Transvestic Disorder DSM-5 302.3 (F65.1)
This Article Is Part of A Series For Paraphilic Disorders
DSM-5 Category: Paraphilic Disorders
Introduction
Paraphillic disorders involve persistent sexual interests other than the courtship behaviors and genital stimulation, either with or without a consenting partner, that are considered within the normal range of human behavior. The Diagnostic and Statistics Manual of Mental Disorders (5th ed., DSM-5, American Psychiatric Association, 2013) further divides these disorders into those concerning the target for eroticism, such as a distinct body type or feature leading to attraction, and those concerning an act of eroticism. For either category, the activities involve must involve risk of or actual physical harm, or cause significant distress to be considered a disorder and not simply a sexual preference (The American Psychiatric Association, 2013).
Transvestic disorder is a specific paraphilic disorder in which the individual is sexually aroused by the act of cross-dressing as the opposite gender, and yet finds the act of dressing and the resulting arousal distressing (The American Psychiatric Association, 2013).
Symptoms of Transvestic Disorder
Transvestic disorder is characterized by at least 6 months of experiencing recurring sexual arousal brought on by the act of cross-dressing. This arousal may manifest as sexual fantasies, behaviors, or urges that cause the patient significant distress or impairment in important areas of function, such as social or occupational settings. In transvestic disorder, feelings of distress at cross-dressing are separate from feelings of gender dysphoria, and individuals identify as their anatomical gender (The American Psychiatric Association, 2013).
Cross-dressing sessions may include as few as one item of clothing, such as an undergarment, or may be as extensive as full clothing, makeup, and wigs or hair styling. This is often accompanied by patterns of purchasing, wearing, and then throwing out cross-dressing clothing in an attempt to quit (The American Psychiatric Association, 2013).
Cross-dressing sessions typically leads to masturbation sessions in younger individuals, while older individuals typically delay gratification in order to extend the cross-dressing session. Individuals who are in sexual relationships may engage in intercourse with their partner either during or after cross-dressing sessions. It is important to note that transvestic disorder is distinct from fetishistic disorder where the target of the fetish is women's undergarments or clothing (The American Psychiatric Association, 2013).
Development and Course of Transvestic Disorder
Signs of transvestic disorder may begin as early as childhood with cross-dressing play beginning prior to puberty. While the desire to cross-dress typically remains at the same intensity or even continues to grow stronger, the level of sexual arousal typically peaks early in puberty before lessening over time. For some individuals, feelings of sexual arousal are replaced with a sense of comfort and belonging, and may lead to the desire to remain in the feminine role for lengthened periods (The American Psychiatric Association, 2013). s
Prevalence of Transvestic Disorder
Transvestic disorder is considered an extremely rare diagnosis, with the DSM-5 (The American Psychiatric Association, 2013) reporting less than 3% of males reporting sexual arousal through cross-dressing. It is interesting to note that transvestic disorder is almost exclusively diagnosed in males, and the vast majority of men identify as heterosexual with only occasional reports of homosexual activity (The American Psychiatric Association, 2013).
Co-morbidity of Transvestic Disorder
Transvestic disorder is often co-diagnosed with autogynephilia, or a male's sexual arousal at the fantasy of himself as a woman, fetishism, and masochism, or the enjoyment of pain during sexual arousal. Interestingly, may cases of autoerotic asphyxia, or strangulation during sexual stimulation and ejaculation, is often associated with transvestic disorder in a statistically significant portion of autoerotic asphyxiation deaths (The American Psychiatric Association, 2013). There is also evidence that transvestic disorder and other paraphilic disorders may be related to diagnoses of obsessive-compulsive disorder, and may respond to traditional OCD treatment (Abdo, Hounie, de Tubino Scanavino, & Miguel, 2001).
In a study from Sweden, 2.8% of men and 0.4% of reported instances of transvestic fetishism, which was strongly correlated with pornography use, frequent masturbation, exposing genitals, voyeurism, and masochism, and yet the overall attitude toward transvestic activities was positive and very few expressed the distress required for diagnosis of transvestic disorder (Langstrom & Zucker, 2005).
In a similar study whose survey data was collected through Canada, it was found that adolescents with gender identity disorder and transvestic disorder showed significantly higher rates of general behavioral problems and difficulty maintaining social relationships (Zucker, et. all, 2012). This cultural difference in attitudes may indicate that the difference between transvestic fetishism (without negative feelings) and transvistic disorder (hallmarked by negative feelings) may be strongly related to social perceptions.
Diagnosis of Transvestic Disorder
Diagnosis of transvetic disorder is based on patient reporting of cross-dressing sessions and of their resulting distress. Reports of cross-dressing without also reporting distress regarding the behavior should not be diagnosed as transvestic disorder (The American Psychiatric Association, 2013).
Treatment of Transvestic Disorder
Due to the distressed feelings that mark the distinction between transvestitism and transvestic disorder, feelings of psychosocial distress and depression are often commonly reported. As such, transvestic disorder should be treated with psychotherapy with a focus on negative self-perception, and the use of antidepressants, particularly serotonergic drugs, should be considered (Balon, 1998).
Transvestic disorder may respond best to a complete treatment program including psychotherapy and psychopharmacological strategies. Coupling psychotropic medications, particularly antidepressants, with antiandrogens, which bind to androgenous sex hormones and aid in reducing the frequency and intensity of sexual urges, may provide individuals with transvestic disorder some relief from the potency of both their physical urges and mental distress (Gijs & Gooren, 1996). While early studies show that this 3-pronged approach (therapy, antidepressants, and antiandrogens) may be clinically effective, it should be noted that fully informed consent is necessary and further studies should be conducted.
Outcomes for Transvestic Disorder
Many men diagnosed with transvestic disorder report as heterosexual and wish to remain in traditional romantic relationships with women. Unfortunately, transvestic behaviors often interfere with these relationships. When compounded with co-diagnoses of depression or suicidal behaviors, it becomes critical for individuals with transvestic disorder to remain in contact with a licensed therapist familiar with LGBT (lesbian, gay, bisexual, and transgendered) issues (The American Psychiatric Association, 2013).
References
Abdo, C.H.N., Hounie, A., de Tubino Scanavino, M., & Miguel, E.C. (2001). OCD and transvestism: Is there a relationship?. ACTA Psychiatrica Scandinavica, 103(6), 471-473.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Balon, R. (1998). Pharmacological treatment of paraphilias with a focus on antidepressants. Journal of Sex & Marital Therapy, 24(4), 241-254.
Gijs, L., & Gooren, L. (1996). Hormonal and psychopharmacological interventions in the treatment of paraphilias: An update. Journal of Sex Research, 33(4), 273-290.
Langstrom, N., & Zucker, K.J. (2005). Transvestic fetishism in the general population: Prevalence and correlates. Journal of Sex & Marital Therapy, 31(2), 87-95.
Zucker, K.J., Bradley, S.J., Owen-Anderson, A., Kibblewhite, S.J., Singh, D., & Choi, K. (2012). Demographics, behavior problems, and psychosocial characteristics of adolescents with gender identity disorder or transvestic fetishism. Journal of Sex & Marital Therapy, 38(2), 151-189.
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