Biological reductionism meets gender diversity in human sexuality.

The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, by J. Michael Bailey. Washington, DC: The Joseph Henry Press, 2003, 233 pages. Cloth, $24.95.

The Man Who Would Be Queen is the most controversial book on transsexuality since Janice Raymond's The Transsexual Empire (1979) and is the latest challenge to what already was a fragile relationship between the scientific and the transgender communities. What is all the fuss about? What does the book say, why is it so controversial, and what does this controversy tell us about sex research with stigmatized populations like the transgender community?

What the Book Says

Bailey argues that there are essentially two types of male-to-female transsexuals who can be distinguished on the basis of their sexual orientation. The first type is homosexual transsexuals, extremely gender-transposed (feminine) men whose sexual object choice is toward men instead of women. According to Bailey, their primary motivation to change sex is to attract more men sexually: "Those who love men become women to attract them" (p. xii).

The second type is autogynephilic transsexuals, meaning paraphilic men whose sexual object choice is toward the image of themselves as women. For this group, the primary motivation for changing sex is to become the object of their desire: "Those who love women become the women they love" (p. xii). According to Bailey, the sexual attraction to men that this latter group may report is secondary to their idea of what it is like to be a woman (i.e., interested in men). The sexual attraction to women that autogynephilic transsexuals may report is deemed less than genuine; they envy, rather than love, other women. As Bailey explains, "Autogynephilic transsexuals might declare attraction to women or men, to both, or to neither. But their primary attraction is to the women that they would become" (p. 147).

By fitting all male-to-female transsexuals into this typology, Bailey attempts to fortify theory and research that postulates a biological link between gender identity and sexual orientation, between gender transposition (demasculinization and feminization) and homosexuality. As Bailey states, "Succinctly put, homosexual male-to-female transsexuals are extremely feminine men" (p. 146).

This is not a new typology. It was coined by Ray Blanchard in the 1980s and has been widely published in the scientific literature (e.g., Blanchard, 1987, 1989). However, Bailey's book is accessible to a lay audience through its non-academic style that, especially to the uninformed reader, makes a very convincing case that the gender diversity found within the transgender community can be reduced to these two types. The book contains eleven chapters divided into three parts. Part one is about childhood femininity among boys, part two about femininity and masculinity among gay men, laying the foundation for part three: the typology of homosexual versus autogynephilic transsexuals.

Unfortunately, the book fails to offer a balanced and well-cited review of the scientific literature that would have shown that the diversity found within this community cannot as easily be reduced to the two types. Bailey dismisses clinical experience and ignores research that provides evidence of much greater diversity in gender identity, gender expression, and transgender sexuality. For example, to explain accounts that do not conform to the typology, he states: "Autogynephiles who claimed to be homosexual transsexuals could account for the apparent cases of homosexual transsexuals who practiced erotic crossdressing" (p. 173).

Why the Book is Controversial

Bailey criticizes scholars who support a social constructionist perspective on transsexuality for giving ideology precedence over science. What he omits is that gender transposition theories have been challenged in the scientific literature on psychological, sociocultural, and biological grounds (Coleman, Gooren, & Ross, 1989). Bailey further limits his focus to male-to-female transsexuals. However, research on female-to-males attracted to men shows that they do not fit as easily into the reductionistic typology (Bockting & Coleman, 1991; Coleman & Bockting, 1987; Coleman, Bockting, & Gooren, 1993).

Another point of controversy is Bailey's portrayal of scholars and clinicians who provide transgender-specific health care and who provide access to sex reassignment services according to the Harry Benjamin Association's Standards of Care (Meyer et al., 2001). According to Bailey, these professionals are ignorant of the homosexual versus autogynephilic typology of transsexuals. Bailey offers several explanations for this. He argues that the two types of transsexuals rarely mix, that gender clinics only see heterosexual (i.e., autogynephilic) transsexuals because homosexual transsexuals tend to obtain their hormones on the black market, that clinicians take their clients' self reports at face value when they shouldn't, and that "sex researchers are not as scholarly as they should be and so don't read the current scientific journals" (p. 176).

These claims do not mirror the experience of the majority of scholars and clinicians in this field (see www.hbigda.org and www.symposion.com/ijt). They do see male-to-female transsexuals attracted to men who mix with male-to-female transsexuals who are in satisfying intimate relationships with women. Members of both groups pursue sex reassignment to alleviate a gender identity conflict, not to attract more men or to satisfy their paraphilic sexual desire. Clinicians also see a number of male-to-female transsexuals who are genuinely bisexual and attracted to both men and women. Clients' self-reports are verified when necessary (e.g., by including in therapy significant others, family, and friends). Although every field has its more or less informed workers, many scholars and transgender-specific health providers (as well as their transgender clients) stay abreast of the scientific literature in the areas of transgender identity and sexuality.

Bailey's perceptions might have been skewed by his lack of contact with the health professionals in this field (he is not a member of the Benjamin Association) and his reliance on very limited field work with a very small sample of transgender informants in Chicago gay bars. Perhaps it is his lack of extensive clinical experience with transsexuals that prompted his criticism of clinicians and prevented him from recognizing that sex and gender are more diverse than is generally assumed.

The reality is that many individuals are encountered in clinical practice who do not fit the typology of homosexual versus autogynephilic transsexuals. These individuals continue to challenge our limited understanding of gender and sexual identity development. Autogynephilia does exist, but in light of this limited understanding, the term is better used as a descriptive phenomenon present in the lives of certain transgender individuals rather than elevated to one of only two essentialist etiological types. It is difficult to understand a clinical population based on limited field research and a read of the literature; it takes extensive clinical experience under supervision to understand and treat clients presenting with such issues as autogynephilia. Moreover, research in nonclinical settings has revealed a greater diversity in gender identity and expression across cultures and throughout time (e.g., Herdt, 1994).

Although some members of the transgender community endorse the typology outlined in the book (e.g., Lawrence, 2004), Bailey's book has elicited a storm of criticism and personal attacks by his informants and by transgender community activists (e.g., Conway, 2003-2004). Allegations include violations of ethical research conduct such as lack of informed consent and dual relationships. The informants and their peers have stated that the book inadequately represents the reality of their experience. In the book, Bailey explicitly states how much he respects his informants, yet information from transsexuals that contradicts his theory is dismissed as self-justification, identity politics, and lies: "... they are often silent about their true motivation and instead tell stories about themselves that are misleading and, in important respects, false" (p. 146).

Self-report bias certainly does exist, but the subjectivity of gender and sexuality is just as valid and undeniable as its biological manifestation. The book proclaims to be "free of ideology," yet a biological, essentialist perspective is simply another point of view. Due to his narrow biological orientation and dismissal of the social constructionist and clinical perspectives, Bailey may have under-appreciated the psychosocial and cultural context (one of intense stigma) in which his transsexual informants actualize their gender identity and sexuality.

What the Controversy Tells Us About Sex Research with Stigmatized Populations

The impact of this controversy is not limited to Bailey and his book. Instead, it is yet another blow to the delicate relationship between clinicians, scholars, and the transgender community. The establishment of mutual respect and trust among these groups has always been complicated. After Hirschfeld (1910) medicalized transvestism and transsexualism, clinicians attempted through psychodynamic and behavior therapy to change transsexuals' gender identity to make it match their sex assigned at birth (for a review see Gelder & Marks, 1969, or Kuiper, 1991).

With Christine Jorgenson's widely publicized sex change and Harry Benjamin's book The Transsexual Phenomenon (1966), the tide turned away from conversion therapy, but clinicians took on the role of gatekeepers controlling access to sex reassignment. In 1979, the sex reassignment program at Johns Hopkins University closed on the basis of a study that evaluated the outcome of sex reassignment (Meyer & Reter, 1979), a study that since has been criticized for being methodologically flawed and politically motivated (Money, 1991). In that same year, Janice Raymond published The Transsexual Empire (1979), in which she attacked transsexuals' claim to womanhood and went so far as to equate sex reassignment with rape (see Stone, 1991). This history has made many transgender persons wary of scholars and clinicians.

Finally, because the inclusion of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) has not resulted in broad health insurance coverage for transgender care, more and more transgender individuals perceive this diagnosis and the need to consult with a mental health provider as unnecessarily pathologizing. The controversy surrounding this book adds to the challenge of delivering transgender health services and threatens the partnerships and participation of the transgender community required to conduct research to promote transgender people's well-being.

Research as well as clinical work with the transgender community has to take into account the stigma that transgender and transsexual individuals experience because of their gender nonconformity. Such stigma contributes to a dynamic that Freire (1970) called the pedagogy of the oppressed, in which transsexuals struggle to question existing norms and validate their unique experiences of gender. In this context, being transsexual means sometimes not knowing who to trust. Bailey appears to have underestimated the power of this dynamic and the vulnerability of his research participants. At the same time, the transgender community needs to be reminded that the vast majority of sex researchers and clinicians are on their side, that they experience stigma associated with the transgender focus of their work, and that they cannot do this work without the cooperation and support of the transgender community.

Science can be part of bringing about desired social change for stigmatized populations such as the transgender community. For example, research on the efficacy of sex reassignment contributed to the decision of several health insurance companies in Minnesota to cover transgender-specific medical care. The Benjamin Association has issued a number of legal briefs to support the civil rights of transgender individuals. Advocacy is an important task of professionals working in this field. It is unfortunate that Bailey and his supporters seem to confuse such advocacy with a less-than-critical stance toward patient self-reports and toward attacks launched by members of the transgender community against this book.

What the Book Could Have Been

An up-to-date, evidence-based discussion of the broader scientific literature on transgenderism and transsexuality, written in a manner accessible to the general public, would have been a valuable contribution. The book could have educated readers about the increasingly visible diversity in gender and sexual orientation among the transgender population and discussed the implications of this diversity for our understanding of sexual identity. It could have shown how the approach of clinicians has changed from trying to identify the "true" transsexual toward client-centered, transgender-affirmative health care. Bailey could have called for more research to explore the next frontier in the study of gender. He could have illuminated how science can play a role in promoting transgender rights and sexual health. Alternatively, Bailey could have stuck to research on sexual orientation with which he is more familiar rather than have ventured into the study of gender, an area he appears to know less about.

Conclusion

This book's primary strength is simultaneously its major weakness: It is a powerful and eloquently described synthesis of available data that supports a reductionistic, biological theory of gender identity and sexual orientation, but without adequately recognizing the role of psychosocial and cultural factors (such as social stigma and cultural constructions of gender) in the development of gender identity. Hence, the book will appeal to those who share Bailey's essentialist point of view while alienating those who favor a biopsychosocial perspective.

We need a book that is as well written as this one, but that is more comprehensive and leaves room for what is yet to be discovered about the diversity in gender and human sexuality. In the interim, we can let the evolving stories of transgender individuals speak for themselves.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. (4th ed.). Washington, DC: American Psychiatric Association.

Blanchard, R. (1987). Typology of male-to-female transsexualism. Archives of Sexual Behavior, 14, 247-261.

Blanchard, R. (1989). The classification and labeling of nonhomosexual gender dysphorias. Archives of Sexual Behavior, 18, 315-334.

Bockting, W. O., & Coleman, E. (1991). A comment on the concept of transhomosexuality, or the dissociation of the meaning. Archives of Sexual Behavior, 20, 419-420.

Coleman, E., & Bockting, W. O. (1988). "Heterosexual" prior to sex reassignment, "homosexual" afterwards. A case study of a female-to-male transsexual. Journal of Psychology and Human Sexuality, 1(2), 69-82.

Coleman, E., Bockting, W. O., & Gooren, L. J. G. (1993). Homosexual and bisexual identity in sex reassigned female-to-male transsexuals. Archives of Sexual Behavior, 22, 37-50.

Coleman, E., Gooren, L., & Ross, M. (1989). Theories of gender transpositions: A critique and suggestions for further research. The Journal of Sex Research, 26, 525-538.

Conway, L. (2003-2004). An investigation into the publication of J. Michael Bailey's book on transsexualism by the National Academies. [Available online at http://ai.eecs.umich.edu/people/conway/TS/LynnsReviewOf BaileysBook.html].

Freire, P. (1970). Pedagogy of the oppressed. New York: Continuum.

Gelder, M. G., & Marks, I. M. (1969). Aversion treatment in transvestism and transsexualism. In R. Green & J. Money (Eds.), Transsexualism and sex reassignment. Baltimore, MD: The Johns Hopkins Press.

Herdt, G. (Ed.). (1994). Third sex, third gender: Beyond sexual dimorphism in culture and history. New York: Zone Books.

Hirschfeld, M. (191011991). Transvestites: An investigation of the erotic drive to crossdress. Amherst, NY: Prometheus Books.

Kuiper, A. J. (1991). Transseksualiteit: Evaluatie van de geslachtsaanpassende behandeling. Amsterdam, The Netherlands: Vrije Universiteit.

Lawrence, A. (2004). Autogynephilia: A paraphilic model of gender identity disorder. Journal of Gay and Lesbian Psychotherapy, 8(1/2), 69-87.

Meyer, W. III, Bockting, W., Cohen-Kettenis, E, Coleman, E., DiCeglie, D., Devor, H., et al. (2001). The standards of care for gender identity disorders, sixth version. International Journal of Transgenderism, 5(1). [Available online at www.symposion.com/ijt/].

Meyer, J. K., & Reter, D. J. (1979). Sex reassignment follow-up. Archives of General Psychiatry, 36, 1,010-1,015.

Money, J. (1991). Serendipities on the sexological pathway to research in gender identity and sex reassignment. Journal of Psychology and Human Sexuality, 4(1), 101-113.

Raymond, J. G. (1979). The transsexual empire: The making of the she-male. Boston: Beacon Press.

Stone, S. (1991). The empire strikes back: A post-transsexual manifesto. In J. Epstein and K. Straub (Eds.), Body guards: The cultural politics of gender ambiguity. New York: Routledge.

Reviewed by Walter O. Bockting, Ph.D., University of Minnesota Medical School, Program in Human Sexuality, Department of Family Medicine and Community Health, 1300 South Second Street, Suite 180, Minneapolis, MN, 55454; e-mail: [e-mail].