Transvestism involves recurrent and intense sexual arousal from cross-dressing, which may manifest as fantasies, urges, or behaviors. Transvestic disorder is transvestism that causes clinically significant distress or functional impairment in one or more important areas of life.
(See also Overview of Paraphilias and Paraphilic Disorders.)
"Cross-dresser" is a more common and acceptable term than "transvestite." Cross-dressing in and of itself is not considered a psychiatric disorder. Cross-dressing occurs in both heterosexual and homosexual men. It occurs less commonly in women, although they have a broader range of clothing considered consistent with gender. Nonbinary people who dress in clothing typically associated with a different birth sex are generally not engaging in "cross-dressing." Some people who engage in cross-dressing do so for a variety of reasons that are not now, and may never have been, associated with sexual arousal (eg, costumes). However, for those cross-dressers who experience clinically significant distress or impairments based on their cross-dressing urges or behaviors, the diagnosis of transvestic disorder may be appropriate.
Males who dress in women’s clothing typically begin such behavior during late childhood. Up to 3% of men have cross-dressed and been sexually stimulated by it at least once, but far fewer report regular cross-dressing (1). Cross-dressing is associated, at least initially, with intense sexual arousal. Sexual arousal that is produced by the clothing itself (not by wearing the clothing) is considered a form of fetishism and may occur with or independent of cross-dressing.
Personality profiles of cross-dressing men are generally similar to age- and race-matched norms. Gender dysphoria is more common in birth sex males with transvestic disorder. Such individuals may report arousal to wearing typically female clothing as teens that diminishes or disappears later in life, accompanied by a desire to live fully in the female gender. Some with transvestic disorder may also experience intermittent gender dysphoria associated with loss, grief, substance use, or depression.
When their partner is cooperative or willing to participate, cross-dressing men may engage in sexual activity in partial or full feminine attire. When their partner is not cooperative, they may feel anxiety, depression, guilt, and shame because of their desire to cross-dress and may experience sexual dysfunction in their relationship. In response to these feelings, these men often purge their wardrobe of female clothing. This purging may be followed by additional cycles of accumulating female clothes, wigs, and makeup, with more feelings of shame and guilt, followed by more purges.
General reference
1. Långström N, Zucker KZ: Transvestic fetishism in the general population: Prevalence and correlates. J Sex Marital Ther 31(2):87-95, 2005. doi: 10.1080/00926230590477934
Diagnosis of Transvestic Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
Diagnosis of transvestic disorder requires the following (1):
Patients experience recurrent and intense arousal from cross-dressing as manifested by fantasies, intense urges, or behaviors.
These fantasies, intense sexual urges, or behaviors cause clinically significant distress or impair functioning at work, in social situations, or in other important areas of life.
The condition has been present for ≥ 6 months.
The clinician must specify whether
Fetishism (sexual arousal by fabrics, materials, or garments) or autogynephilia (arousal by thoughts or images of self as a woman) are present.
The patient is living in a controlled environment (eg, institution) or in full remission (ie, at least 5 years without distress/impairment in an uncontrolled environment)
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC.
Treatment of Transvestic Disorder
Social and support groups
Sometimes psychotherapy
Most cross-dressers do not present for treatment, and most people who engage in cross-dressing do not have a psychiatric disorder related to their involvement with cross-dressing. Those who do present for evaluation or treatment are usually brought in by an unhappy spouse, referred by courts, or self-referred out of concern about experiencing negative social and employment consequences. Some cross-dressers present for treatment of comorbid gender dysphoria, a substance use disorder, or depression.
Although there are no controlled studies, social and support groups, both in-person and on the internet, for men who cross-dress are often very helpful (1, 2).
No medications are reliably effective, although selective serotonin reuptake inhibitors have been tried and occasionally are beneficial in patients with a substantial obsessive-compulsive component to their clinical presentation (3).
Psychotherapy, when indicated, is aimed at self-acceptance, family therapy, and modulating risky behaviors.
Later in life, sometimes in their 50s or 60s, cross-dressing men may present for medical care because of gender dysphoria symptoms and may then meet diagnostic criteria for gender dysphoria.
Treatment references
1. Newring K, Wheeler J, Draper C: Transvestic fetishism: Assessment and Treatment. In Sexual Deviance: Theory, Assessment, and Treatment, Edited by Laws DR and O'Donohue WT. Guilford Press. p. 285.
2. Moser C, Kleinplatz PJ: Transvestic fetishism: Psychopathology or iatrogenic artifact? NJ Psychologist, 52(2):16-17, 2002.
3. Balon Rez-Sierra D, Balgobin C, Wise TN: Treatment of paraphilic disorders. In Practical Guide to Paraphilia and Paraphilic Disorders. Edited by Balon R. Springer/Springer International Publishing AG. 2016. p. 43-62.
Key Points
Most cross-dressers do not meet the clinical criteria for transvestic disorder.
Diagnose transvestic disorder only if cross-dressing causes clinically significant distress or impairs functioning, and the condition has been present for ≥ 6 months.
No medications are reliably effective; psychotherapy and support groups may help.
