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Psychopathology or Iatrogenic Artifact?
The act of wearing the stereotypic articles of clothing of the other sex is known as cross-dressing. Obtaining erotic enjoyment from the process of cross-dressing is known as transvestism. The cross-cultural (Ford & Beach, 1951) and trans-historical (Bullough & Bullough, 1977) records indicate that cross-dressing is not rare. However, whether erotic arousal from cross-dressing exists cross-culturally and trans-historically is much more difficult to ascertain. Little attention has been paid to subjective erotic arousal experienced during sexual acts. It is easier to observe behavior than to discern individual motivation.
Magnus Hirschfeld coined the term "transvestism" in 1910 (Bullough & Bullough, 1977). Havelock Ellis (1936) termed the same phenomena "Eonism," but included individuals that would now be considered "effeminate homosexuals" and those with gender dysphoria. Kinsey did not ask questions about cross-dressing (Gebhard & Johnson, 1979) and defined transvestism only as cross-dressing (Kinsey, Pomeroy, Martin & Gebhard, 1953).
Benjamin (1966) described a continuum between those who cross-dress for erotic reasons and those who dress as an expression of gender identity (e.g. transsexuals). There are many different varieties of individuals who cross-dress. They include (but are not limited to) "drag queens" (and "kings"), the transgendered, transsexuals, transvestites, "she-males," female impersonators (also known as gender illusionists), and some "psychotic" individuals who believe that they are members of the other sex.
The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) is considered by many to be the definitive authority on the diagnosis of mental disorders. This reference text is revised regularly and purports to be factually correct, reflect new information available, and be up-to-date. It classifies unusual and strong sexual interests (i.e., paraphilias) as psychopathological. The DSM states it is "…supported by an extensive empirical foundation" (APA, 2000, p. xxiii). However, there is no objective support in the literature for the belief that these sexual interests stem from psychopathology or constitute a form of psychopathology per se. Except for historical precedent, why should strong sexual interests (unusual or otherwise) be diagnosed as mental disorders? (See Moser  for a critique of the concept of "paraphilia.") A reevaluation of the entire paraphilia section of the DSM (2000) is in order, but the present paper will be focused on discussion of Transvestic Fetishism (TF), the DSM term for transvestism.
The current edition of the DSM (APA, 2000) continues to list TF as a mental disorder, although the latest research available does not support the inclusion of this diagnosis. Brown, Wise, Costa, Herbst, Fagan and Schmidt (1996, p. 265) conclude, "Cross-dressers…are virtually indistinguishable from non-cross-dressers." This statement takes on added importance because Wise and Schmidt were members of the DSM-IV-TR (2000) Sexual and Gender Identity Disorders Text Revision Work Group, (i.e., the committee responsible for revising this section of the DSM).
The diagnostic criteria define this disorder as occurring specifically among heterosexual men. Neither women nor homosexual men are likely to receive this diagnosis. This reflects on how narrowly masculinity is defined in this culture and on the cultural context in which the diagnostic process is embedded.
To illustrate the problems with this diagnosis, consider the following case:
Mr. A is a 40-year-old man, married for 15 years, with no children, who works as a truck driver. He seeks psychotherapy for depression characterized by dysphoric mood, anhedonia, insomnia, fatigue, and feelings of hopelessness. The current episode began one month ago. He reports the precipitating events include the possibility that he may be fired and that his wife is considering divorce. You make a diagnosis of Major Depressive Episode.
Now assume that the same patient is sitting in your office while cross-dressed. He describes a history of erotic arousal when dressed in female attire, but now finds cross-dressing is calming. His employer discovered his cross-dressing - (in private, not while on the job) - from a co-worker in whom Mr. A confided. His employer states he must act "to preserve the company image." His wife always disliked the cross-dressing and feels the behavior "must be sick"; she does not want to endure the embarrassment its revelation may bring. Mr. A reports cross-dressing overall has had a positive effect on his life. He admits that having to keep it secret has been stressful and he had periods of self-loathing in the past because he thought cross-dressing was sick. Over time and with the help of several transvestite support groups, these problems have been resolved. How will your diagnosis, treatment plan and goals change with this new information?
According to the DSM (APA, 2000), in order to make a diagnosis of TF, both of the following criteria must be met:
To be a mental disorder, the sexual interest in cross-dressing must cause either distress or impairment. It is dubious if TF qualifies as a mental disorder or how it should be classified, if it does not cause distress or impairment. The criteria of distress and impairment will be examined separately.
Mr. A is distressed about his job and marriage, but not about his cross-dressing. Although he did experience some distress in the past, this now appears resolved. The diagnostic criteria do not say that the distress had to occur in the last six months; only a six month duration is needed. If it is meant literally, then Mr. A has an incurable condition, even if none of the "signs" or "symptoms" is currently present. If the criterion is sexual excitement in the last six months, then he does not meet the diagnostic criteria for TF.
The DSM indicates that the motive underlying the cross-dressing can change in character and that the sexual arousal may disappear. In these cases, it is suggested that, "…the cross-dressing becomes an antidote for anxiety or depression or contributes to a sense of peace and calm" (APA, 2000, p. 574-5). Should this behavior, which can be regarded as adaptive rather than distressing, be construed as psychopathological? The rationale for pathologizing a coping skill is questionable.
While his employer and wife may have a problem with his sexual interest, Mr. A apparently does not. His impairment, if any, comes from the fact that his job and marriage are in jeopardy. If he was unable to perform the duties of his job (e.g., he was too busy dressing to actual drive the truck), then this dysfunction may qualify for a diagnosis of mental disorder. If we accept that his problems arise from the societal attitudes he is forced to endure, then we must question whether a diagnosis of psychopathology is valid. If TF is a mental disorder, we imply that women or African Americans, who also experience problems arising from discrimination, are similarly subject to diagnosis.
When non-paraphilic (normophilic) individuals are distressed or even dysfunctional because of an inability to find accepting and supporting partners, they are not defined as having psychosexual disorders. We do not assume that individuals are mentally disordered if potential partners reject them because the former are fat, poor, or even ugly. Why does being rejected for non-standard sexual interests imply a mental disorder?
Common concerns that some therapists use as reasons to treat TF:
In the case presented, the therapist might be "seduced" into attempting to extinguish Mr. A's cross-dressing behavior, despite its adaptive value. The focus on his TF, with the concomitant de-emphasis of his other problems may lead to iatrogenic problems. He may be deprived of focused treatment for his depression, marital therapy, or even a referral to an attorney to defend his interests in a "wrongful termination" suit.
There is no empirical evidence that TF is problematic, let alone a mental disorder. Even if it does qualify as a disorder, the interpretation and application of the diagnostic criteria lack consistency and clarity; that is the reliability and validity of the diagnosis remain dubious.
We have criticized the Soviet and Chinese mental health establishments for pathologizing those with unconventional political beliefs; we should not make an analogous mistake concerning those who have unconventional sexual interests.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders(4th ed., Text Revised). Washington, DC: American Psychiatric Association.
Benjamin, H. (1966). The transsexual phenomenon. New York: Julian Press.
Brown, G.R., Wise, T.N., Costa, P.T., Herbst, J.H., Fagan, P.J., & Schmidt, C.W. (1996). Personality Characteristics and Sexual Functioning of 188 Cross-Dressing Men. The Journal of Nervous and Mental Disorders 184, 265-273.
Bullough, V.L., & Bullough, B. (1977). Sin, sickness, and sanity. New York: New American Library.
Ellis, H. (1936). Studies in the Psychology of Sex, (Vol. III, Part 2). New York: Random House.
Ford, C.S., & Beach, F.A. (1951). Patterns of sexual behavior. New York: Harper & Row, Publishers.
Gebhard, P.H., & Johnson, A.B. (1979). The Kinsey data: Marginal tabulations of the 1938-1963 interviews conducted by the Institute for Sex Research. Philadelphia, PA: W. B. Saunders Company.
Kinsey, A.C., Pomeroy, W.C., Martin, C.E., & Gebhard, P.H. (1953). Sexual behavior in the human female. Philadelphia, PA: W. B. Saunders Company.
Moser, C. (2001) Paraphilia: Another Confused Sexological Concept. In: P. J. Kleinplatz (Ed.) New directions in sex therapy: Innovations and alternatives (pp. 91-108), Philadelphia: Brunner-Routledge.