Autogynephilia and the Problems with Psychoanalysis: A Response to Joseph Burgo

Why empirical evidence, not clinical anecdotes, should shape the discussion on autogynephilia.

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About the Author

Dr. Michael Bailey is an American psychologist, behavioral geneticist, and professor at Northwestern University best known for his work on the etiology of sexual orientation and paraphilia. As professor for 35 years, and a researcher for over 40, Bailey has published over 100 academic articles.

Bailey is a leading expert on the topic of autogynephilia, the phenomenon of males being aroused by the thought or image of themselves as female. In 2003, Bailey wrote The Man Who Would Be Queen, a book that examines gender identity, sexual orientation, and the role of autogynephilia in male-to-female transgender experiences.

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The psychoanalyst Joseph Burgo has discussed gender dysphoria, and especially autogynephilic gender dysphoria, in several essays on this site and elsewhere, as well as on podcasts. In response to critical reactions on Twitter/X (including by me), Burgo has challenged skeptics to explain what is wrong with his ideas. Because Burgo’s ideas are receiving attention on influential sites, including Reality’s Last Stand, I have decided to meet this challenge.

Another reason is that I have found a (small?) autogynephilia-obsessed contingent of the gender-critical to be as ideological, overconfident, and hostile to anyone questioning their prejudices as transgender activists, and I (no doubt vainly) hope to persuade them of their errors. This contingent is particularly disappointing, because I have spent much of my recent research time studying rapid-onset gender dysphoria and providing evidence for it. I would have thought I’d be considered an ally. Oh well. I have thick skin.

I have been planning to write about autogynephilia (AGP) for Reality’s Last Stand for some time now, and this is my first contribution. I intend to write several more pieces on AGP because it is an important topic that’s not being discussed well by either trans rights activists or gender criticals. This first essay is different from what is to come, however. Here, I will address the problematic nature of the evidence Burgo has provided for his views, rather than what we generally know about AGP. In future essays, I will focus on scientific findings related to AGP, including recent, not-yet-published data. I will especially try to address common concerns about AGP among those who consider themselves gender critical.

Burgo’s Ideas About Autogynephilia

In a 2023 essay “Autogynephilia and the Sexualization of Shame,” Burgo asserts that a major cause of autogynephilia is core shame: “the felt experience that your development went terribly awry, and as a result, there’s something foundationally wrong with you.” He highlights men he saw in therapy who he believes exemplify his theory. For example, David was raised by alcoholic parents who had no affection for each other or for him. He felt ugly, “deformed and defective,” “too repulsive and strange for anyone to care about.” During puberty, David discovered that he was especially aroused by pornography featuring psychological humiliation, such as “forced feminization videos where a contemptuous, dominant woman would humiliate a man.” This led to cross dressing with masturbation in adulthood, reflecting “David’s desperate attempt to transform suffering into some kind of pleasure, to find sexual gratification in the very thing that caused him the most pain.” 

The other case histories that Burgo offers similarly show early adversity. Seth “was the only child of an unhappy marriage and his parents divorced when he was seven. Since then, his father has remained a remote figure, intervening irregularly over the years. His mother strikes me as struggling with a personality disorder and seems to have become a shut-in as she’s gotten older.” Casey “is a 17-year-old trans-identified boy who hates himself, hates his looks, and hates his body.” “But mostly he hates himself and his big ugly body. He thinks he’s a loser. In the terms I’ve been using, he struggles with profound shame at his core.”

There is no hint how these males’ unhappiness causes AGP, defined as a male’s sexual arousal by the fantasy of being a woman. Burgo agrees:

I don’t know that I can explain exactly how core shame became welded to sexual arousal, but I see it as David’s desperate attempt to transform suffering into some kind of pleasure, to find sexual gratification in the very thing that caused him the most pain.

Burgo also sees a role for narcissism in AGP development. Defensive narcissism rather than grandiose narcissism:

As I see it, taking oneself as the object of one’s own desire is the epitome of narcissism, but experts in this area don’t understand what I mean. Not true, I’ve been told. Autogynephiles can’t be narcissists because they’re not at all grandiose. Again, I think we can blame the DSM5, this time for its diagnostic criteria defining Narcissistic Personality Disorder. Inflated sense of self-importance: fantasies of unlimited success, excessive need for admiration, and so on. A view of narcissism as a defensive character structure warding off some unconscious and unbearable experience fits neither the zeitgeist nor our medicalized view of mental disorders.

Again, Burgo declines to provide an explanation of how defensive narcissism–“warding off some unconscious and unbearable experience”–leads to a male’s sexual arousal by the fantasy of being a woman.

How Strong Is the Scientific Support for Burgo’s Beliefs About AGP?

The scientific method doesn’t require test tubes, brain scans, math, or even experiments. In a classic essay, the social psychologist and public intellectual Carol Tavris mentioned “two core elements of the scientific method…The first is skepticism: a willingness to question received wisdom. The second is a reliance on gathering empirical evidence to determine whether a prediction or belief is valid.” Burgo, I will be the first to admit, is commendably willing to question received wisdom. But he falls short on the second core element, the reliance on gathering empirical evidence.

Burgo’s evidence consists of his opinions about a few patients he has seen. That’s it. Furthermore, he hasn’t ever tried to assemble good measures of the key variables he’s interested in: AGP, core shame, and defensive narcissism.

You know the dictum “Correlation isn’t causation” right? Just because ice cream sales and drownings tend to be elevated during the same time of year doesn’t mean that eating ice cream causes drowning. Well, Burgo hasn’t even attempted to establish correlation. He lacks key information, namely, whether autogynephilic males outside of his practice have higher rates of core shame and defensive narcissism compared with other males.

Here’s a study one could do, to see if Burgo’s ideas have promise: First, find good measures of AGP, core shame, and narcissism. Second, survey a large sample of males with those measures. I’d also include questions about parents, aiming to get at how good or bad they were during respondents’ childhood and adolescence. And measures of gender dysphoria and neuroticism (a personality trait associated with negative feelings). Regarding the latter measures, it could be that AGP is associated with bad mental health only in a subset of persons who have other issues. Internet sites for paid research participants exist, and these have some AGPs. The cost for a sufficiently large sample (maybe 1,000 responses) would be several thousand dollars. If Burgo wants to fund such a study, I will help him implement it, out of scientific collegiality. But I don’t think his ideas are sufficiently promising to do this on my own.

Competing Explanations of Autogynephilia

Burgo dismisses the leading scientific theory of autogynephilia: “We commonly hear terms like ‘erotic target location error’ that sound scientific and explain precisely nothing.” Here is the abstract (published summary) of a scientific study published in 2023 concerning that theory. Compare the quality of its evidence with that offered by Burgo:

Some men sexually attracted to types of persons (e.g., women) or things (e.g., animals) also have internalized sexual attractions: sexual arousal by the idea of being the type of person or thing to whom they are attracted. Consequently, some of these men develop erotic target identity inversions, in which they imitate, yearn to be, or identify as an instance of their erotic target. Erotic Target Identity Inversion Theory predicts that for every external erotic target to which men are attracted, a subset of men will develop an internalized sexual attraction, which may cause an erotic target identity inversion. We examined these predictions in Internet surveys of three samples of men with paraphilic sexual interests: 322 men attracted to amputees, 1501 men attracted to animals, and 402 men attracted to severely obese persons. All samples included substantial minorities of men reporting internalized sexual attractions and erotic target identity inversions specific to their external sexual attractions (e.g., men attracted to amputees who are also aroused by the fantasy of being amputees and wish to become amputees). The correlation between degree of each internalized sexual attraction and degree of its corresponding erotic target identity inversion was approximately 1.0 after correction for attenuation. In each sample, participants’ specific internalized sexual attraction was positively correlated with autogynephilia, likely the most common internalized sexual attraction in men. Erotic Target Identity Inversion Theory can potentially explain a variety of otherwise puzzling phenomena, including transgender identity among female-attracted natal males and men seeking amputations of healthy limbs.

I’ll write more about these ideas in future essays. Right now, I’ll just say that the differences between Burgo’s speculative essays and our careful empirical studies are stark.

The Problems with Data Obtained During Therapy

Scientific limitations of patients’ (or if you prefer, clients’) disclosures during therapy sessions are notoriously problematic, for at least two reasons. First, the set of patients seen by any therapist is not sufficient to establish whether a generalization is correct. (They don’t know whether AGPs who aren’t their patients have core shame, for example.) Second, therapists tend to have preconceptions that affect what they notice, remember, and believe. Let’s go back to Carol Travris’ classic essay. She wrote that the two core elements of the scientific method—skepticism and reliance on empirical evidence—“are almost entirely lacking in the training of most psychotherapists today”:

You don’t get to sit in your chair and decide that autism is caused by cold, rejecting “refrigerator” mothers, as Bruno Bettelheim did. But legions of clinicians (and mothers) accepted his cruel and unsubstantiated theory because he was, in fact, Bruno Bettelheim. It took skeptical scientists to compare the mothers of autistic children with those of healthy children, and to find that autism is not caused by anything parents do; it is a neurological disorder.

The scientific method is designed to help investigators overcome the most entrenched human cognitive habit: the confirmation bias, the tendency to notice and remember evidence that confirms our beliefs or decisions, and to ignore, dismiss, or forget evidence that is discrepant. That’s why we are all inclined to stick to a hypothesis we believe in. Science is one way of forcing us, kicking and screaming if necessary, to modify our views. Most scientists regard a central, if not defining, characteristic of the scientific method to be what Karl Popper called “the principle of falsifiability”: For a theory to be scientific, it must be falsifiable —you can’t just show me observations that confirm it, but also those that might show the theory to be wrong, false. If you can twist any result of your research into a confirmation of your hypothesis, you aren’t thinking scientifically. For that reason, many of Sigmund Freud’s notions were unfalsifiable. If analysts saw evidence of “castration anxiety” in their male patients, that confirmed Freud’s theory of its universality; if analysts didn’t see it, Freud wrote, they lacked observational skills and were just too blind or stubborn to see it. With this way of thinking, there is no way to disconfirm the belief in castration anxiety.

Yet many psychotherapists perpetuate ideas based only confirming cases—the people they see in therapy—and do not consider the disconfirming cases. The popular belief in “the cycle of abuse” rests on cases of abusive parents who turn up in jail or therapy and who report that they were themselves victims of abuse as children. But scientists would want to know also about the disconfirming cases: children who were beaten but did not grow up to mistreat their children (and, therefore, did not end up in therapy or jail), and people who were not beaten and then did grow up to be abusive parents. When the researchers Joan Kaufman and Edward Zigler reviewed longitudinal studies of the outcomes of child abuse, they found that although being abused does considerably increase the risk of becoming an abusive parent, more than 70 percent of all abused children do not mistreat their offspring—hardly an inevitable “cycle.”

I am not saying that therapists’ opinions originating from their interactions with patients are worthless. They are a source of scientific hypotheses. But they have big limitations. And hypotheses need to be tested in good empirical studies.

The Problems with Psychoanalysis

After Burgo published one of his essays here on Reality’s Last Stand, I complained on an email discussion group. I had thought it unlikely that those with scientific training and values, such as Colin Wright, would find Burgo’s essay credible, especially given Burgo’s psychoanalytic approach. In reply, two persons with scientific training and values said they found the essay “fascinating.”

Exasperated, I then recalled the allure that Freud had for me when I first learned about his ideas as an undergraduate. The unconscious, dream interpretation, omnipresent sexual motivation (okay I didn’t care for the Oedipal thing). The power I felt “knowing” these things that most didn’t. Being able to interpret others’ behavior via motives they weren’t even aware of.

Freud was inspirational as long as I didn’t think too much about the question “but how did he know these things?” Freud’s evidence consisted almost entirely of what his patients told him during their psychoanalytic sessions with him. (Exceptions included his own dreams.) Early on, Freud insisted that the success of his therapy showed that his interpretations were correct. Later, when it became clear that his therapy wasn’t often successful, he changed his mind about needing to show that patients improved. Somehow, he just knew the truth.

My analytic-minded roommate—a philosophy major—began my process of de-enchantment with Freud, by asking me difficult questions: “How do you know that? What’s the evidence?” My first semester of graduate school—when I had a couple of classes taught by psychoanalytically-oriented faculty who never addressed the evidence issue—made me a determined ex-Freudian.

It’s not just me who’s become disenchanted. Psychoanalysis has all but vanished from institutions of empirical science, including academia outside of the humanities (the least healthy departments of the contemporary university). A psychologist sympathetic with, but frustrated by, psychoanalysis wrote in 2001: “Psychoanalysis is dying, and maybe it should.” In an article entitled “Is Psychoanalysis Still Relevant to Psychiatry?” a prominent research psychiatrist wrote: “The field may only survive if it is prepared to dismantle its structure as a separate discipline and rejoin academia and clinical science.”

Nor is it just Freud. His descendants diverged in various ways, but none that made their science better. This includes Melanie Klein, who influenced Burgo. In his book An Evidence-Based Critique of Contemporary Psychoanalysis, psychoanalytically trained research psychiatrist Joel Paris wrote:

Klein proposed that problems in adulthood were largely related to intrapsychic conflicts in infancy. But since she exclusively depended on clinical methods, no researchable hypotheses emerged that could have tested her theory. Moreover, while many of Klein’s ideas were based on what she called “infant observation”, they actually consisted only of speculations about what infants might be thinking.

I grant that Burgo’s observations on adult patients are more promising than Klein’s on infants.

Does psychoanalysis have any value? Although I don’t understand why, many people I respect have been impressed by psychoanalysis, even after acknowledging its limitations. These include Joel Paris, previously mentioned; the important research clinical psychologist Paul Meehl; Jordan Peterson; and the influential literary critic Harold Bloom. None of these persons defended psychoanalysis as a tool for scientific knowledge, however. For example, while naming Freud “the greatest modern writer,” Bloom wrote:

Intended theoretically as science, and pragmatically as therapy, psychoanalysis has become something very different, and perhaps always was quite different from what Freud said he wanted it to be. A science presumably is more than a descriptive discipline, supposedly is capable of verification and perhaps need not depend upon metaphors in its pursuit of reality. Yet all of Freud’s copious writing is intensely metaphorical, very little of it is verifiable, and much of it is devoted to what cannot be described.

I must confess that I don’t get the appreciation for Freud et al. or any kind of psychoanalysis. But if you do, that’s okay. I don’t get poetry either; that’s probably my limitation. But no one should be using psychoanalysis to argue for factual claims about human nature.

Expertise and Evidence

Some gender critical views—including that biological sex is binary, that there is insufficient evidence to support medical gender transition in adolescents and children, and that there is an epidemic of socially contagious gender dysphoria affecting adolescent girls—are persuasive because they are supported by rigorous scientific evidence. Legal cases have made inroads using testimony of experts such as James Cantor and Hilary Cass, whose reports provide thorough analyses of scientific evidence. Experts become experts because they adhere to good scientific practice. Burgo is clearly well-meaning and intelligent, and perhaps has some valuable insights about autogynephilia. But if his views are to be taken seriously, he needs to take Carol Tavris to heart and gather some empirical evidence.

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