How it all starts
Cross-gender fantasies in autogynephiles can start anywhere between early childhood and the onset of puberty; Lawrence reports that most of the respondents who specified an age of onset indicated a start between 4 and 6 years old, although this is likely due in part to selection bias (those with later age of onset are less likely to specify it, since the timing wouldn't seem as significant). Explicitly erotic feelings often started later, usually by puberty, though some reports also indicated an erotic aspect to the fantasies even in early childhood.
Expression of a fundamentally erotic fantasy prior to puberty sounds rather odd to modern Americans, but this is because our culture has a strong belief in childhood innocence -- a defense against bad actors like molesters, maybe, but not exactly accurate. Boys as young as toddlers get erections, and frequently displays of emotion associated with their eventual sexual orientation are present in early childhood.
At any rate, many respondents engaged in cross-dressing from an early age, and a good number of them reported erotic feelings from it then, though for others they did not start -- or were not remembered as such -- until later.
We maybe shouldn't read too much into occasional cross-dressing or cross-gender wishes at a young age, though. Lawrence points out that non-erotic cross-dressing or occasional wishes to be the opposite sex are fairly common, quoting studies that found these in several percent (varying by age) of preadolescent boys. Still, when these behaviors are erotic, that probably means something; several respondents mentioned masturbating to fantasies or while cross-dressing at as young as 6 (!) years old.
Lawrence notes that the existence of cross-gender fantasies and cross-dressing doesn't indicate consistent and persistent cross-gender wishes or a persistent cross-gender identity in childhood; indeed one narrative reports these from 4-6 years old, followed by a relative cessation in late childhood until it came back in full erotic force at puberty. This is a quite different pattern than the "classic" MtF presentation which includes consistent cross-gender wishes starting in early childhood.
What about cross-gender behaviors, such as playing with girl's toys, a choice of female friends, and so on? Here the data is more muddy. Partially this is because the normal range of male behavior is quite wide, many ordinary boys occasionally play with girl's toys, or prefer girls over boys as friends. Lawrence also cites a study which (p 82)
found that “preferring girls’ games and toys as a child” was one of the most frequent areas in which MtF transsexuals reported having lied to or misled their psychotherapists
So studies based on self-reported preferences should be taken with a grain of salt. The data seem equivocal; it's possible that autogynephilic MtF transsexuals are more likely than other boys to exhibit cross-gender behaviors as children, but it's also possible that the distribution is in reality much like the distribution for ordinary boys, and the prevalence of later in life reports to the contrary are mostly due to misremebering and misinterpretation of memories.
Many of Lawrence's respondents explicitly denied having female-typical interests in childhood; oddly, at least one of them still seemed to interpret his experience as evidence that he wasn't male enough; quoting Lawrence at length (p 83):
It is surprising that a boy who became cadet lieutenant-colonel at his military high school and was an avid water-skier and cross-country runner would conclude he was “not successfully masculine” simply because he was not proficient at baseball. Green (2008) observed that MtF transsexuals sometimes hold stereotyped views of masculinity and femininity and are apt to conclude that, if they deviate from the masculine stereotype in any way, they cannot really be men. Green gave the example of a gender dysphoric patient who concluded he was transsexual in part because he was not interested in cars and football. Although Green makes an important point, another explanation might be that autogynephilic men who are unremarkably masculine but experience a strong and seemingly inexplicable desire to be female might be eager to find evidence, however insubstantial, of psychological femininity or unmasculinity that would help them make sense of their cross-gender wishes.
Along similar lines, a number of other respondents described some instances of feminine interests and behaviors, but with no indication that these were common or persistent, about which Lawrence says (p 85):
In my clinical practice, I not uncommonly elicit histories like these from nonhomosexual gender dysphoric male patients. In many cases, the feminine behaviors in question turn out to be a few isolated and unrepresentative episodes (e.g., “For a time my closest playmate was a girl”—for 2 months one summer; “When I was 6, I used to play with dolls”—on three or four separate occasions). These isolated episodes of feminine behavior nevertheless feel quite meaningful to the men who experienced them. I almost never get the sense that these patients are trying to mislead me by portraying these childhood episodes as more representative than they genuinely are. Instead, I believe that these patients are desperately trying to make sense of their powerful cross-gender wishes and are grasping at straws in an effort to find evidence of childhood femininity that might help to explain their adult feelings.
I think that Lawrence is exactly correct here. Memories are, more than we would like, malleable things, and there is a lot of internal pressure to make sense of the powerful feelings involved. It probably takes an unusual level of commitment to the truth to not make mountains out of relative molehills in such cases.
An interlude about self-descriptions
Lawrence takes some space to discuss how the respondents processed the standard "woman trapped in a man's body" framing in light of their autogynephilia. Some asserted that that expression fit them, others adopted the "man trapped in a man's body" variation (Lawrence published a shorter piece with the same title as the book, and some of the respondents had read it); still others tried other variations or denied that the (original) expression fit them without providing an alternative.
I didn't find all this particularly interesting, except for the following quote from one respondent (p 88):
The best phrase to describe my belief about myself is that “I desire (or need) to be a woman with all my heart, in every way,” as opposed to feeling “I have always been a woman.”
Keep that one in your back pocket. I suspect it's the key to this whole mess.
Autogynephilia over a lifetime
The vast majority of autogynephilic MtF transsexual/transgender people (Lawrence here uses both terms, to include those who don't have an intent to fullly transition, I think) express that their autogynephilia has continued during their entire adult life. This is not great news to people who might expect that they will "just grow out of it" (though I will note that the fraction of people who don't report lifetime persistence is nonzero). Lawrence adduces this as evidence for the autogynephilia-as-sexual-orientation hypotheses, though I'm not sure it's really evidence for that over it being "just" a paraphilia.
Perhaps surprisingly, a large fraction of MtF transsexuals who had undergone SRS also reported continuing autogynephilia, and some of them reported that feminization fantasies (about becoming female) were necessary for them to acheive orgasm. Others said that contemplating their own body was now sexually arousing. Some respondents also reported a lessening or cessation of autogynephilic fantasy after transition, but people also frequently reported a lessening of their sex drive in general, so it's kind of hard to tell what's going on.
Four Types of Autogynephilia
Following Blanchard, Lawrence divides the actions and fantasies typical to autogynephilia into four types:
Transvestic autogynephilia: Erotic cross-dressing, basically. Lawrence's contention is that "transvestic fetishism" in the old sense is in most cases a subtype or expression of autogynephilia.
Anatomic autogynephilia: Fantasies/actions having to do with having female anatomic features. Typical examples include: breasts, genitalia, body structure, facial structure, soft skin, etc.
Physiologic autogynephilia: Fantasies/actions having to do with female physiological functions. Examples include pregnancy and breastfeeding, but also more unusual fantasies like menstruation.
Behavioral autogynephilia: Fantasies/actions having to do with engaging in (stereotypically) feminine behaviors. This can cover pretty much anything, and in some of the accounts of this you can see some pretty sexist underlying assumptions, honestly. One particularly important type of behavioral autogynephilia is the "act or fantasy of engaging in sexual activity with a man as a woman", which Lawrence thinks is particularly significant for interpreting data and in a clinical setting.
These are not mutually exclusive (e.g. cross-dressing could also be behavioral, or as an aid to anatomic fantasy, etc) and they frequently co-occur (all are present to an extent in most of the transsexual survey respondents). It's important to also note that autogynephilic behavior can consist of pure fantasies, actions, or both.
Lawrence goes on to give details of each of these types; we'll hit just a few of the highlights.
Lawrence says that transvestic autogynephilia is the most prevalent type, and that "almost all autogynephilic males probably experience it". The first part is probably true if Lawrence is correct that almost all fetishistic cross-dressing is just a species of autogynephilia. I'm not so sure about the second part.
Transvestic autogynephilia can center around almost any type(s) of feminine clothing. There's the stereotypical one, of course: clothes that men find sexually attractive when worn by women: lingerie or high-heels, for instance. There's women's clothes that are associated with key parts of femal anatomy, such as panties (the number of respondents that talked about wearing panties is crazy) and bras. But this can also include ordinary and unremarkable women's clothing.
The reasons that these men cross-dress can vary a bit also. We can group into roughly five categories (these are mine, from reading the examples; Lawrence doesn't explicitly categorize like this):
Because it's arousing, with no reference as to why.
Because it helps to imagine oneself as a woman, and that is arousing.
Because it is exciting, pleasurable, or "comfortable" as such, but with no conscious experience of sexual arousal (Lawrence thinks that this is usually due to low-grade sexual arousal that the cross-dresser is unaware of).
Because it facilitates female-typical behavior.
As (2), but not necessarily experienced as arousing.
There's some clear overlap between these, and between cross-dressing and other manifestations of autogynephilia as well.
According to Blanchard and Lawrence, although transvestic autogynephilia is more common, anatomic autogynephilia is (perhaps understandably) the one most associated with gender dysphoria and the desire for SRS.
The two big ones here are having breasts and having female (external) genitalia. Testimony after testimony reports a strong desire for breasts and female genitals, and often intense sexual arousal at fantasizing about having them. Of course, having female genitals mean not having male genitals, so many respondents report sexual excitement at the idea (or fact!) of the removal of their male genitalia, and frequently become uncomfortable with the continued existence of their penis and/or testes. We can see how the positive desire to have a female body leads to the negative body-associated dysphoria popularly associated with transsexualism.
There's also some weird cases. Some men expressed a strong desire for a female body, even to the point of seeking SRS, but no desire to be female in any other way. Others (Lawrence did not count these as transsexuals) went as far as to use feminizing hormones to develop breasts, but had no interest in having female genitalia. (You might call them boob men.)
Some people have pregnancy or lactation fetishes. Some autogynephiles have pregnancy or lactation fetishes about themselves. This manifestation of autogynephilia is probably the least common, but it is present. It seems pregnancy and breastfeeding were the most common fantasies, here, but menstruation fantasies were also present. Some people reported also taking actions to act out or pretend to enact their fantasies, such as stuffing a pillow to pretend (to themselves) to be pregnant, or urinating on sanitary pads.
While the specifics seem weird, the origin seems (to me) to be clear: these people are obsessed with having female experiences, and what experiences are more quintessentially female than ones associated with reproduction?
("But wait," I hear you saying. "Isn't there another important experience associated with reproduction?" We'll get to that.)
This manifestation of autogynephilia has to do with engaging in "feminine behaviors", as understood by the autogynephile, of course. Sometimes these are explicitly erotic, other times, they are part of the general program of fantasizing about being a woman.
Examples include: having a feminine voice, using a feminine name, tossing one's hair, being "one of the girls", being in a women's locker room or restroom without sexual overtones (yes, multiple people reported sexual arousal at the thought of not having sexual arousal), having to sit/squat to urinate, acting sexy, taking birth control pills, getting manicures, and so on.
There's a lot of crossover with the other categories, especially transvestism (wearing women's clothes, especially in public, is a behavior).
Of particular public interest here is the bathroom/locker room thing. It's safe to say that there probably are some trans people who are getting horny about using the women's bathroom or locker room, but the reason they do it is not to ogle or engage in predatory behavior, but because it makes them feel like a woman (and that makes them horny). You can decide for yourself whether that makes it better or not. (To respond to the inevitable, yes, there are also predators that are using the trans-bathroom-thing as cover. I have no idea how much overlap they have with trans people.)
And then there is the ultimate female behavior, which also touches on female anatomy and physiology.
Sex with men
Here we have the autogynephilic sexual fantasy as it touches on fantasizing about sex. Sexual behavioral autogynephilia is pretty common, and one common form of it involves the fantasy of (as a woman, this is important) having sex with men. From one perspective this is very odd -- autogynephilia is, presumably, due to a malfunctioning heterosexual male sexuality, and heterosexual men are not exactly well known for fantasizing about having sex with men.
Nevertheless, it is explicable, and its explanation has some pretty important implications. The explanation is this: what autogynephiles have is a desire to be female, and what is more quintessentially female than enacting the female role in reproduction? Add this to the fact that the desire is sexual, and it is unsurprising that "being a woman having sex with a man" is a potent fantasy. It hits all the high points: female anatomy, female physiology (reproduction), female behavior, and, of course, sex.
The only problem is that (with possibly a few exceptions) they aren't actually attracted to men.
Lawrence spends a lot of time describing how the autogynephilic transsexuals surveyed dealt with this, and drawing out the implications. Some of this analysis goes back to Blanchard (who is cited here). I'll give the quick summary.
Many of these fantasies (and actions, when autogynephilic MtF transsexuals do have sex with men) involve an explicit desire to be validated as being "real women", being desirable, and other ways in which it proves femininity and enables other aspects of female experience.
Most of these fantasies seem to involve a "faceless" (that word was literally present in many testimonies) man, not a particular individual, or any particular imagined male attributes. This allows the fantasizer to enact "having sex with a man as a woman" without having to deal with the the fact that they are not actually attracted to men. Many people reported that they found the idea of sex with a man to be exciting, but only when they were also fantasizing about being a woman or otherwise inhabiting a female role; they found the idea repulsive otherwise.
Many of the autogynephilic MtF transsexuals report that their sexuality changed, from exclusively attracted to women to bisexual or even exclusively androphilic as part of or after their transition. All I have to say about that is that if they are right about some of the reasons they gave, society gave up on gay conversion therapy too soon.
Lawrence suggests that a better question than the standard of asking whether someone is sexually attracted to men or to women is to ask who the first person they fell in love with is, or whether they habitually fall in love with men (respectively boys for adolescents) or women (resp. girls). Lawrence observed that only one of the respondents here claimed to fall in love with men, despite many claims of orientation change or sexual fantasies involving men, and speculates that a real androphilic sexual orientation among autogynephilic MtF transsexuals is extremely rare.
This lends some credence to the explanation that Blanchard gave of the puzzle that many autogynephiles report, across a number of studies, that they are either bisexual or exclusively androphilic. Some of this might be lying, but more likely it is reporting of autogynephilic sexual fantasy of being a woman having sex with a man as sexual attraction to men. They are both about sex, and there's some powerful internal pressure to adopt the narrative that says "it's because you're a (normal) woman".
A funny tidbit is the stories some of these people tell to explain their (pre-transition) attraction to, and sexual behaviors with, women (marriages with children are not uncommon). Lawrence quotes several who attributed it to "internalized homophobia". Suuuure.
In the final part of this review, we'll look at how autogynephilia interacts with other parts of sexuality, and what all this means: to the autogynephilic transsexuals themselves, to non-transsexual autogynephiles, and to everyone else.