DSM-IV-TR criteria

• Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
• The fantasies, sexual urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning. It involves using nonliving objects to obtain sexual arousal.
• Specify if :
  • With Gender Dysphoria: if the person has persistent discomfort with gender role or identity

Associated features

• Common symptoms associated with this psychological disorder do not seem to vary greatly, but these symptoms do vary in severity. Transvestic Festishism is defined as a paraphilia by the DSM and usually occurs in patients as one of several paraphilias. These disorders, known as paraphilias, are a group of mental disorders characterized by several types of obsessions involving sexual practices or activities that incorporate sexual practices involving non-consenting or inappropriate partners, or unusual means of arousal. The main feature of this disorder is recurrent sexual urges or sexual desires involving dressing in clothing normally worn by the opposite sex. This is often also referred to as cross-dressing. A diagnosis of this disorder is usually made only if an individual has acted out on these urges or if the urges seem to interfere with everyday activities for the individual. The frequency at which the urges occur is the deciding factor in the severity of cases. For some individuals, the urge occurs often and is necessary for sexual arousal, while in some individuals they may not be necessary or present unless triggered by outside influences (e.g. stress). When these outside influences are absent, individuals with less severe cases are typically able to function in a normal sexual manner. Participation in transvestism is usually gradual, over time the sufferer begins to assume the identity of a member of the opposite sex based on his or her perceptions of that sex. Transvestic behavior in patients is closely associated with achieving some sort of sexual gratification. A person that practices transvestic fetishism often finds it difficult to distinguish from the opposite gender. They have often adopted many qualities specific to that gender (e.g. mannerisms, clothing, materials, and other items associated with the opposite gender). In extreme cases some individuals undergo hormonal or surgical procedures to change their appearance to that of the opposite sex (gender reassignment surgery.) The DSM states that one should not be considered homosexual in nature just because of transvestism, although some do occasionally have homosexual encounters. Some individuals with transvestic behavior appear to be motivated by autogynephilia which is a condition in which the individual is sexually stimulated by fantasies that their own bodies are female.
• The ICD-10 adds the additional exclusion criteria that the disorder is not a symptom of another mental disorder such as schizophrenia. It also includes a separate diagnosis of Dual-role Transvestitism characterized by non-erotic cross-dressing and the absence of desire toward permanent sex reassignment.

Child vs. adult presentation

It is difficult to determine differences in the presentation of this disorder between children and adults because the disorder typically begins during childhood and progresses further into adulthood if untreated.

Gender and cultural differences in presentation

• Individuals diagnosed with this disorder are typically male; females are rarely diagnosed. A few cases have been reported, but virtually no information is available on female occurrences of the disorder. This may be due to the fact that, in Western cultures, women may dress in a number of socially accepted ways, while men are more limited in socially accepted attire. It should be noted, however, that in current times, there are fewer diagnoses of this disorder. Today there is a greater degree of acceptance regarding this condition and the disorder is generally seen as harmless to others.
• Some Dutch studies suggest adult transsexualism ratios of 1:11,900 in males and 1:30,400 in females. In adults transsexualism is difficult to estimate or diagnose. In children there have been reports of 10-16%.

Epidemiology

Estimation is difficult in adults but probably less than 2% to 5% in the general population, but is difficult to estimate or diagnose.Transvestic Fetishism is slightly more prevalent in the child population because that is where it usually begins.

Etiology

• Some individuals may be unaware of the root causes of the disorder in their cases. Possible causes of this disorder could be adolescent curiosity or factors stemming from encounters in childhood as simple as dressing up in the clothes of one’s mothers or sister if the individual in question is male. In adults, many of these individuals will steal their relatives/or girlfriends undergarments and hide them when they are not around. They will wait for the opportune time to wear these things when alone for fear their “little secret” will come out. The activity is found enjoyable and therefore repeated, but the reasoning behind the enjoyment is unconscious. It has been suggested that the disorder can sometimes be caused by mothers creating gender confusion by dressing the boy as if he were a girl. This behavior is sometimes related to the mother’s anger towards men or anger at the fact that she had a son rather than a daughter. Such occurrences are rare and support for this notion is lacking.
• Ray Blanchard has suggested an etiological association between transvestic fetishism and “non-homosexual gender identity disorders” (i.e., FTMs sexually attracted to men, both men and women, or neither, and MTFs attracted to women, both men and women, or neither). This is based on retrospective studies of transvestic male fetishists and MTFs where Blanchard has identified a common element of “autogynephilia”–which Blanchard defines as a man’s eroticization of himself as being or dressing as a female.

Empirically supported treatments

• The most common diagnosing practice is taking a history or by engaging in direct observation. A diagnosis is only made if a patient is markedly distressed by an inability to dress as they desire or if the disorder interferes with normal activities in daily life. Known treatments for the disorder were developed when the disorder was less accepted. These treatments often utilized aversion therapy involving electrical shocks, but these treatments were largely unsuccessful.
• Another type of treatment referred to as orgasmic reorientation has also been tried with little success. The goal in this type of therapy was to attempt to help people learn to respond sexually to generally accepted stimuli. With the view of the disorder changing with the times there is less focus on treatment of the disorder and more encouragement for societal acceptance.

Prognosis

• The prognosis for treatment of transvestic fetishism is poor, as most persons with this disorder do not desire to change. Most cases in which treatment was demanded by a spouse as a condition of continuing in a marriage have not been successful.

• The video below is an interview with Eddie Izzard who is a stand-up comedian, but also has a fetish for cross-dressing. Most people with this disorder are able to lead normal lives and most of them “dress up” in their own privacy; however, it is clearly seen in this interview that Eddie Izzard mixes his fetish in with his every day life.