Transvestic fetishism is diagnosed only in heterosexual males who experience intense sexual urges and sexually arousing fantasies involving cross-dressing. Usually the men report episodes of actual cross-dressing associated with sexual arousal and masturbation. They may dress in women’s clothes fully or wear only women’s undergarments. Some men involve their female sexual partners with their cross-dressing. Sexual experiences with males when cross-dressed are usually only experimental. Men may report embarrassment, guilt, and shame and at times throw away all female apparel and suppress interests in cross-dressing. If the man reports persistent discomfort with his masculine gender identity or role, “with gender dysphoria” should be noted as part of the diagnosis.

The differential diagnosis with gender identity disorders can be difficult in men who may cross-dress frequently for relief of stress, with infrequently reported sexual arousal or no current sexual relationship.

Some men who had previously met the diag-nostic criteria for transvestic fetishism go on to seek sex reassignment, although for most men the cross-dressing activities remain similar throughout their lives, with some decrease in frequency with aging. Transvestic fetishism can also be combined with other paraphilias, such as masochism. In some types of sexual masochism, cross-dressing and a variety of other activities are used for humiliation, without arousal associated with the clothing; these cases would not be considered transvestic fetishism. Cross-dressing for entertainment (but not sexual purposes) in homosexuals or female impersonators is not fetishistic.

Childhood episodes of being punished by being cross-dressed are reported by some men with histories of transvestic fetishism. Many transvestites report episodes of cross-dressing as a child and in most cases in adolescence.