Ray Blanchard is an American-Canadian sexologist who served as the head of clinical sexology services in the law and mental health program at the Centre for Addiction and Mental Health (CAMH) in Toronto from 1995 to 2010. His research on paraphilias, gender-identity disorders, and sexual orientation spans nearly 40 years. From 2008 to 2012 he was a member of the Sexual and Gender Identity Disorders Work Group for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.
On May 11, after he posted a clinically informed opinion on transgenderism in response to a direct question, Blanchard’s Twitter account was suspended for violating its “Hateful Conduct” policy. His account was later reinstated, and Twitter apologized for this “error.” (Others have been less lucky.) Here, Blanchard expands on the content of his offending Twitter thread and discusses transgenderism with National Review’s Madeleine Kearns.
Madeleine Kearns: You believe transsexualism and gender dysphoria to be a mental disorder. Am I correct in saying that’s how it appears in the DSM-5 [the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, which is the bible of psychiatry]?
Ray Blanchard: Yes. The diagnostic entity is called gender dysphoria in DSM-5. It was first introduced in DSM-III under the name transsexualism, and it was still called transsexualism or gender-identity disorder, I forget which, in DSM-IV, but in DSM-5 the name of the entity got changed to gender dysphoria. But the diagnostic criteria are fairly similar.
Kearns: Why was there a name change then? Was that to avoid the word “disorder”?
Blanchard: Yes, it was primarily to make patients and also trans activists and transsexual-activist groups feel happy or that they had been listened to, but I would say that the name change probably owed more to — or owed as much to politics as it did to any change in the science.
Kearns: What do we mean by “gender identity”?
Blanchard: What do I mean by it?
Kearns: Yes. Let’s start with that.
Blanchard: Well, back in the days when I was writing a lot on that topic, which is quite a while ago now, I tended to avoid the phrase “gender identity” because I think that it’s a trivial concept when it’s applied to normal people. I mean normal men and normal woman know what sex they are, and they respond to that automatically, like when looking for a washroom. But I think it’s only at very unusual moments that a normal man or woman has a conscious awareness of “I’m a woman” or “I’m a man,” and this is often a highly emotional situation.
So, I don’t find the concept of “gender identity” useful for normal people, and the concept of cross-gender identity is really not a normal gender identity which has found itself lodged in the wrong body. Cross-gender identity is a constant preoccupation with, and unhappiness about, the individual’s gender. So, I guess you could say I believe in cross-gender identity, but I don’t much believe in gender identity.
Kearns: What’s the difference between transsexualism, which is a word that you actually hear less often now, and transgenderism?
Blanchard: In a word: fashion. Transgenderism was at one point meant to be a broader umbrella term that would include transsexuals who either were aspiring to, or had undergone, sex-reassignment surgery, as well as people with less or remitting forms of gender dysphoria. That was the original difference between transgenderism and transsexualism, that transgenderism was the broader category. Subsequent to that happening, transsexualism gradually became a dirty word, and who knows why. It’s this kind of word magic that always happens in contemporary politics. I’ve started deliberately using the word transsexualism again.
Kearns: So “transgenderism,” or at least my understanding of it, collapses all distinctions so that it doesn’t really matter if you’ve had surgery or if there have been no physical changes. In that sense, “transgenderism” is more comprehensive. Is that accurate?
Blanchard: Transgenderism is definitely more comprehensive than transsexualism, but I need to, not correct you, but I want to point out one thing here, and it’s that even in the days when the standard word that people used was “transsexualism,” there was still inconsistent usage, some people reserving it for individuals who had undergone sex-reassignment surgery and some people using it simply to mean a patient who has a continuous, chronic, and unremitting sense of being or of wanting to be the opposite sex. Even in the days when transsexualism was the standard word, there was inconsistent usage as to whether or not the person had to have had surgery or be surgery-tracked.
Kearns: And in what sense do you use it?
Blanchard: I use it in the sense of someone who has the most extreme form of gender dysphoria and not in the sense of someone who has undergone sex reassignment. I just use it to mean somebody who feels very strongly, and at all times, that they should have been, or in some essential Platonic sense actually are, the opposite sex.
Kearns: It seems to me that many activists hold two contradictory positions simultaneously. One is that transgenderism is not a mental disorder and the other is that gender dysphoria is a mental disorder. How does one make sense of that?
Blanchard: I think it’s this kind of Talmudic reading of the DSM. It’s like, well, gender dysphoria is a mental disorder because that’s now listed in the DSM. But transsexualism isn’t a mental disorder because that’s no longer a word used in the DSM. It’s just this kind of weird, naïve outsiders’ literalist interpretation of how the DSM is written.
Kearns: Is it anything do with the fact that, obviously for insurance and medical providers, there would need to be a medical problem in order for it to justify treatment?
Blanchard: Absolutely. There has to be a diagnosis in order for third-party payment. Whether we are talking public or private insurance, there has to be a diagnosis of some disorder to pay for sex-reassignment surgeries or for people who have drug plans in order to pay for testosterone injections or estrogenic medications for biological males. So this is something that for the trans activists is a stumbling block. If there isn’t a disorder of some sort, then all individuals who wanted to have sex-reassignment surgery or exogenous hormones would be paying the whole cost themselves.
Kearns: Right, because it would be essentially a cosmetic treatment at that point?
Kearns: I’m really interested in your work on “paraphilia.” What is the difference between “paraphilia” and, say, a “disorder” or an even older term perhaps, a “perversion”?
Blanchard: Yeah sure, “perversion” was an older label for what’s now called paraphilia. Correct.
Kearns: And is the only difference a linguistic one where the morally loaded connotations of the word are removed? Or is there a substantive difference?
Blanchard: I don’t think there is any substantive difference. I mean the word “pervert” had become part of the lay vocabulary and was routinely used as an insult or as a derogatory comment whether seriously or in jest. Everybody knew the word pervert, had a vague idea of what it meant, and knew that it was something bad. So, the word paraphilia was substituted because it had a nice medical sound to it, and it had not and still has not entered the popular vocabulary as an insult.
Kearns: In the study of sexuality, how do we ascertain and define what is “normal”?
Blanchard: Well “normal” is virtually never defined. I guess the issue is how we define “disorder” — and that’s a very difficult problem. I think that a lot of lay people have the notion that some place somewhere there is this official definition of disorder and that one can decide whether or not any given behavior or constellation of behaviors is a disorder by comparing that to the official definition of disorder, conceived in something like the official kilogram stuck in some lab in Paris, and the reality is that there isn’t one single definition of disorder that you can compare anything to and decide if it is or is not a disorder.
Kearns: Do you worry at all about a sort of concept creep, where something that maybe wouldn’t have been a problem or at least a medical problem in the past is now a problem? I’m thinking specifically of gender dysphoric young people and the extent to which clinicians give out the diagnosis.
Blanchard: Well, I wouldn’t call that concept creep. I’d call that a problem with the quality of training and expertise of people doing the diagnosis.
I mean — yes. There were people concerned about concept creep during the last revision of the DSM-5, or the last revision of the DSM which eventually became the DSM-5. But I know from having been on one of the work groups that there was a constant preoccupation everywhere, among people involved in the work groups, not to keep expanding the number of things called disorders — because everyone was aware that this was an issue. I can’t say that it was an issue in the general public because the general public doesn’t concern themselves with this, but in the intelligentsia there was an issue with increasing numbers of behaviors being listed as disorders. So there was a lot of awareness of this.
Kearns: I guess that relates to the earlier point about a sort of overexpansion of definitions with the transgenderism versus the earlier concept of transsexualism.
Blanchard: Yes. Clearly in the days when transsexualism was the standard diagnostic entity that people were concerned with, everybody was aware that there were lower degrees of dissatisfaction with biological gender.
Kearns: Let’s talk a little bit about the difference between the females and the males with gender dysphoria. You’ve noted in past research that virtually all female gender dysphorics are homosexual. Do you think that is still the case with the new “Rapid Onset Gender Dysphoria” (ROGD) sub-category [a description coined by the medical doctor and researcher, Lisa Littman, in 2018, which describes the unprecedented surge of teen girls identifying suddenly as the opposite sex]?
Blanchard: No, I don’t. I think one of the things that distinguishes the ROGD cohort is a greatly larger proportion of cases who think of themselves as gay men trapped in women’s bodies. This had existed in previous decades, but it was maybe a handful of biological females who said, “I feel like a gay male, and I would like to have surgery or hormones so that I can live my life as a gay male.” It did exist, but it was very, very rare. Now among the ROGD cohort I can’t give you numbers, but I get the impression that’s it’s much, much more common for the ROGD girls to present that way than it ever has been.
Kearns: And is that a sort of body-image problem or a response to trauma?
Blanchard: I think that these ROGD kids are such a mishmash of kids with a variety of personality pathologies and social problems. I wouldn’t really know what to tell you about what’s within that mix.
Kearns: Okay but as for what Littman describes as the “social contagion” element, I obviously understand that it’s very complicated and there are lots of moving parts, but do you have any sense of any particular thing that helps explain the sudden spike of cases of these kids?
Blanchard: No, I don’t. I think there have historically been precedents, and they have typically involved more females than males, which is also true like in the ROGD phenomenon. For example, recovered memory was a fad for a while, and ritual satanic child abuse was a fad. Typically, these involved more female adolescents than males for whatever reason.
If you want to go a little further back in history and look at the Salem witch trials in the U.S. in the late 17th century, most of the individuals who were claiming to have been attacked by witches and who were executed as witches were predominantly female. While it was older ladies who were hanged as witches, it was young ladies who accused them of witchcraft. So there seems to be something about a young adolescent female population that is particularly vulnerable to certain kinds of psychiatric phenomena.
Kearns: That is fascinating. And obviously distinct from the work you did on the males who were either the autogynephilic [erotically aroused by the thought of themselves female] or homosexual transsexuals [wanting to become women, because they are uncomfortable and conspicuously feminine as men]. Do you have a sense of how these two categories relate to the new form of transgender women [males] who, other than maybe taking some hormones, haven’t really altered their male genitalia at all?
Blanchard: Well there certainly seems to be a lot more of them now than there ever was before. In the days when I was working in the field, certainly a large proportion of biological males went ahead and had vaginoplasty. I’m not sure what is with this new crop because I had left the area and was working on other things. So, this was before the Internet basically. Which seems to have somehow encouraged a different social organization of people with gender-identity disorders.
Kearns: You said in the Twitter thread, the one that got you suspended for 24 hours, that you think that sex-change surgery is still the best treatment for adults who have been carefully screened and who have tried other forms of treatment which haven’t worked. Do you have thoughts on the body of research which has contraindications and the suggestion that this can make matters worse?
Blanchard: Well that’s a very interesting question. I can’t think of any body of research that systematically identified which of your cases are going to be psychiatric catastrophes, but that doesn’t mean there isn’t any, because I haven’t worked in that area for many years now. But the emphasis was always on how you select cases for surgery and what proportion of them have regrets, which was usually considered a kind of touchstone of a bad outcome. But I don’t know about much research on the cases who actually reverted. Probably the biggest source of information on that now would be these cases who have been ROGD girls and now are starting to revert back to the female roles. There’s a group of them who have been doing YouTube videos, so there’s more activity from that quarter.
Kearns: You suggest that 21 is a good age. Why 21 as opposed to, say, 18?
Blanchard: Any age-specific criterion of mine of course is going to be arbitrary. So why 21 and not 20? Why 21 and not 22? It could be the same question. The clinic that I worked at was 21, and were there patients who had surgery and regretted it? Yes, absolutely there were, but it was maybe 2 or 3 percent of patients who after surgery decided to go back to living in their original gender role and interestingly, none of them ever blamed us for having approved them for surgery, even though they eventually rejected their role. So I think wherever you set that line, you are going to make some mistakes.
The question is what the more serious mistake is, not approving surgery [for someone] who could benefit but has to wait a few extra years, or approving surgery [for someone] who is not going to benefit and is going to regret and now be permanently surgically altered for the rest of their life.
When you set an age cutoff, it’s not merely a question of how many errors are you going to make in the conservative direction or in the liberal direction, but it’s also a matter of what are the consequences of one kind of error versus the other kind of error. The consequences of being too conservative with regards to an age limit for surgery are basically that the person might have to live for one or two or three years with their original body unaltered when they would have been just as well if they had surgery a few years earlier. But that’s correctable. Once you’ve cut off somebody’s penis and testis or removed their uterus and ovaries, these are irreversible [procedures]. So there is an asymmetry in the two different kinds of errors, not approving surgery when it would have been okay and approving surgery when it’s not okay.
Kearns: As a lay person on this, it seems to me that the sort of vast range of treatments have now been channeled into a narrative of “affirmation” versus “conversion.” How do we make sense of this?
Blanchard: Well I think the use or the application of the words “conversion therapy” to the situation where you are just trying to see if the child can be made to accept his or her biological sex was a deliberate cynical strategy on the part of trans activists to piggyback on the success of the gay-rights movement and say, “What you’re trying to do with children, in getting them to accept their anatomical sex, is the same as what we used to do with gay people and lesbians.” It’s a deliberate attempt to try and piggyback issues that pertained to transsexualism to issues that had pertained to homosexuality, and I think the comparison is specious. It’s a deliberate attempt to confuse the two issues.
Kearns: Yes, it’s been very successful in the mainstream media and so on and so forth.
Blanchard: That’s for sure.
Kearns: Why do you think that is?
Blanchard: That’s a good question. Educated people in general have a sympathy for the downtrodden or the unfortunate that’s built into liberal-arts education in the Western world — and I think that’s a good thing. I think it’s a good thing that people should get some kind of built-in bias towards the underdog and towards the suffering. But I think in this case, that tendency and that bias on the part of liberal media has been misused by trans activists to influence treatment of cases of those who would actually do better in the long term if they could simply accept their anatomic sex, and here I’m talking about the young kids, 60 to 80 percent of whom are going to normalize in gender identity even without any clinical intervention.
Kearns My final question for you is do you see future editions of the DSM changing with regards to gender dysphoria, and if so, how?
Blanchard: I would like to say that I think things will continue as they are, but I think what we are seeing is a staggering influence of a very small number of people on society. For example, so many schools have gone out of their way to basically encourage gender transition. So I think at some point this has to correct itself, but it could be a long time before the pendulum swings back to some kind of middling position where we neither deny treatment to transsexuals who could profit from it nor encourage people to go down that route who could make an adjustment in some way that’s better in the long term.