Transvestic fetishism is a chronic condition that has its onset in the first decade of life and is characterized by a natural history that includes highly variable frequencies of cross-dressing and “remissions,” lasting from months to several years, wherein the urge to cross-dress appears to be consciously suppressed (Croughan et al. 1981). Retrospective studies and clinical experience support the general consensus that few, if any, transvestites relinquish cross-dressing completely after any form of treatment, despite difficulties they may encounter with family, spouses, and society. Short-term follow-up is insufficient to judge a treatment as a success if “curing” transvestism is the stated goal. Wise (1990) concisely summarized the last century of treatments for transvestism as both difficult and basically disappointing.

Models of transvestism that focus largely on the fetishistic component of transvestism are incomplete and must take into account the affective and opposite gender expression aspects described by many transvestites (Brooks and Brown 1994; Bruce 1967; Docter 1988; Docter and Prince 1997). Dissociation of cross-dressing from sexual activity is common as transvestites approach middle age (Croughan et al. 1981). Psychotherapeutic treatments should take this clinical reality into account (Adshead 1997).

Many of the promising case reports described above involve treatment of multiple paraphilias and not transvestic fetishism alone. Generalization from these complex cases, using uncontrolled and unblinded treatments administered by enthusiastic clinical researchers, is problematic at best.

Hirschfeld (1910) recognized the tenacity of transvestism and the low probability that psychotherapeutic treatments would curb the desire to cross-dress. Alternatively, he suggested that the physician reconsider his or her motivations for this treatment approach in the first place, summarizing transvestism as “basically a harmless inclination by which no one is injured, [therefore], from a purely medical standpoint, nothing can be said against the actual putting on of the clothing of the opposite sex” (p. 235). Indeed, many of the motivations for psychiatric treatment (

see Table 70-2) are problems related to the interface between society and transvestism, and those who present for treatment appear to be experiencing “ego-dystonic transvestism.”

Finally, Green (1987) encouraged mental health professionals to view the treatment for cross-gender behaviors in a broader social context, especially given that many of these behaviors are characterized more by social deviance than by established definitions of mental disorder as described in DSM-IV:

Treatment intervention…[can be] focused on helping these people adjust to their society. What can be done to help society to adjust to these people? Can the behavioral scientist also be effective as a social activist? Can the researcher/therapist modify societal attitudes so that atypical sexual life-styles which do not infringe on the liberties of others do not cause conflict for the atypical individual?” (Green 1987, p. 262)