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302.3 Transvestic Fetishism
Transvestic Disorder
A. Over a period of at least six months, in a male, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross‑dressing. [11]
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if: [12]
With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)
With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)
[1] The Paraphilias Subworkgroup is proposing two broad changes that affect all or several of the paraphilia diagnoses, in addition to various amendments to specific diagnoses. The first broad change follows from our consensus that paraphilias are not ipso facto psychiatric disorders. We are proposing that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder.
This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it. This change in viewpoint would be reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, Sexual Sadism would become Sexual Sadism Disorder; Sexual Masochism would become Sexual Masochism Disorder, and so on.
In general, the distinction between paraphilias and paraphilic disorders is reflected in the format of the diagnostic criteria for specific paraphilias. Paraphilias are ascertained according to the “A” criteria, and paraphilic disorders are diagnosed according to the “A” and “B” criteria. The distinction between paraphilias and paraphilic disorders is discussed in the context of specific diagnoses by Blanchard (2009b, 2009c).
The second broad change applies to paraphilias that involve nonconsenting persons (e.g., Voyeuristic Disorder, Exhibitionistic Disorder, and Sexual Sadism Disorder). We propose that the B criteria suggest a minimum number of separate victims for diagnosing the paraphilia in uncooperative patients. This was done to reflect the fact that a substantial proportion—perhaps a majority—of patients referred for assessment of paraphilias is referred after committing a criminal sexual offense. Such patients are not reliable historians, and they are typically not candid about their sexual urges and fantasies. The criteria have therefore been modified to lessen the dependence of diagnosis on patients’ self-reports regarding urges and fantasies. This change also addresses the past criticism that the word “recurrent” in the DSM-IV-TR A criteria says nothing beyond “more than once” and is too vague to be clinically useful. The reason for diagnosing specific paraphilic disorders from multiple, similar offenses in uncooperative patients is to achieve a level of diagnostic certitude closer to the certitude in diagnosing these disorders from self-reports in cooperative patients. It is not derived from legal theory or practice.
The suggested minimum number of separate victims varies for different paraphilias. This represents an attempt to obtain similar rates of false positive and false negative diagnoses for all the paraphilias. The logic runs as follows: Paraphilias differ in the extent to which they resemble behaviors in the typical adult’s sexual repertoire. For example, sexual arousal from seeing unsuspecting people in the nude seems more probable, in a typical adult, than sexual arousal from hurting or maiming struggling, terrified strangers. It follows that the more closely a potentially paraphilic behavior resembles a potentially normophilic behavior, the more evidence should be required to conclude that the behavior is paraphilically motivated. We have therefore suggested, for example, three different victims for Voyeuristic Disorder but only two different victims for Sexual Sadism Disorder. We felt that fewer than three victims for Voyeuristic Disorder would result in too many false positives and more than two victims for Sexual Sadism Disorder would result in too many false negatives.
[11] The word “heterosexual” was removed because some transvestites interact sexually with other males, especially when cross-dressed, and may subjectively perceive themselves as bisexual.
[12] There is a need to distinguish different types of transvestism according to the foci of the patient’s erotic interest. Transvestites vary greatly in their overt behavior and in their mental content during sessions of cross-dressing. Some seem quite similar to simple fetishists in their preference for very specific garments and report no conscious thoughts of themselves as female even while dressed in multiple pieces of female attire. Other transvestites, whom Blanchard (1989) has called autogynephiles, are most aroused by the thought or image of themselves as women. As a practical matter, the autogynephilic type seems to have a higher risk of developing gender dysphoria. This was confirmed in a secondary data analysis reported by Blanchard (2009c). The results of that analysis clearly suggested that the addition of the proposed specifiers to the diagnosis of Transvestic Disorder could provide clinically meaningful information as well as data useful for research.
References
Blanchard, R. (1989). The classification and labeling of nonhomosexual gender dysphorias. Archives of Sexual Behavior, 18, 315–334.
Blanchard, R. (2009b). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior. Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9536-0
Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3.
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TRANSVESTIC DISORDER
1. During the past two weeks, how often did you feel a sexual urge to dress as a member of the opposite sex, style your hair as a member of the opposite sex, or otherwise groom yourself as a member of the opposite sex?
1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day
2. During the past two weeks, how often did you feel sexually aroused while imagining (or remembering) yourself dressing as a member of the opposite sex, styling your hair as a member of the opposite sex, or otherwise grooming yourself as a member of the opposite sex?
1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day
3. During the past two weeks, how sexually exciting was the idea of dressing as a member of the opposite sex, styling your hair as a member of the opposite sex, or otherwise grooming yourself as a member of the opposite sex?
1. Not at all exciting
2. Slightly exciting
3. Moderately exciting
4. Strongly exciting
5. Extremely exciting
4. During the past two weeks, how many times did you masturbate or have sexual intercourse while dressed or made up as a member of the opposite sex?
1. 0
2. 1
3. 2
4. 3
5. 4 or more
5. Over the course of your life, excluding the past two weeks, how many times did you masturbate or have sexual intercourse while dressed or made up as a member of the opposite sex?
1. 0
2. 1
3. 2
4. 3–50
5. More than 50
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DSM-IV
Transvestic Fetishism
A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
With Gender Dysphoria: if the person has persistent discomfort with gender role or identity
