A consideration of treatment issues in men with transvestic fetishism requires, first, an appreciation of the multiple motivations for cross-dressing. Cross-dressing is a complex social and psychological phenomenon involving sexual, affective, and identity components. Despite the fact that feminine identity expression was recognized as a motivator for cross-dressing by some early observers (Ellis 1936; Hirschfeld 1910), modern psychiatrists have generally focused on the sexual (fetishistic) aspects of transvestism to the virtual exclusion of the other relevant motivations, thereby incompletely appreciating the multifaceted nature of this behavior. This has had negative treatment implications and has resulted in the commonly held view that psychiatry can be of no benefit to distressed men with this disorder. This is far from the case, as psychiatrists have proven themselves to be very helpful not only to transvestites but also to their spouses and families (G. R. Brown 1999).

Although sexual arousal associated with cross-dressing is universal in adolescent and young adult transvestites (Croughan et al. 1981; Docter 1988; Docter and Prince 1997), the linkage of sexual excitement and cross-dressing is diminished or lost altogether in 25% to 65% of older transvestites (Docter 1988). In a recent survey of 851 cross-dressers with a median age of 45 years, 86% expressed an increased “need to express my opposite sex gender role” with their advancing years, whereas only 14% reported that women’s clothing itself was the key element in their arousal (Brooks and Brown 1994).

Brierley (1979) described these observations as constituting two stages of cross-dressing: an early fetishistic stage and a later identity stage. Docter (1988), in a large-scale, extensive study (N = 110), reported early, middle, and late stages of cross-dressing, with a general increase throughout these stages in the frequency of complete cross-dressing, emphasis on feminine expression, and frequency of passing convincingly as a woman for brief periods (Docter 1988). Whereas sexual arousal was ranked as the most important motivation during the first decade of transvestic behavior, nonerotic pleasure and expression of “the girl within” were reported as the primary motivations of older transvestites. Often, those who continued to experience sexual arousal did not require fetishistic activity to achieve erection, have intercourse, or reach orgasm (G. R. Brown 1994; G. R. Brown et al. 1996). This observation is consistent with the continuum of intensities of fetishistic arousal described by Gebhard (1969), ranging from level 1 (slight preference for transvestic activity) to level 4 (transvestic stimuli taking the place of a partner). Using this framework, level 3 and 4 transvestic fetishists (obligatory fetishism) would be the subset of transvestites most likely to present to a psychiatrist for treatment (or to be brought in by spouses who may feel erotically excluded from their husbands’ sexual lives).

Cross-dressing clearly has mood-elevating properties for many transvestites (Docter 1988) and may relieve tension or alleviate boredom for others (Bruce 1967; Buhrich 1978). Over 90% of 851 cross-dressers studied by Brooks and Brown (1994) reported feeling euphoric when assuming the opposite-gender role. This may partially account for the observation that few, if any, transvestites ever cease cross-dressing permanently, despite months to years of abstinence from that behavior. In my clinical practice, spanning over two decades, I have never seen a man who “used to be” a transvestite. With sufficiently lengthy follow-up, all “purges” (i.e., selling, destroying, or giving to charity all female attire) come to an end. This modern experience is entirely consistent with the research of Hirschfeld (1910), who concluded that it is highly improbable that the transvestite drive can be made to disappear. Croughan et al. (1981) reported 1 year as the longest average abstention period before a transvestic individual resumed cross-dressing; three or more lifetime purges occurred in about 30% of the transvestites they followed. Brooks and Brown (1994) noted that over 75% of cross-dressers admit to purging cross-gender behaviors and cross-dressing at least once, with a median of 4 and a maximum of 50 lifetime purges. These purges are the behavioral expression of ambivalence, shame, and guilt (Wysocki 1993) experienced by many transvestites in regard to cross-dressing behavior. Although “curing” the desire to cross-dress is an unrealistic treatment goal, psychiatrists can certainly bring their skills to bear in dealing with these debilitating issues as the transvestite seeks to reach a higher level of self-understanding and accommodation to the likelihood that the desire will never disappear.

The need to express the feminine aspects of the self (i.e., “the girl within” [Prince and Bentler 1972]) is rated as a primary motivation for cross-dressing by many middle- and late-stage transvestites. This important motivation is absent from all DSM criteria and has therefore been neglected as a focus of investigation or treatment. Transvestite publications (e.g., TV/TS Tapestry, Tennessee Vals Newsletter, Femme Mirror) are replete with stories, self-analyses, and articles that discuss this potent motivation in detail. Hirschfeld (1910) also extensively addressed this motivation.

Buhrich (1978) and Docter (1988) recorded these men’s conscious motivations for cross-dressing based on interview data. Reported motivations included a feeling of comfort or ease; relief of tension; escape from pressures of the masculine role; feeling sensuous, elegant, or beautiful; sexual arousal or enhancement; and expression of traditionally feminine aspects of their personalities. Clinicians working with self-referred transvestite patients have emphasized obsessive-compulsive motivations (Lukianowicz 1959a; Stekel 1930) and narcissistic gratifications (Benjamin 1966; Buhrich 1978; Wise and Meyer 1980b).