2026 update: Five Canadian physicians argue that the Canadian Paediatric Society remains stuck in a pre-Cass approach to transgender youth care, relying on weak evidence to support an affirmation-first model. They say Canada is ignoring growing international moves toward more cautious, evidence-based care focused on psychological assessment and comorbidities rather than early medical intervention.

Canada’s Paediatric Gender Medicine Must Follow Evidence

While other jurisdictions adopt balanced, evidence-based protocols for treating gender dysphoria, the CPS has doubled down on an obsolete policy instructing doctors to reflexively ‘affirm’ trans-identified youth.

QuilletteChan Kulatunga Moruzi

Ray Blanchard is an adjunct Professor of Psychiatry at the University of Toronto who specialises in the study of human sexuality, with a particular focus on sexual orientation, paraphilias, and gender identity disorders. In the 1980s and 1990s he developed a theory around the causes of gender dysphoria in natal males that became known as ‘Blanchard’s transsexualism typology’. This typology—which continues to attract a great deal of controversy—categorizes trans women (that is, natal males who identify as women) into two discrete groups.

The first group is composed of ‘androphilic’ (sometimes termed ‘homosexual’) trans women, who are exclusively sexually attracted to men and are markedly feminine in behaviour and appearance from a young age. They typically begin the process of medical transition before the age of 30.

The second group are motivated to transition as a result of what Blanchard termed ‘autogynephilia’: a sexual orientation defined by sexual arousal at the thought or image of oneself as a woman. Autogynephiles are typically sexually attracted to women, although they may also identify as asexual or bisexual. They are more likely to transition later in life and to have been conventionally masculine in presentation up until that point.

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Although Blanchard’s typology is supported by a wide range of sexologists and other researchers, it is strongly rejected by most trans activists who dispute the existence of autogynephilia. The medical historian Alice Dreger, whose 2015 book Galileo’s Middle Finger included an account of the autogynephilia controversy, summarises the conflict:

There’s a critical difference between autogynephilia and most other sexual orientations: Most other orientations aren’t erotically disrupted simply by being labeled. When you call a typical gay man homosexual, you’re not disturbing his sexual hopes and desires. By contrast, autogynephilia is perhaps best understood as a love that would really rather we didn’t speak its name. The ultimate eroticism of autogynephilia lies in the idea of really becoming or being a woman, not in being a natal male who desires to be a woman.

I interviewed Blanchard over email and Skype. The text has been lightly edited for clarity.

What has been the response to your work on autogynephilia, both within the trans community and without?

Ray Blanchard: I introduced the word and the concept of autogynephilia—the tendency of certain males to become sexually aroused by the thought or image of themselves as females—in 1989 as an extension of the concept of transvestic fetishism. The DSM diagnosis, Transvestic Fetishism, was defined in psychiatry at that time as sexual urges and fantasies involving cross-dressing in heterosexual males.

I published my early writings on autogynephilia in specialty journals with very small circulations. I intended them for a tiny readership of clinicians who specialized in the assessment and management of gender-dysphoric patients. However, this work attracted the attention of two individuals who decided to promote it more broadly, one online (Anne A. Lawrence) and one in a book (J. Michael Bailey). These efforts, especially the book, enraged three influential trans women—two of them senior academics—who attempted to get Bailey fired from his teaching position at Northwestern University for writing it. This campaign has been documented in detail by Alice D. Dreger, a medical historian. Paradoxically, the efforts of trans activists, then and today, to completely suppress any mention of autogynephilia in public discourse has resulted in an increased public awareness of it. I think the self-defeating behavior of trans activists has persisted because the idea of autogynephilia cuts too close to the bone. If the idea had no resonance with them, they would simply have ignored it, and the idea of autogynephilia would just be one of many forgotten hypotheses of gender identity disorder.

Subsequently other strange and unexpected (to me) events befell my notion of autogynephilia. Modern trans activists reframed transsexualism/transgenderism as a political problem rather than a clinical problem. The flat denial that autogynephilia exists became a canon of modern trans activism, trans activism become a sub-department of the Social Justice Movement, and the Social Justice Movement became a primary combatant in the ongoing, pervasive Culture Wars.

Transgenderism and the Social Construction of Diagnosis

Tannehill subsequently posted the article to the Facebook page of the World Professional Association for Transgender Health (WPATH).

QuilletteLisa Marchiano

The upshot is that most trans activists—and, in solidarity, their “allies”—deny that autogynephilia exists. Since most university psychologists, sociologists, and humanities professors are “allies,” the topic of autogynephilia may be omitted from Human Sexuality or Gender Studies courses for a generation. The other side in the Culture Wars (whatever one wishes to call that side) are prepared to recognize the existence of autogynephilia as soon as they learn of it, but they tend to hurl it as an insult at male-to-female trans who offend them. That, of course, is not what I intended when I coined the term 30 years ago.

At present, many heterosexual MTFs—in their own view, lesbian trans women—police online forums ceaselessly for any mention of autogynephilia. If a newcomer posts that he thinks that autogynephilia describes his own experience, they will quickly let him know that this is wrongthink and that autogynephilia does not exist. It is therefore hard to get any sense of how many autogynephilic gender dysphorics privately think that autogynephilia describes their own experience, because stating that online will produce scorn and other negative reactions.

Has the prevalence of autogynephilia increased in recent decades, or are autogynephiles simply more likely to transition than they once were?

I very much doubt that the prevalence of autogynephilia per se, or the prevalence of autogynephilic gender dysphoria, has increased. I think that what has changed is the proportion of autogynephilic trans who have “come out” to their families, friends, and employers, not the total number of autogynephilic trans. Forty years ago, an autogynephile’s decision to transition to the female role often had negative consequences in the personal and employment spheres. Now that decision is as likely to get them praised for courage as it is to get them criticized for selfishness and irresponsibility.

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What will it take for this contagion to be seen for what it is, so that its most damaging effects can be prevented?

QuilletteLisa Marchiano

The change in consequences for the androphilic trans has been much less. They tend to be conspicuously feminine (or effeminate) in manner, even when they are trying to “butch it up,” and this was as true 40 years ago as it is now. The androphilic trans had less social status to lose by transitioning then, and that is also true now.

When I looked at the relative numbers of autogynephilic and androphilic gender-dysphoric males back in 1987, the autogynephilic cases were already a majority, approaching 60 percent. The proportion had reached 75 percent by 2010, and it might be even higher now.

I don’t know of any evidence of significant populations of autogynephilic MTF trans in any non-Western countries. That doesn’t mean such individuals don’t exist. It could simply mean that, for non-homosexual males, the social cost of “coming out” as trans is much higher in non-Western cultures.

Would you recommend medical transition as a means of treating gender dysphoria in patients with autogynephilia?