Perhaps the first serious attempts to understand gender dysphoria were made by the German Jewish physician Magnus Hirschfeld (1868 – 1935). He founded the “Scientific Humanitarian Committee”, probably the first advocacy group for transgender and homosexual human rights. Hirschfeld first proposed the term “transvestitism” in 1910 , and differentiated this condition from homosexuality. In fact, he identified four types of transvestite, with an erotic interest in men, women, both and neither. He was interested in a spectrum of sexual identities and behaviours, and was the first person to use the term “transsexual” .
Hirschfeld carried out the first sex reassignment surgeries. For each patient, a series of four operations was required. The first of these, on Dora R., a German patient, was successful. The second patient to be treated was Lili Elbe of Denmark, whose story is portrayed in the film “The Danish Girl”. Hirschfeld’s initial surgery was successful, but after later stages, performed by a different surgeon, Elbe contracted an infection and, without access to antibiotics, died subsequently.
Hirschfeld also noted that some men are sexually aroused by the feminine component within – they may be attracted to the “woman within” as well as, or instead of, women outside of them. Blanchard suggests that this is perhaps the first identification of the condition that he later described as autogynephilia . Hirschfeld also noted that a variety of types of sexual orientation are found in transvestites: some are attracted to men, some to women and some appear to be asexual but identified “an inner psychological kernel” – the idea of self as woman.
Blanchard suggests that a number of early writers identified an erotic self-attraction, for example quoting Otto Fenichel (1897 – 1946) who described fantasises that the masculine element of the transvestite’s personality could “have intercourse with the feminine (ie. himself), while noting that “in Fenichel’s view, the transvestite’s driving fantasy was not the conscious thought of himself as a woman with a vulva but rather the unconscious thought of himself as a woman with a penis.”
Blanchard suggests that subsequent generations of clinicians became focussed over-much on the outward manifestation of the condition – cross-dressing behaviour – to the extent that in the 2000 version of the American Psychological Association’s Diagnostic and Statistical Manual, the diagnostic criteria for what is called “transvestic fetishism” made “no mention of erotic ideation regarding the female persona” . The prevalent understanding was that the condition was associated with the presence of specific objects: the subject became aroused by feminine artefacts (for example, clothing), presentation (eg. removal of body hair) or behaviour (speech or bodily movements). Males exhibiting cross-gender behaviour were thus thought to be two principal types: “transvestites (heterosexual males who engage in cross-gender fantasy or behavior only when they are erotically aroused), [and] transsexuals (men have a long-standing and nonfluctuating desire to possess a female body and to live permanently in society as women)” .
For Blanchard this missed the point: fundamentally, for that class of persons that he describes as “autogynephilic” the foundation of the condition was the fantasy of the self as a woman. This did not necessarily require the presence of a specific physical artefact, as evidenced by the case of one particular patient, “Philip”, who had no interest in cross-dressing but who imagined himself to be a woman when he masturbated. For Blanchard this patient was “the final evidence that the erotic idea of being a woman could exist in the complete absence of any interest in women’s clothing or any other fetish-object.” 
- Hirschfeld, M. “Die Transvestiten. Eine Untersuchung ueber den erotischen Verkleidungstrieb mit umfangreichem casuistischem und historischem Material.” Alfred Pulvermacher & Co, Berlin, 1910, Vol I-II.
- Hirschfeld, M. “Die intersexuelle Konstitution”, Jahrbuch fuer sexuelle Zwischenstufen 1923, 23, 3-27.
- Blanchard, R. “Early History of the Concept of Autogynephilia”, Archives of Sexual Behavior, 2005, 34, 439–446.
- Blanchard, R. “Clinical observations and systematic studies of autogynephilia”, Journal of Sex and Marital Therapy, 1991, 17, 235–251.
- Blanchard, R. “Typology of Male-to-Female Transsexualism”, Archives of Sexual Behavior, 1985, 14, 247-261.