Mental health professionals’ understanding of comorbidity in transvestism is rudimentary, largely because it has not been systematically studied. Such work would require reliable diagnostic assessments in a large group of transvestites derived from nonclinical sources and not merely based on case reports and small series. In

Table 70-3, the comorbid conditions that have been reported in transvestites are enumerated; however, no data exist to suggest that any of these conditions are more or less likely in transvestites than in age-matched community samples of men who do not cross-dress.

In fact, a study of 188 non-treatment-seeking cross-dressing men who completed personality and sexual-functioning surveys were found to be nearly identical to age- and race-matched non-cross-dressing men (G. R. Brown et al. 1996). Clinicians who may evaluate distressed transvestites should nonetheless be aware of the additional conditions with which some of these patients may present.

Transvestite entertainment literature frequently includes themes of sadomasochism, female domination, and bondage in conjunction with cross-dressing activities (Buhrich and McConaghy 1976; Stoller 1975). However, only 5% of 504 transvestites surveyed by Prince and Bentler (1972) reported participating in cross-dressing while being dominated by a woman. Buhrich and McConaghy (1976) noted, nonetheless, that a fantasy interest in these activities was found to be much more likely than actual participation. Multiple paraphilias are common in those who present for treatment in tertiary referral centers, suggesting that these conditions co-occur in highly selected clinical populations (Abel 1989; Kafka 1991). Kafka (1991) observed significant comorbidity between paraphilias (including transvestic fetishism) and nonparaphiliac sexual addictions. His small sample was limited to patients with comorbid mood disorders and included one transvestite who also suffered from compulsive masturbation. It is unclear how prevalent compulsive, but conventional, sexuality is in the broader population of transvestites, although experience in nonclinical settings suggests that it is not highly prevalent (G. R. Brown 1994). Berlin has written extensively on the comorbidity and management issues in men with multiple paraphilias in forensic settings (Berlin and Meinecke 1981; Berlin and Schaerf 1985; Berlin et al. 1991).

Transvestites who present to psychiatric clinics are often in crisis as a result of family discovery of their cross-dressing or occupational difficulties arising from these activities (Wise 1990; Wise and Meyer 1980a, 1980b). The adjustment disorders they experience are generally short-lived and respond to psychotherapeutic intervention, leaving the patient and therapist to contemplate how, or whether, to address the transvestic behaviors (Wise 1987). Adjustment disorders, when left untreated, may grade imperceptibly into major mood disorders (particularly dysthymia and major depressive disorder). Kafka (1991) observed significant comorbidity between mood disorders and paraphilias in individuals seeking treatment for paraphilias.

Marital problems are probably the most common comorbid condition seen in transvestites who present for treatment (Cairns 1997). This scenario was illustrated in the case description above and is often related to a wife’s lack of awareness of her husband’s interest in cross-dressing prior to emotionally committing to a long-term relationship. Twenty-seven percent of Prince and Bentler’s (1972) sample and 60% of G. R. Brown’s (1994) couples reported that the wife had no knowledge of her husband’s cross-dressing before marriage. Accidental discovery of cross-dressing activities often results in the wife’s demanding that her husband seek professional help. These transvestites are often merely placating their wives when they agree to see a mental health care provider, or else they pursue the strategy of attempting to make the therapist their ally in the marital struggle (G. R. Brown 1990b; Wise 1987). Marital discord may also be associated with erectile dysfunction experienced by some transvestic fetishists if they are not allowed to wear at least some article(s) of female attire prior to, or during, sexual activity. Although erectile dysfunction was once thought to be a common problem, G. R. Brown (1994), in the largest published survey to date of wives of transvestites from nonclinical sources, found that the prevalence of erectile dysfunction in general was no higher in transvestites than in age-comparable men in the general population and that less than half of the transvestite men had ever worn any article of female clothing during marital sexual encounters. Erectile dysfunction of psychogenic origin may be the presenting complaint in a small minority of men who ultimately seek treatment, however.

The increased risk of human immunodeficiency virus (HIV) disease in those transvestites who are commercial sex workers has been noted (Boles and Elifson 1994). HIV risk behaviors should be evaluated in men who come to clinical attention. Cross-dressers who work as prostitutes may be gay “drag queens” or have gender identity disorder (GID), often accompanied by substance dependence.

A small number of case reports have described the co-occurrence of transvestism and psychosis (Liebman 1944; Lukianowicz 1959b; Ward 1975). For example, Lukianowicz (1959b) described 15 cases of transvestism in the context of either bipolar disorder or schizophrenia. This is still the largest case series reported to date. Lukianowicz concluded, however, that transvestites were no more likely to have neurotic or psychotic disorders than other men. Ward (1975) described the successful lithium treatment of transvestism associated with bipolar disorder, manic phase. This was one of only two reports to mention lithium treatment in men with transvestic fetishism, the second of which combined sertraline with lithium (Rubenstein and Engel 1996). There is no modern epidemiological evidence to support an increased risk of psychotic disorders in men who cross-dress fetishistically.

Several investigators have examined the personality profiles and characteristics of men who cross-dress. Although the results from J. K. Meyer’s (1974) analysis of limited psychoanalytic data suggested that transvestites may have borderline personality organization, results of personality inventories have not been consistent with this view. For example, G. R. Brown et al. (1996) administered the NEO Personality Inventory (Costa and McCrae 1985) to a group of 83 self-identified transvestites and found only an increased propensity to openness to new experiences in comparison with a “normative” male comparison group. Slightly elevated neuroticism scores (introversion) were noted on the Eysenck Personality Inventory (Eysenck and Eysenck 1964) by Buhrich (1981). Bentler and Prince (1970) administered a personality instrument derived from the Minnesota Multiphasic Personality Inventory (Hathaway and McKinley 1943) to 300 transvestites and a control group and found no significant differences. As is the case with the prevalence of other comorbid conditions, the question of whether Axis II personality disorders are more likely to be found in transvestites has not been definitively answered because of the difficulty of conducting such research using an unbiased sampling technique. What is clear, however, is that many men with transvestic fetishism are highly successful, well-integrated members of the community who cannot be readily identified by their interpersonal styles or personality functioning (G. R. Brown et al. 1996; Prince and Bentler 1972). Personality assessment may be a useful clinical tool in treating those who self-identify as patients, just as such techniques are considered generally informative for other outpatients seeking psychotherapeutic intervention. Psychiatrists who begin a course of psychotherapy with a transvestite for specific target symptoms may benefit from this information in formulating a treatment plan. The other implication from these findings is that many cross-dressers are in no way identifiable in their day-to-day lives at work, school, church, and elsewhere. It is not unusual for them to live “double lives,” carefully concealing their cross-dressing activities even from their wives for several decades. The typical “drag queens” or cross-dressers caricatured in the media are generally not the patients who seek psychiatric assistance.