Definition

Clothing is the unconscious language of the spirit.

Emanuel Hermann (1878)
Magnus Hirschfeld, a progressive German sexologist and contemporary of Freud, originally described a group of 17 cross-dressers he termed die transvestiten (the transvestites), from the Latin trans (“across”) and vestitus (“dressed”) (Hirschfeld 1910/1991). Transvestism originally described a broad array of individuals who literally cross-dressed, irrespective of their motivation for doing so. It therefore was applied to both men and women (1 of the 17 cases described by Hirschfeld was female), as well as to individuals with gender identity disorders who cross-dressed without erotic motivation (e.g., case numbers 129 and 130 in von Krafft-Ebing 1886/1965). Hirschfeld was also the first investigator to classify transvestism as a specific sexual variation and to remove it from the purview of homosexuality. Unlike later authors, however, he argued against classifying transvestites as simple fetishists, and recognized the complexity of cross-dressing as an expression of aspects of personality traditionally associated with the opposite sex.

Benjamin (1954, 1967) examined more than 300 cross-dressers and developed a system to distinguish forms of transvestism. Type I transvestites were heterosexual cross-dressers who derived both emotional relief and sexual arousal from cross-dressing. Type II transvestites included those who reported early fetishistic arousal and later a desire to obtain feminizing treatments. Type III were transsexuals who never experienced sexual stimulation from cross-dressing. Benjamin later refined his system to include six types by subdividing the original three categories based on sexual orientation (Benjamin 1966). For readers interested in more detail, Schaefer and Wheeler (1995) provide an analysis of Dr. Benjamin’s first 10 cases.

Stoller (1971) distinguished among seven types of cross-dressing men, of which fetishistic transvestites, transsexuals, and homosexual cross-dressers are those most commonly seen in clinical settings. Through extensive interviews with members of a transvestite social club, Buhrich and McConaghy (1977b, 1977c, 1979) differentiated three clinically distinct categories of transvestism: the nuclear transvestite (a truly heterosexual, fetishistic cross-dresser with no gender identity disturbance), the marginal transvestite (often gender dysphoric, bisexual, and effeminate as a child), and the fetishistic transsexual (a man with gender identity disturbance, a history of fetishistic activity, and homosexual orientation). The reader is referred to Docter (1988), Stoller (1985), and Denny (1998) for complete discussions of the phenomenological history of research into cross-gender behaviors in the 20th century.

The modern definitions of transvestism (i.e., since 1980) have focused specifically on recurrent and persistent cross-dressing by heterosexual males for the purposes of sexual excitement and anxiety reduction or avoidance. There has been little nosological evolution in the past three versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. In DSM-III-R (American Psychiatric Association 1987), the general criteria developed for DSM-III (American Psychiatric Association 1980) were refined, and the name of the diagnosis was changed to transvestic fetishism. The only changes instituted in DSM-IV (American Psychiatric Association 1994) are the new specification of whether or not the patient is experiencing gender dysphoria and the important addition of a clinical-significance criterion (B). The complete DSM-IV criteria for the diagnosis of transvestic fetishism are listed in

Table 70-1.

Most etiological theories of transvestism proposed by psychiatrists in the past have focused on the psychodynamic underpinnings of “perversion.” For example, Alexander (1935) postulated that transvestism represents a defense against an overly harsh superego, thus protecting the individual against self-destruction. Person and Ovesey (1978) emphasized the importance of unconscious merger fantasies with the mother and identification with the lost mother of infancy.

Stoller proposed a comprehensive model for the development of transvestism. He reported that, in psychoanalytic treatment, some transvestites recalled the humiliation of “petticoat punishments” at the hands of adult women, wherein the young boy was punished for a transgression by being forced to wear girl’s clothing publicly (Stoller 1974). As adolescents, they turned this “childhood trauma into adult triumph” by cross-dressing fetishistically. As such, transvestism was interpreted by Stoller as an “erotic form of hatred” toward powerful, abusive adult women (Stoller 1975).

Greenson (1968) discussed the difficulty boys experience in attempting to “dis-identify” with their mother and counteridentify with their father to establish healthy masculinity. He emphasized the gender aspects of transvestism by summarizing as follows:

The fact that transvestism is almost exclusively a male disease and more widespread than commonly believed, is a more impressive testimonial for man’s dissatisfaction with maleness and his wish to be a female. (Greenson 1968, p. 371)

A thorough discussion of the etiology of transvestism can be found in discussions by G. R. Brown (1995), Hirschfeld (1910), Green (1976, 1985, 1987), and Zuger (1966, 1978, 1988). Green and Zuger discuss developmental aspects of childhood gender nonconformity and adult outcomes.

Consistent with the current definition of transvestism, the focus in this first section is on transvestism in heterosexual males, largely because of the relative clinical rarity of nontranssexual cross-dressing in women. Stoller (1982, 1985) did report on three cases of apparently fetishistic cross-dressing in women, but such cases are rarely encountered clinically. Of the few cases that have come to clinical attention, most of the women cross-dressed as an expression of masculine gender identity and would be considered individuals with a gender identity disorder (E. Gutheil 1930; von Krafft-Ebing 1886/1965). Cross-dressing by homosexual and bisexual men is generally not associated with fetishistic arousal (Docter and Prince 1997) and is specifically excluded from the DSM-IV definition of transvestic fetishism.