It was an “aha” moment, says Ray Blanchard. In the mid-1980s, the clinical psychologist was working at the Clarke Institute of Psychiatry in Toronto, trying to work out what motivated gender-dysphoric men who wanted cross-sex hormones and surgery. And now he had met “Philip,” a patient whose case history made him feel that suddenly everything was clear.

Understanding Blanchard’s moment of revelation requires a closer look at earlier clinicians’ observations. For all the sanitised accounts in newspapers and memoirs, they had always understood that cross-sex identification had a great deal to do with sexual desire, and played out differently according to sexual orientation. “There was never a question throughout the twentieth century whether there are different types of transsexuals,” says Blanchard. “The question was how best to classify them.”

Blanchard started with two broad groupings: androphilic males and the rest. The first group were the minority—former “sissy boys” who had persisted in wanting to be girls, highly feminine in their presentation and interests. The rest were quite different, and more varied. Many had wives and children, and conventionally masculine jobs and pastimes. Some reported fantasising during sex that they were women and their female partners were men penetrating them, or that they and their wives were lesbians. Yet others described themselves as bisexual or asexual—lacking in any sexual desire. It was not easy for an observer to see why they might seek to be accepted socially as women, or what they meant when they said they felt like “women inside.”

The sole cross-sex behaviour that many reported, erotic transvestism, is a common fetish of heterosexual men. A study in Sweden in 2005 found that 2.8 percent of males experienced sexual arousal in response to cross-dressing. For some, it is sufficiently intense and central to their sexual arousal to constitute a “paraphilia”—an atypical, extreme sexual interest that may be classed as a disorder if it causes serious problems or distress. But male cross-dressers do not usually express cross-sex identification. “I was looking for the bridge,” says Blanchard, “between wearing women’s clothing as a masturbatory aid and wanting to be a woman.”

And then he met “Philip.” A 38-year-old with an MBA, Philip suffered gender dysphoria severe enough to have caused episodes of depression. He recalled throwing a penny into a wishing-well when he was six and praying to be turned into a girl. His sexual experiences had been with women, and during them he imagined being a woman too. When he masturbated, he imagined his naked body as a woman’s, focusing on the breasts, vagina, and soft skin. Sometimes he imagined a man was penetrating the vagina.

Philip said he had cross-dressed once in childhood but never since, because he got nothing from it. His readiness to describe his cross-sex fantasies made it unlikely that he was concealing a history of erotic cross-dressing. And hence Blanchard’s “aha” moment: “Here you had what, up till that point, had been called transvestism, and there were no clothes.” Women’s attire was not the true object of such a man’s affections, he concluded: rather, the clothes were the means whereby a man gave life to that object, namely himself in female form. Blanchard turned to Greek to name this sexual desire: “autogynephilia,” which means love of oneself as a woman.

Understanding the life histories and motivations of these newly identified “autogynephiles” posed several thorny problems. Since they had shown no signs of gender dysphoria or cross-sex identification as children, a prospective study, such as that carried out by Richard Green, was not an option. Complicating matters, by this point gender doctors had realised that their patients were intentionally deceiving them. An informal network had developed, with post-operative transsexuals coaching pre-operative ones in what to say to get approved for surgery: that your earliest memory was of knowing that you were truly a girl, and that you had been certain of that inner truth ever since.

Patients also lied about their sexual desires and experiences. Doctors at many clinics (though not the Clarke) regarded androphilic men as the only suitable candidates for surgery: in a homophobic world, turning gay men into straight (trans) women seemed to make sense. A patient who was sexually interested in women might therefore not admit it. On the other hand, one who seemed too interested in men risked being written off as a confused gay man. This double-bind might lead some to deny interest in sex altogether. Another reason this might happen is that men who wish they had a woman’s body commonly find their male genitalia disgusting, and may become adept at screening out awareness of the physical signs of arousal.

To get at the truth about autogynephilia despite these obstacles, Blanchard used two techniques. One was phallometry, in which a pressure gauge is used to measure tumescence. Patients listened to stories about presenting as a woman—very dull ones, so as not to excite anyone who did not have an erotic interest in cross-dressing. (Here is a sample: “You put on your eye shadow, mascara, and lipstick.”) Most of the men in Blanchard’s second group who had denied an erotic interest in cross-dressing became aroused. The other was a questionnaire developed for gauging motivation to provide socially acceptable answers. The patients who denied erotic cross-dressing, or who claimed to be bisexual or asexual, scored more highly, suggesting that they were more likely to be saying what they thought doctors wanted to hear.

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All in all, Blanchard saw no reason to change his initial broad-brush division between androphilic transsexuals and the rest. The self-described bisexuals in the second group, he concluded, were autogynephiles who were attracted to women, but also desired men to validate their female identities. Those who described themselves as asexual were concealing their desires, perhaps even from themselves. He later drew finer distinctions within the group of autogynephiles, according to the nature of the fantasies. If these centred on clothing, the man was more likely to be content without medical transition. If they centred on the body, especially on imagined female genitalia, he was more likely to be severely dysphoric, and less likely to be able to find peace without surgery.

None of Blanchard’s work was intended to put obstacles in the way of transition. He wanted to understand the clinic’s patients, and help them decide what to do. Many were conflicted: concerned for their wives and children, and perhaps their careers. Moreover, autogynephilic desire seemed to compete with ordinary heterosexual desire, and could be temporarily eclipsed by a new partner. A man who had started fantasising about being a woman during adolescence might fall in love, conclude that those fantasies were a phase and marry—only for them to return years later. If the significance of persistent fantasies of having female genitalia was more widely known, fewer people would be made miserable by marriages entered in good faith that ended in misery when the husband transitioned.