Blanchard, Bailey, and Lawrence theory

The Blanchard, Bailey, and Lawrence theory (an informal name) is a taxonomy of gender dysphoria in biological males, including male-to-female transsexuals. It was proposed in the late 1980s by Ray Blanchard, a sexologist at the Centre for Addiction and Mental Health (then, the Clarke Institute of Psychiatry) in Toronto. The acronym "BBL" was coined by critics of the theory and refers to Drs. Ray Blanchard, J. Michael Bailey, and Anne A. Lawrence, the developer and two prominent researchers and proponents of the theory. The term was originally used by critics in a derogatory sense, but has become more common in usage as this theory has received more widespread attention in academia.

Summary of the idea
Ray Blanchard conducted a series of taxonomic studies of biological males with gender dysphoria (i.e., are discontented with their biological sex), including male-to-female transsexuals (i.e., individuals who have or plan to undergo medical sex reassignment), concluding that there exist two distinct types. One type of gender dysphoria/transsexualism are those individuals who are exclusively attracted to men, whom Blanchard referred to as homosexual transsexuals. The other group includes those who are attracted to females (gynephilic), attracted to both males and females (bisexual), and attracted to neither males nor females (analloerotic or asexual); Blanchard referred to this latter set collectively as the non-homosexual transsexuals. Blanchard has also reported that the non-homosexual transsexuals (but not the homosexual transsexuals) exhibit autogynephilia, a paraphilic interest in having female anatomy.

Origins
Blanchard has recounted how he arrived at this taxonomy of male-to-female transsexualism and coined the term autogynephilia. His concept follows from observations by earlier sexologists such as Magnus Hirschfeld, Harry Benjamin, and Blanchard's collaborator Kurt Freund, who had previously reported evidence that there exist two types of cross-gender identity. Freund hypothesized that gender dysphoria in homosexual males than different from gender dysophoria in heterosexual males. Blanchard notes that "Freund, perhaps for the first time of any author, employed a term other than 'transvestism' to denote erotic arousal in association with cross-gender fantasy."

In the 2000 revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the section on gender identity disorder specifies transvestic fetishism is a related paraphilia. Although the concept of this paraphilia is mentioned in the DSM, some psychologists object to the pathologizing of gender variance and paraphilia.

Homosexual transsexuals
According to Blanchard, "Homosexual gender dysphorics are those who, from the earliest sexual awareness in childhood or puberty, feel attracted only to men. The individual's masturbatory fantasies and romantic daydreams are of males; if he also has sexual encounters or love relationship in real life, these are exclusively or almost exclusively with men....The childhood behavior of homosexual gender dysphorics, unlike that of [non-homosexual] gender dysphorics, closely resembles that DSM-III-R diagnosis of gender identity disorder of childhood....As boys, they are unusually deficient in, or afraid of, physical competitiveness: They avoid rough-and-tumble play, are frightened of fistfights, and strongly dislike team sports. They prefer to play with girls, to play girls' games, and to play with girls' toys, in particular, Barbie-type dolls" (p. 69).

Richard Docter referred to this as primary transsexualism, but described it the same way: "This category describes individuals who have presented a lifelong history of gender dysphoria, a history of cross-gender identity, and an absence of fetishism associated with cross-dressing. It is imperative that early childhood roots of major gender discontent are revealed. Sexual preference is usually homosexual from an early age. There usually will have been a history of cross dressing. Stoller [believes] the male primary transsexual (whatever he may be called) is an extremely feminine male who has never functions in typically masculine roles and who has a feminine 'core gender identity'" (p. 25).

Non-homosexual transsexuals
According to Blanchard, most non-homosexual transsexuals, "take part in normal boys' activities without outward signs of effeminacy, and most experience sexual arousal when they first begin cross-dressing. [They] tend to work in male-dominated occupations, and the majority get married at least once. When they are not deliberately feminizing their attire, their anatomy, or their presentation, they are unremarkably masculine in demeanor and appearance" (p. 57).

Blanchard developed a questionnaire with items such as, "Have you ever become sexually aroused while picturing yourself having nude [emphasis in original] female body or with certain features of the nude female form?" and "Have you ever been sexually aroused by the thought of being a woman?" The homosexual transsexuals were significantly less likely to endorse such items than were the non-homosexual transsexuals. Blanchard concluded that it is the sexual arousal associated with the image of one's self in female form that motivated the non-homosexual (but not the homosexual) transsexuals.

Blanchard classified autogynephilic sexual fantasies into four subtypes:
 * Transvestic: arousal to the act or fantasy of wearing women's clothing
 * Behavioral: arousal to the act or fantasy of doing something regarded as feminine
 * Physiologic: arousal to fantasies of female-specific body functions
 * Anatomic: arousal to the fantasy of having a female body, or parts of one

In another study based on questionnaire responses, Blanchard divided individuals according to whether they reported experiencing the most sexual arousal to the image of themselves as nude women, as fully clothed women, or as women dressed in underwear. The group who reported experiencing the greatest arousal to the image of themselves as nude women also reported the greatest desire to undergo surgical sex reassignment.

Research comparing homosexual with non-homosexual transsexuals
Homosexual transsexuals show several characteristics different from non-homosexual transsexuals:

When surveyed about sexual arousal, over 80% of non-homosexual transsexuals report some history of experiencing sexual arousal while cross-dressing, whereas fewer than 10% of homosexual transsexuals report experiencing such arousal.

When surveyed about their recollections of being feminine in childhood, homosexual transsexuals report having been significantly more feminine than do non-homosexual transsexuals.

In a follow-up study of post-operative transsexuals, Blanchard found that both types of male-to-female transsexuals respond well to sex reassignment, but that the homosexual transsexuals are less likely to regret doing so.

Homosexual transsexuals are physically shorter, lighter, and lighter in proportion to their height than non-homosexual transsexuals. Blanchard hypothesized several possible explanations for this difference, including that homosexual transsexuals might begin puberty earlier, like gay men do, which results in smaller size.

Homosexual transsexuals seek sex reassignment at younger ages, on average, than do non-homosexual transsexuals. The average age of the non-homosexual transsexuals in Blanchard's sample is around 39, whereas the average of the homosexual transsexuals was 23.6. Moreover, the homosexual transsexuals reported that cross-gender wishes preceded cross-dressing by 3–4 years, whereas the non-homosexual transsexuals reported that their first cross-gender wishes occurred around the time they first cross-dressed.

Homosexual transsexuals have an increased number of older brothers, relative to non-homosexual transsexual. This difference, called the fraternal birth order effect also distinguishes gay men from their heterosexual counterparts,  from which Blanchard concludes that there exists some relationship between whatever factors produce homosexuality and whatever factors produce the homosexual subtype of transsexualism. No birth order effects have been observed to occur female-to-male transsexuals.

Many of the findings from Blanchard's comparisons of these two types have been replicated. Smith (2005) reported, "In this study the two subtypes were indeed found to differ on many characteristics. Replicating some of the previously observed differences, we found that compared with non-homosexual transsexuals, homosexual transsexuals reported more cross-gendered behavior, appearance and preference in childhood, and they reported less sexual arousal while cross-dressing in adolescence, applied for SR [sex reassignment] at a younger age, and fewer were (or had been) married."

Clinical implications
Formal gender clinics began operating in the 1960s and 1970s, leading to long-term follow-up studies that began appearing in the research literature in the 1980s and 1990s. These studies have examined heterogeneous samples of male-to-female transsexuals who received clinical approval to undergo surgical sex reassignment and proceeded to do so.

In the taxonomy proposed by Harry Benjamin in the 1960s, sex reassignment surgery was indicated only in transsexuals whom he called "feminine" and had Kinsey scale ratings of 4-6 (more homosexual than not). In contrast, Blanchard wrote that being a non-homosexual transsexual ought not contraindicate surgical sex reassignment, noting instead that non-homosexual transsexuals should be evaluated with caution.

Three studies compared the outcomes of homosexual transsexuals with non-homosexual transsexuals. Each of these reported that the majority of persons of each type benefited from sex reassignment, although both Blanchard and Smith reported that the few cases of regret that did occur all came from the non-homosexual group.

Adoption of distinction between homosexual and non-homosexual gender dysphoria
The concept began receiving attention outside of sexology when sexologist Anne Lawrence, a physician and sexologist who self-identifies as autogynephilic, published a series of web articles about the concept in the late 1990s. Lynn Conway and Andrea James responded to Lawrence's essay. Conway started an investigation into the publication of Bailey's book by the United States National Academy of Sciences. Accusations of misconduct by Bailey were leveled. Northwestern University investigated Bailey, but did not reveal the findings of that investigation and did not comment on whether or not Bailey had been punished. According to intersex activist and bioethics specialist Alice Dreger, who is now one of Bailey's supporters, two of the four transwomen who accused Bailey of misusing their stories were not mentioned anywhere in the book.