other social partners, followed by a review of findings on sex differences (or lack thereof) in primate behavioral development from a variety of species in wild and naturalistic settings. These include differences in physical and social development, including play, grooming, and object manipulation patterns, as well as nursing and the development of foraging behavior.


Madison, Söderlund. Objectivity and realms of explanation in academic journal articles concerning sex/gender: a comparison of Gender studies and the other social sciences (full text pdf)

Moser, C. Autogynephilia in Women. Journal of Homosexuality. 2009

Moser, C. Blanchard’s Autogynephilia Theory: A Critique

Murad, M et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. 2009.

Objective To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self-reported psychosocial outcomes.


Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.


Newhook, JT, et al. A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. 2018

(pdf download)

ABSTRACT Background: It has been widely suggested that over 80% of transgender children will come to identify as cisgender (i.e., desist) as they mature, with the assumption that for this 80%, the trans identity was a temporary “phase.” This statistic is used as the scientific rationale for discouraging social transition for pre-pubertal children. This article is a critical commentary on the limitations of this research and a caution against using these studies to develop care recommendations for gender-nonconforming children.

Nuttbrock et al. A Further Assessment of Blanchard’s Typology of Homosexual Versus Non-Homosexual or Autogynephilic Gender Dysphoria.


Olson-Kennedy, J et al. Health considerations for gender non-conforming children and transgender adolescents.

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Paul, JP. Childhood cross-gender behavior and adult homosexuality: the resurgence of biological models of sexuality.  1993


Research on the causes of homosexuality frequently treat it as a matter of disturbed gender identity and/or gender role. Recently, attempts have been made to link cross-gender behavior among boys with adult homosexuality. Often this research presumes a common biological determinant to both the childhood behavior patterns and homosexuality in adulthood. Authors have described such childhood cross-gender behavior in boys as part of a “prehomosexual” configuration. This paper argues that the research to date suffers from (1) a failure to differentiate such concepts as gender identity, gender role and sexual orientation, (2) a reliance upon potentially inappropriate dichotomies in describing such concepts, (3) problematic interpretations of research that makes few distinctions between human sexual behavior and sexual behavior among rodents, and (4) the contradictions implicit in seeking simple biological determinants of constructs (such as cross-gender behavior) that are culturally determined. The author argues that any potential biological factors contributing to sexual orientation must be mediated by a complex sequence of experiences and psychosocial factors. Therefore, the essentialists’ search for a simple congruence between physiological or biological traits and homosexuality may be expected to fail.


Rametti et al. White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. 2011

NOTE: This study ONLY tested homosexual transsexuals (HS). Non HS (AGP) trans were screened out. Its results DO NOT apply to these latter.


MtF transsexuals differed from both male and female controls bilaterally in the superior longitudinal fasciculus, the right anterior cingulum, the right forceps minor, and the right corticospinal tract.


Our results show that the white matter microstructure pattern in untreated MtF transsexuals falls halfway between the pattern of male and female controls. The nature of these differences suggests that some fasciculi do not complete the masculinization process in MtF transsexuals during brain development.

Rekers, G A et al. Childhood gender identity change: Operant control over sex-typed play and mannerisms. 1976

Abstract: To our knowledge this case is the first successful change of childhood gender identity that is documented by pre- and post-diagnostic assessment procedures. Deviant sex-typed behaviors were modified in a 5-yr-old boy judged by an independent clinician to be a high risk for adult transsexualism. In Study 1, the child’s mother was trained to reinforce “masculine” play behaviors and to extinguish “feminine” play behaviors in the clinic. This intrasubject study introduced new procedures designed to maximize the generalization of the treatment effect to play in the alone condition. Study 2 was designed to modify the child’s cross-gender mannerisms through the use of a response-cost and verbal prompt procedure. The cross-gender mannerism “flexed elbow” decreased as a function of the treatment. At the follow-up 25 months after treatment terminated, the evaluation by an independent clinician indicated the therapeutic change to a male gender identity.

Note:  this article’s language is telling. It describes a conditioning therapy for a boy who was ‘a high risk for adult transsexualism’. This pathologisation of transsexualism persisted until the 21st century and exists even now. Being transsexual is not a disorder, any more than being homosexual is. But this paper and others like it are routinely trotted out by anti-trans groups, specifically to harm HSTS.

Further, there is no follow-up to show how the boy developed into adulthood. Perhaps he became a confused, dysphoric ‘gay male’.


Rieger G et al Sexual orientation and childhood gender nonconformity: evidence from home videos. 2008.


Homosexual adults tend to be more gender nonconforming than heterosexual adults in some of their behaviors, feelings, and interests. Retrospective studies have also shown large differences in childhood gender nonconformity, but these studies have been criticized for possible memory biases. The authors studied an indicator of childhood gender nonconformity not subject to such biases: childhood home videos. They recruited homosexual and heterosexual men and women (targets) with videos from their childhood and subsequently asked heterosexual and homosexual raters to judge the gender nonconformity of the targets from both the childhood videos and adult videos made for the study. Prehomosexual children were judged more gender nonconforming, on average, than preheterosexual children, and this pattern obtained for both men and women. This difference emerged early, carried into adulthood, and was consistent with self-report. In addition, targets who were more gender nonconforming tended to recall more childhood rejection.


Rieger G et al. Childhood gender nonconformity remains a robust and neutral correlate of sexual orientation: reply to Hegarty (2009). 2009.


In this issue, P. Hegarty (see record 2009-09998-015) comments on an article by G. Rieger, J. A. W. Linsenmeier, L. Gygax, and J. M. Bailey (see record 2007-19851-006) that compared videos of homosexual and heterosexual people from childhood and adulthood. The current authors claim it is reasonable to treat masculinity-femininity as a bipolar scale and present justification for the approach used in the earlier study. Measures used by Rieger et al. (2008) yielded large differences between homosexual and heterosexual participants, and these differences are likely to be more meaningful than the low and nonsignificant within-group correlations on which Hegarty chose to focus. The authors address his suggestion that they are working within a paradigm detrimental to the well-being of homosexual and gender-nonconforming individuals and suggest that greater openness to research such as theirs could have beneficial consequences.

Rieger et al.   Sexual Arousal and Masculinity-Femininity of Women. 2015

Studies with volunteers in sexual arousal experiments suggest that women are, on average, physiologically sexually aroused to both male and female sexual stimuli. Lesbians are the exception because they tend to be more aroused to their preferred sex than the other sex, a pattern typically seen in men. A separate research line suggests that lesbians are, on average, more masculine than straight women in their nonsexual behaviors and characteristics. Hence, a common influence could affect the expression of male-typical sexual and nonsexual traits in some women. By integrating these research programs, we tested the hypothesis that male-typical sexual arousal of lesbians relates to their nonsexual masculinity. Moreover, the most masculine-behaving lesbians, in particular, could show the most male-typical sexual responses. Across combined data, Study 1 examined these patterns in women’s genital arousal and self-reports of masculine and feminine behaviors. Study 2 examined these patterns with another measure of sexual arousal, pupil dilation to sexual stimuli, and with observer-rated masculinity-femininity in addition to self-reported masculinity-femininity. Although both studies confirmed that lesbians were more male-typical in their sexual arousal and nonsexual characteristics, on average, there were no indications that these 2 patterns were in any way connected. Thus, women’s sexual responses and nonsexual traits might be masculinized by independent factors. (PsycINFO Database Record

Sexual Arousal and Masculinity-Femininity of Women (PDF Download Available). Available from: [accessed Feb 20 2018].

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Roberts et al. The deep human prehistory of global tropical forests and its relevance for modern conservation 2017


Significant human impacts on tropical forests have been considered the preserve of recent societies, linked to large-scale deforestation, extensive and intensive agriculture, resource mining, livestock grazing and urban settlement. Cumulative archaeological evidence now demonstrates, however, that Homo sapiens has actively manipulated tropical forest ecologies for at least 45,000 years. It is clear that these millennia of impacts need to be taken into account when studying and conserving tropical forest ecosystems today. Nevertheless, archaeology has so far provided only limited practical insight into contemporary human–tropical forest interactions. Here, we review significant archaeological evidence for the impacts of past hunter-gatherers, agriculturalists and urban settlements on global tropical forests. We compare the challenges faced, as well as the solutions adopted, by these groups with those confronting present-day societies, which also rely on tropical forests for a variety of ecosystem services. We emphasize archaeology’s importance not only in promoting natural and cultural heritage in tropical forests, but also in taking an active role to inform modern conservation and policy-making.

Ross, Walinder et al. Cross-cultural approaches to transsexualism; A COMPARISON BETWEEN SWEDEN AND AUSTRALIA 1981



Several hypotheses with regard to the influence of societal factors including the rigidity of the society with regard to sex roles, sexual equality and homosexual behaviour were tested comparing prevalence, incidence and sex ratio of transsexualism between Sweden and Australia, two societies which differ with respect to these factors while otherwise remaining comparable as Western democratic societies of about the same size and level of technological development. Significant differences were found between the two countries in both frequency and sex ratio of transsexualism. These findings are discussed and it is concluded that societal influences seem to have an influence on the number of transsexuals presenting as patients. Further research is needed to assess whether these factors also influence aetiology and development of transsexualism.

Ruigrok, A et al. A meta-analysis of sex differences in human brain structure. 2014


Savic & Arver. Sex dimorphism of the brain in male-to-female transsexuals. 2011

Savic, I et al.Sexual differentiation of the human brain in relation to gender identity and sexual orientation. 2010

Abstract (extract)

A number of studies show patterns of sex atypical cerebral dimorphism in homosexual subjects. Although the crucial question, namely how such complex functions as sexual orientation and identity are processed in the brain remains unanswered, emerging data point at a key role of specific neuronal circuits involving the hypothalamus.

Sexton, L et al Where the Margins Meet: A Demographic Assessment of Transgender Inmates in Male Prisons

Smenenyna, S et al. The Relationship between Adult Occupational Preferences and Childhood Gender Nonconformity among Samoan Women, Men, and Fa’afafine.’afafine

Smith, Y et al Transsexual subtypes: Clinical and theoretical significance 2006




The present study was designed to investigate whether transsexuals can be validly subdivided into subtypes on the basis of sexual orientation, and whether differences between subtypes of transsexuals are similar for male-to-female (MF) and female-to-male transsexuals (FMs). Within a large transsexual sample (n=187), homosexual and nonhomosexual subjects were compared on a number of characteristics before the start of treatment. Differences within MF and FM groups were also investigated. Homosexual transsexuals were found to be younger when applying for sex reassignment, reported a stronger cross-gender identity in childhood, had a more convincing cross-gender appearance, and functioned psychologically better than nonhomosexual transsexuals. Moreover, a lower percentage of the homosexual transsexuals reported being (or having been) married and sexually aroused while cross-dressing. The pattern of findings was different for MFs and FMs. No differences between homosexuals and nonhomosexuals were found in height, weight, or body mass index. A distinction between subtypes of transsexuals on the basis of sexual orientation seems theoretically and clinically meaningful. The results support the notion that in the two groups different factors influence the decision to apply for sex reassignment. The more vulnerable nonhomosexual transsexuals may particularly benefit from additional professional guidance before and/or during treatment.


Swaminathan, N. Study Says Brains of Gay Men and Women Are Similar; Brain scans provide evidence that sexual orientation is biological. Scientific American, June 16, 2008


Todd, B K et al. ‘Preferences for ‘Gender-typed’ Toys in Boys and Girls Aged 9 to 32 Months.’ 2016

Tsoi, WF. Developmental profile of 200 male and 100 female transsexuals in Singapore. 1990




Two hundred male and 100 female transsexuals compared with 100 male and 80 female heterosexuals were studied in Singapore. Transsexuals started their psychosexual development earlier than controls. Transsexual feelings started in childhood. Male transsexuals went through a homosexual phase followed by a transvestite phase, before they became transsexual. Female transsexuals did not go through distinct phases. Cross-dressing was one of the early signs of transsexualism and started earlier in females. None of the transsexuals were married, in contrast to reports showing that up to 50% of Caucasian transsexuals had been married. Cultural differences may explain the contrasts between Singapore transsexuals and patients from Western countries.


Veale, Clarke and  Lomax, “Sexuality of Male-to-Female Transsexuals”


Wallien MS, et al. Psychosexual outcome of gender-dysphoric children. 2008 J Am Acad Child Adolesc Psychiatry.


OBJECTIVE: To establish the psychosexual outcome of gender-dysphoric children at 16 years or older and to examine childhood characteristics related to psychosexual outcome.

METHOD: We studied 77 children who had been referred in childhood to our clinic because of gender dysphoria (59 boys, 18 girls; mean age 8.4 years, age range 5-12 years). In childhood, we measured the children’s cross-gender identification and discomfort with their own sex and gender roles. At follow-up 10.4 +/- 3.4 years later, 54 children (mean age 18.9 years, age range 16-28 years) agreed to participate. In this group, we assessed gender dysphoria and sexual orientation.

RESULTS: At follow-up, 30% of the 77 participants (19 boys and 4 girls) did not respond to our recruiting letter or were not traceable; 27% (12 boys and 9 girls) were still gender dysphoric (persistence group), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric. Both boys and girls in the persistence group were more extremely cross-gendered in behavior and feelings and were more likely to fulfill gender identity disorder (GID) criteria in childhood than the children in the other two groups. At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation.

CONCLUSIONS: Most children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality.


Watkins Christopher D. Creating beauty: creativity compensates for low physical attractiveness when individuals assess the attractiveness of social and romantic partners 2017.

Weinberg MS et al. Men sexually interested in transwomen (MSTW): gendered embodiment and the construction of sexual desire.2010

Winter, S. Of transgender and sin in Asia.

Winter S, Udomsak N (2002) Male, Female and Transgender : Stereotypes and Self in Thailand.

Winter S. Gender Stereotype and Self among Transgenders: Underlying Elements.

Winter S. Language and Identity in Transgender.

Winter S and King M. Well and Truly Fucked: Transwomen, Stigma, Sex Work and Sexual Health.

Winter, S. Transpeople (Khom Kham Phet) in Thailand.

Wu-jing, He Gender differences in creative thinking revisited: Findings from analysis of variability


Zucker, K. et al. Physical attractiveness of boys with gender identity disorder

Zucker, K J, et al. Sex-typed Behavior in Cross-Gender-Identified Children: Stability and Change at a One-Year Follow-up 1986


Children referred because of concerns about their gender identity development were compared to their siblings on 4 sex-typed measures (15 variables) at both assessment and a 1-year follow-up. At assessment, the gender-referred children different from their siblings on all but one variable. At follow-up, the gender-referred children either maintained or significantly reduced their degree of cross-gender behavior; compared to their siblings, however, they continued to differ on the majority of measures. Degree of behavioral change at follow-up correlated positively with number of therapy sessions (child, parent, and total) and the child therapist’s emphasis on gender identity issues.

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