Lou Sullivan was a trans activist best known for being one of the first people to publicly identify as a trans gay man—that is, a trans man attracted to other men. Refused gender-affirming surgery by the gender clinic at Stanford University because of his orientation, he campaigned for the removal of sexual orientation from the list of criteria for a diagnosis of “gender identity disorder.” His journey to gender-affirming healthcare was prolonged by psychiatrists’ belief that, as Sullivan expressed it, there was “no such thing as a female-to-male who wants to be a gay man.” Sullivan did eventually manage to access genital reconstruction surgery in 1986; he discovered he was HIV+ later that same year, and died in 1991.

Decades later, studies on gender identity and sexual orientation would affirm Sullivan, showing that there is “such thing” as a trans gay man. In fact, transgender people are less likely to be heterosexual than their cisgender counterparts (meaning exclusively attracted to women if they’re trans men, or exclusively attracted to men if they’re trans women). In the 2015 U.S. Transgender Survey, only 19 percent of trans women and 23 percent of trans men defined themselves as heterosexual or straight. Despite the reality, the cultural expectation that trans people are heterosexual continues—not just as a result of society-wide heteronormativity, but also as the result of a long history of medicine and sexology policing and pathologizing trans romantic and sexual desires.

Trans healthcare and theory about trans identity are both rife with heteronormative bias, the roots of which reach back to 19th and early 20th century psychology. In one of the first sexual pathology texts, the 1886 book Psychopathia Sexualis, German psychologist Richard von Krafft-Ebing created a taxonomy of “deviant” sexual types. Influential in 20th century forensic psychiatry, the book’s typology categorizes the desire of a person who is assigned male at birth and later takes on a feminine role or identity—called “metamorphosis sexualis”—as the final stage of homosexual contagion. Rather than use the exclusive attraction to men (“androphilia”) or women (“gynophilia”) as part of his clinical definition of transness, Krafft-Ebing pathologized all forms of non-cisheterosexual desire while also claiming transgender identity was merely an extension of being cisgender and gay. 

This notion of trans identity as the ultimate outcome of homosexuality influenced how trans-related medicine was practiced for much of the 20th century. By this logic, trans womanhood was characterized by attraction to men, and trans manhood by attraction to women. Yet, even when the circumstances for the examination of transness shifted from sexual pathology to gender-affirming medicine, characterizing trans identity through attraction continued as a “diagnostic” when individuals attempted to access gender-affirming medical care.

For example, in 1966, endocrinologist and sexologist Harry Benjamin published one of the first scales to diagnose “transsexuality”: the Sex Orientation Scale (SOS). Benjamin explicitly included a patient’s Kinsey scale score, which rated how attracted the individual is to males and/or females, as a factor in the SOS. Conflating gender identity with sexual orientation, the SOS characterized “moderate intensity” and “high intensity” trans women as being predominantly or exclusively attracted to males, respectively. While Benjamin noted that both “moderate intensity” and “high intensity” trans women requested hormones and gender-affirming surgery, he described only “high intensity” trans women as having usually attained both. Under Benjamin’s SOS typology, then, trans women who did attain gender-affirming surgery were explicitly linked to their degree of attraction to men.

The use of sexual orientation as a criteria for a diagnosis of “gender identity disorder” and, in turn, access to gender-affirming healthcare continued into the late 20th century. The American Psychiatric Association (APA) and the Harry Benjamin International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health) did eventually remove sexual orientation from their list of diagnostic criteria. But this change occurred only after Lou Sullivan lobbied for it, and psychiatrist Ira Pauly screened an interview of Sullivan at the 1989 APA annual meeting. 

“[T]rans women’s desires for sex and understandings of themselves as sexual beings are policed in ways that cisgender women’s desires aren’t.”

While discrimination in healthcare provision based on sexual orientation is not currently recommended by WPATH or the APA, it wasn’t until the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) that the classification of people with gender dysphoria by sexual orientation was finally removed. But even when sexual orientation isn’t treated as diagnostic in itself, medicine and sexology have policed trans desire by creating taxonomies and classifications based on sexuality. 

One of the most well-known typologies that distinguishes trans people based on sexual orientation was created by sexologist Ray Blanchard in 1985. Under this system, Blanchard distinguishes exclusively androphilic trans women (trans women exclusively attracted to women) from those who are not. Trans women who are attracted to women and/or not attracted to men (including bisexual, lesbian, and asexual women) are classed as “autogynephilic,” which means they are sexually aroused by the idea of themselves as a woman and transition to fulfill these fetishistic desires. In other words, Blanchard argues that trans women’s desires for particular embodiments and understandings of themselves as women are really the result of sexual fantasy.

Blanchard doesn’t deny that either group within his typology is trans, and he argues that both benefit from access to transition. Yet, by arguing that the indentities of trans women who aren’t exclusively attracted to men is the result of fetishism, he pathologizes those desires that lie outside of attraction to cisgender men. Because of typology’s such as Blanchard’s, trans women’s desires for sex and understandings of themselves as sexual beings are policed in ways that cisgender women’s desires aren’t.

Specifically targeting trans women and other transfeminine people likely results from what what biologist and gender theorist Julia Serano has termed transmisogyny, which prescribes that “femaleness and femininity are inferior to, and exist primarily for the benefit of, maleness and masculinity.” Even when examining trans women who are exclusively attracted to men, researchers have created typologies based on how the trans women they studied chose to have sex. 

For instance, psychologists Frank Leavitt and Jack C. Berger conducted a 1990 study to examine the sexual histories of trans women attracted to men, particularly in how these women used their genitals during sex prior to gender-affirming surgery. In Leavitt and Berger’s sample, the women who chose to use their genitals during sex were characterized as having “emotional disturbance” and “difficulties in making the transition to full-time feminine living,” thus making them unideal candidates for transition related medical care. They were placed in contrast to the trans women in the sample who chose not to have sex involving their genitals; these women were described as “nuclear transsexuals,” meaning they were closer to the “ideal” candidate for transition. Leavitt and Berger’s conclusion that trans women who want to use their genitals during sex are unideal candidates for transition related medical care has been picked up by other researchers, such as psychologist Robert Stoller. Stoller has argued that trans women whose “genitals give them pleasure” should be excluded from gender-affirming surgery. 

While sexual orientation is no longer considered part of the criteria for a diagnosis of gender dysphoria—a diagnosis that is still required to access gender-affirming medical care where informed consent is not available—the legacy of policing trans sexual desire in both heterosexist and misogynistic ways continues to this day. Some healthcare professionals go so far as refusing to care for gay trans people. Even as these fields change their approaches to conceptualizing trans identity, broadening the definitions of acceptable desires, the historical damage done to trans individuals’ lives and to trans communities through misogyny and homophobia remains.