Prior to a discussion of treatment, it should be noted that some authors have questioned whether the act of cross-dressing in itself constitutes a psychiatric disorder meriting treatment (Brierley 1979; G. R. Brown 1995; Gert 1992; Pomeroy 1975). The traditional definition of a mental disorder requires the presence of clear dysfunction in one or more major areas (occupational, interpersonal, or intrapsychic) of a person’s life (American Psychiatric Association 1994). Social deviance per se does not constitute a definition of a mental disorder warranting diagnosis and treatment.

Figure 70-1 presents a clinical algorithm for approaching the assessment and treatment of a man who cross-dresses. Those who do not meet criteria for a psychiatric disorder exit the algorithm with respect to this diagnosis. The figure notes that psychiatrists who design a treatment plan more akin to that utilized for patients who have similar target symptoms of guilt, shame, self-loathing, marital problems, and a tendency to engage in high-risk behaviors will find that they can often be of substantial assistance to these men and their spouses. Treatment of comorbid conditions, such as depression, marital problems, substance dependence, and erectile dysfunction, is often successful and can result in enhanced quality of life and more discreet, non-self-destructive cross-dressing behaviors. The components on the left arm of the algorithm are addressed in the second section of this chapter.

Docter (1988) noted the considerable heterogeneity in the transvestite population, with some men engaging in transvestic behaviors as a secretive, occasional, pleasurable recreation with no apparent dysfunction and others engaging in obligatory, “addictive,” public cross-dressing that is clearly self-destructive and potentially damaging to their families. Although more than 43% of cross-dressers in a survey conducted by Brooks and Brown (1994) reported having seen a mental health professional at some time in their lives, less than 5% believed that there was a cure for their transgendered behavior.

Stoller’s comments on transvestites who present for treatment capture the essence of the central dilemma faced by many cross-dressers and their therapists:

Although he may ask the psychiatrist to cure him of the transvestism, what he is really asking is to be cured of his pain. He generally does not consider his transvestism as painful. Quite the contrary, it is most enjoyable; what it stirs up in others is what leads to pain. (Stoller 1968, p. 62)

For self-identified transvestites who present for treatment, therapeutic modalities aimed at curbing, or eliminating, the desire to cross-dress have spanned a wide range of options. Earlier treatments included psychoanalysis (Bak 1953), faradic (Marks and Gelder 1967) or chemical aversion (Pearce 1963), and electroconvulsive therapy (ECT) (Liebman 1944). Unmodified ECT is mentioned in only a single case report in the literature, in which the patient was described as homosexual, transvestic, and psychotic (Liebman 1944). The patient’s cross-dressing appeared solely in the context of active psychosis. ECT apparently was effective in treating this man’s psychosis and the associated secondary symptom of cross-dressing. However, it is doubtful, based on the extensive case history provided, that this man was a fetishistic transvestite.

In addition to the above, modern treatments have included a variety of insight-oriented psychotherapies, behavioral therapies, psychopharmacological treatments, and self-help support groups targeting self-acceptance as an outcome. These treatment modalities will be discussed in turn.

Psychotherapy
The mainstay of treatment for transvestism from the early 1900s to the mid-1970s was psychodynamically oriented psychotherapy or psychoanalysis. In his extensive discussion of the psychotherapeutic management of transvestism, Brierley (1979) clearly distinguished between the goal of curing transvestic fetishism and the goal of addressing the potential complications (e.g., legal, financial, family, marital) of cross-dressing. Any treatment approach must be clear in establishing realistic goals based on the modern literature on the tenacity of urges to cross-dress. Therapists embarking on a psychotherapeutic treatment relationship with a transvestic fetishist should also be aware of these men’s attitudes toward treatment. In their sample of patients, Prince and Bentler (1972) found that of the 24% of 504 transvestites who had seen a psychiatrist, only 38% had actually been engaged in treatment; the remaining 62% had received only a single evaluation or a few sessions. Only 5% of those who received treatment reported a temporary cure (lasting anywhere from 1 month to several years), whereas 53% considered the experience a complete waste of time and money. Twenty-five years later, in a repeat of the survey to anonymous participants, nearly twice as many respondents reported having sought counseling or some type and more found it to be useful (Docter and Prince 1997).

The effectiveness of psychotherapy in either curing transvestism or alleviating the desire to cross-dress has never been demonstrated. Analyses of case reports generally consist more of discussions of speculative etiologic theory than of rigorous examination of treatment response. Only rarely have reports documented the resolution of cross-dressing behavior (although long-term follow-up is generally not available), at least temporarily, but these outcomes are completely based on patient self-report, which is fraught with difficulties (R. C. Rosen and Kopel 1977). For example, Wise (1979) described his psychotherapeutic treatment of a gender-dysphoric middle-aged transvestite who ultimately relinquished cross-dressing behavior after an extended course of insight-oriented treatment. Although Wise recommended individual outpatient psychotherapy for transvestites, he was openly pessimistic about treatment outcome if the main goal was to resolve cross-dressing (Wise 1987).

Coles (1986) described an analytically oriented psychotherapy with a transvestite on a once-per-week basis. That patient abruptly discontinued the treatment after 9 months, but self-reported refraining from cross-dressing for at least 6 months. This author’s experience is consistent with the premise that transvestism is a deeply rooted part of the self system that can be consciously suppressed for varying lengths of time but will generally be expressed again if the follow-up period is sufficient.

There have been no reports on the utility of group psychotherapy with homogeneous groups of non-gender-dysphoric transvestites. Stermac et al. (1991) qualitatively described their experience with a treatment group for gender-dysphoric heterosexual men, many of whom were transvestites. Their therapeutic approach provided a supportive group forum wherein patients could explore various lifestyle options and learn to adapt to gender-dysphoric feeling states without resorting to surgical intervention. The group was designed to offer support and use group dynamics to enable learning and realistic feedback regarding cross-dressing issues. No outcome data were provided.

Based on ethically permissible treatments, the number of reported successfully treated cases of transvestism (where success is defined as suppression of cross-dressing behaviors and fantasies) is small, and therapeutic nihilism regarding this goal is commonplace. Only one case report exists in which the therapists used a different definition of success - namely, greater self-acceptance of transvestism with the goal of decreased secondary symptoms (i.e., shame, guilt, depressed mood, and suicidality) and maintenance of cross-dressing behavior as a controlled, discreet activity that would not likely lead to public exposure, occupational problems, or adverse social consequences (Cliffe 1987). In this treatment approach, as discussed in some detail by Pomeroy (1975) and Peo (1988) and illustrated in

Figure 70-1, the tenacity of urges to cross-dress in transvestism, based on a number of potent reinforcers, is acknowledged, and the low probability that most transvestites will ever relinquish this activity voluntarily is recognized (Bruce 1967; Docter 1988; Hirschfeld 1910). Perhaps more important, this therapeutic stance recognizes that many of the problems experienced by transvestites are directly related to society’s intolerance of transgendered behaviors or gender ambiguity and not to cross-dressing per se (Pomeroy 1975). The fact that a majority of transvestites are neither arrested nor treated clinically (Wise 1987) supports the view that many transvestites discreetly engage in their behavior without untoward social, legal, or occupational consequences and often come to accept this aspect of their psyche as an integral, vital part of their personality.

Pomeroy (1975) reassured his transvestite patients that their cross-dressing was “benign” and that their problems were social in nature. He believed that the most important therapeutic task was to develop self-acceptance for transvestic behavior, which would ultimately lead to both greater control over the behavior and a diminished drive to cross-dress. He cautioned that an initial period of 6-24 months of increased cross-dressing activity would sometimes be observed after a transvestite informed his spouse of his cross-dressing behavior and she expressed tolerance or acceptance of his behavior. Later, however, the transvestite’s realization that he now had greater freedom to cross-dress with the full knowledge of a supportive individual (e.g., therapist, spouse) often resulted in self-limiting of cross-dressing, as it no longer represented a forbidden activity (Pomeroy 1975).

Pursuing self-acceptance as a legitimate treatment goal to reduce the comorbidity associated with transvestism in some patients is analogous to the dramatic change in therapeutic stance surrounding treatments for ego-dystonic homosexuality in the last two decades. Electric shock and chemically aversive treatments designed to change sexual orientation (e.g., Feldman and MacCulloch 1971) have given way to psychotherapies based on self-exploration, enhancement of self-esteem, and ultimate acceptance of an immutable characteristic of the patient. It is this approach that is most likely to be of benefit to cross-dressing men, and in which psychiatrists can be of substantial benefit to these men and their partners.

Behavioral Therapies
Marks and Gelder (1967) used faradic (electrical) aversion techniques to apply operant conditioning methods to circumscribed sexually deviant behaviors in carefully selected patients. They suggested that this approach might be preferable to apomorphine or emetine in that it is safer and less unpleasant. Marks and Gelder described the use of an “electric shock box” and a crude penile plethysmograph to measure autonomic responses to real or imagined cross-dressing stimuli. Uncomfortable electric shocks were delivered to the leg in an intermittent reinforcement schedule when the patient either cross-dressed or fantasized about cross-dressing topics. All five patients studied (two fetishists and three transvestites), described as having “well-integrated personalities,” demonstrated complete extinguishing of penile erection previously associated with cross-dressing themes after about 2 weeks of inpatient treatments. Marks and Gelder noted that fantasies and preoccupations about women’s clothing items disappeared as treatment progressed, whereas fantasies about heterosexual intercourse increased. Both the patients and their spouses reported increased sexual activity with their spouses following treatment. Marks and Gelder concluded that “sexually deviant desires and practices diminished or disappeared” in all patients, but cautioned that such treatment should be used only in highly motivated patients “where no other effective treatment is available” (Marks and Gelder 1967, p. 11).

Ethical concerns and professional controversy have always surrounded the use of electrical and chemical aversive behavioral control procedures for the treatment of transvestism, especially in the light of its noncriminal nature and general lack of victimization of others (unlike, for example, the consequences of pedophilic acts) (V. Bancroft 1981). Therefore, alternative behavioral therapies have been explored. For example, Lambley (1974) reported on a single case study in which a combination of orgasmic reconditioning, heterosexual social skills training, and conjoint behaviorally oriented sex therapy with a willing partner resulted in a change in the patient’s reported sexual fantasies from predominantly cross-dressing themes to predominantly heterosexual fantasies not involving transvestite themes.

In the late 19th century, sexual deviations were commonly treated by using posthypnotic suggestions that patients would feel nausea and disgust if they engaged in the forbidden behavior. J. Bancroft (1974) suggested that hypnotherapy was a useful therapeutic precursor to more direct forms of aversive therapy. Hypnotic states are generally associated with enhanced vividness of mental imagery (Glick 1972) and can therefore increase the potency of covert sensitization techniques that rely on aversive images.

Wright and Humphreys (1984) described the adjunctive use of hypnosis to enhance a behavioral treatment program that focused on covert sensitization, which involved repeated associations between imagined cross-dressing behaviors and aversive imagery. Their patient was a transvestite who had been arrested for exhibitionism, a secondary activity he had engaged in on only two occasions when he was under severe stress. He was trained in hypnotic relaxation techniques for 3 weeks. Then, while in a state of hypnotic relaxation, the patient was instructed to fantasize the scene when the police arrested him for indecent exposure. The word “police” served as a cued-recall stimulus to enable employment of the aversive imagery on demand. Posthypnotic suggestion was also used, producing the unpleasant imagery whenever the patient fantasized about or engaged in cross-dressing activities. There were no self-reported recurrences of stealing clothes or cross-dressing for about 2 years after the patient’s last treatment, but the patient reported another episode of indecent exposure unassociated with cross-dressing. The authors speculated that the ingredients of success of their novel treatment strategy included the individualized “meaningfulness” of the aversive stimuli (i.e., vivid images of arrest and humiliation), the pairing of behavioral techniques (covert sensitization) with hypnosis, and the use of posthypnotic suggestion to enable rapid application of the aversive stimuli. They likened this procedure to a “cognitive shock box” (Wright and Humphreys 1984, p. 9).

Self-regulatory behavioral treatments have also been attempted, largely focusing on the use of biofeedback. R. C. Rosen and Kopel (1977) used a penile plethysmograph and visual erotic stimuli to train a transvestite to exercise voluntary control over penile tumescence when viewing or fantasizing about cross-dressing-related scenarios. Contingent biofeedback training under these conditions was found to have strong and specific treatment effects limited to nontumescence in the presence of deviant stimuli but not in the presence of “appropriate” heterosexual stimuli. When this type of biofeedback training was combined with intensive marital and sexual therapy, R. C. Rosen and Kopel originally believed that the patient had remained abstinent from cross-dressing for 16 months (based on patient self-report). However, the patient was rearrested for transvestic exhibitionism and admitted that he had deceived the therapists. He had, in fact, resumed cross-dressing shortly after the treatment ended. This case demonstrates the difficulties inherent in relying on patient self-report regarding engaging in stigmatized behaviors like cross-dressing.

Long-term outcomes of successful aversion therapy following the model of Marks and Gelder (1967) have also been disappointing. A. Rosen and Rehm (1977) described one patient who stopped cross-dressing altogether for 15 months but resumed daily cross-dressing after experiencing several psychosocial stressors. A second patient refrained from cross-dressing for up to 3 years, with a return to pretreatment baselines while feeling depressed and anxious. The authors concluded that aversive conditioning procedures are powerful short-term treatments for transvestism but may be best used as a component of a multimodal treatment program. Behaviorists’ experiences support the premise that treatment plans designed to “cure” the fantasy and behavioral aspects of transvestic fetishism are likely to fail.

Pharmacological Treatments

Pharmacological approaches designed to curb or eliminate transvestic fetishism have been attempted for more than three decades. The antidepressants, antiandrogens, and anxiolytics have been used most extensively, although the cumulative number of patients in the literature treated with any medication specifically for transvestism is very small. There are no FDA-approved treatments for transvestic fetishism. Extensive double-blind controlled trials are nonexistent. The medications listed in

Table 70-4, therefore, have been used only in one or more case reports or in small case series.

Buspirone Fedoroff (1988) initially reported the use of buspirone in a patient with transvestism and generalized anxiety disorder. In an A-B-A design, 5 mg of buspirone administered four times a day was found to reduce the patient’s symptoms of anxiety and urge to cross-dress. Benzodiazepines alleviated the symptoms of anxiety but did not noticeably affect the patient’s cross-dressing fantasies or behaviors. Without inducing sexual dysfunction, buspirone treatment reportedly resulted in a complete cessation of cross-dressing within 3 weeks. Removing buspirone for 1 week caused a recurrence of anxiety and a strong urge to cross-dress again, and reinstitution of treatment was again effective in suppressing the behavior. A follow-up report indicated that the patient elected to discontinue treatment because he felt he could now cross-dress recreationally, in a controlled fashion, knowing that treatment would be available if needed in the future (Fedoroff 1989).

Fedoroff (1989) also described a second case involving an atypical paraphilia with a secondary component of transvestic fetishism limited to women’s undergarments. Buspirone 20 mg/day was reported to be effective in decreasing paraphiliac fantasies and behaviors in this patient. A 7-month follow-up indicated successful suppression of deviant behaviors, measured by patient self-report. It is notable that this case report relied not only on the patient’s verbal self-report but also on a concurrently recorded sexual fantasy diary secretly kept by the patient but not revealed to his treating physician until after the treatment had been successful. Fedoroff speculated that buspirone might be a specific treatment for paraphilias that have a transvestic fetishism component. No controlled studies have tested this interesting hypothesis.

Selective serotonin reuptake inhibitors Some investigators have conceptualized paraphilias, including transvestic fetishism, as sexual addictions (Carnes 1983) or sexual compulsions (Coleman 1988; Kafka 1991). The popularity of viewing any excessive behavior, including sexual behavior, as an addiction has led to 12-Step group treatments modeled after Alcoholics Anonymous (e.g., Sex and Love Addicts Anonymous 1986). The view that transvestic fetishism represents an obsessive-compulsive spectrum disorder has not been supported in open clinical trials of medications commonly used for obsessive-compulsive disorder (OCD) (e.g., fluoxetine, fluvoxamine). In a series of five patients with mixed paraphilias, including one with transvestic fetishism, sadomasochism, and compulsive masturbation, Stein et al. (1992) used selective serotonin reuptake inhibitors to treat “compulsive” paraphiliac behaviors. The patient with transvestism received fluvoxamine 300 mg/day for 2 weeks, then 200 mg/day for 6 weeks. No change in cross-dressing behaviors or fantasies was noted. The authors concluded that serotonin reuptake inhibitors were useful treatments for OCD, and possibly for nonparaphiliac sexual compulsions such as compulsive masturbation, but not for transvestism.

The fundamental differences between most paraphilias, including transvestic fetishism, and OCD may account for the lack of treatment response observed in Stein et al.‘s (1992) limited trial. Patients with OCD usually experience their symptoms as intrusive, senseless, and ego-dystonic. They often report relief of symptoms after completing rituals. Transvestism is more complex than a simple sexual ritual and is generally associated with pleasure during the act of cross-dressing - whether or not orgasm ensues - and shame, guilt, or remorse afterward (at least in transvestites who self-identify as patients in need of care). A majority of transvestites, if given the choice of receiving a hypothetical fully effective treatment that would completely suppress all cross-dressing fantasies and behaviors or continuing with their transvestic behaviors, would probably decline treatment (Bruce 1967). This is in stark contrast to those who have OCD. In fact, Rani and Drummond (1996) reported worsening of transvestic fetishism with treatment targeting comorbid primary chronic OCD. Therefore, Stein et al. (1992) noted that transvestic fetishism may be more similar to impulse-control disorders as defined in DSM-III-R. They remarked that the cardinal features of impulse-control disorders are very similar to those of paraphilias: 1) failure to resist an impulse, 2) an increased sense of tension before committing the behavioral act, and 3) an experience of release, pleasure, or gratification in an ego-syntonic manner while performing the act. Comorbidity between transvestic fetishism and impulse-control disorders (e.g., kleptomania, intermittent explosive disorder, trichotillomania, pyromania) has not been reported, however.

In contrast, Kafka (1991) used fluoxetine for the treatment of paraphilias, including transvestic fetishism, based on the underlying hypothesis that paraphilias are more likely to lie on the affective disorders spectrum. In an open trial of 10 patients with a variety of paraphilias and nonparaphiliac sexual addictions associated with comorbid mood disorders, patients received antidepressants (predominantly fluoxetine) or lithium carbonate. One of the patients was described as a bisexual transvestite. All patients except for this patient experienced “substantial and sustained improvement” in both affective and sexual symptoms. The bisexual transvestite subject received fluoxetine 40-60 mg/day for at least 5 weeks. He experienced a 3-week symptom-free interval before relapsing to baseline behaviors. Kafka speculated that paraphiliac individuals who seek clinical attention exhibit hypersexuality as a “reversed” (i.e., atypical) neurovegetative symptom of depression and, on that basis, could benefit from antidepressant treatment for both depressed mood and hypersexual, unconventional sexuality. Further, Kafka theorized that paraphilias, including transvestic fetishism, may constitute a “sexual dysregulation disorder” affiliated with mood disorders. This concept purportedly accounted for his observation that antidepressant treatment of patients with hypersexual paraphilias often resulted in a decrease in sexual drive to normative levels and a qualitative change in the content of sexual fantasy and behavior toward mutuality and conventionality, similar to effects reported for antiandrogen treatment (Kafka 1991). It is unclear how this theory applies to the majority of paraphiliac individuals, including transvestites, who do not have abnormally elevated sexual drives.

V. Jorgensen (1990) reported that the combined use of fluoxetine, psychotherapy, and conjoint marital therapy was successful in alleviating the urge to cross-dress in a recently retired man with marital discord. She attributed the self-reported resolution of both cross-dressing behaviors and fantasies, beginning within days of treatment, in large part to fluoxetine. Others (Lehrman 1991) have suggested that the rapid response was more likely accounted for by psychotherapeutic interventions.

Estrogens Many transvestites come to clinical attention because of episodic gender-dysphoric crises, often precipitated by depression or personal loss (Wise and Meyer 1980a). They seek relief for their immediate problems in a permanent assumption of the female gender role, a role that has provided temporary, soothing respite from stress in the past. Estrogen preparations have been used to nonspecifically decrease sexual drive in patients with transvestic fetishism. Jones (1960) described the treatment of a transvestite with marital problems and ego-dystonic private cross-dressing with stilbestrol 1 mg administered three times a day. “Complete suppression” of cross-dressing behaviors was maintained throughout the 10-month observation period. One milligram per day was prescribed as a maintenance dosage.

This treatment approach was also used by Brantley and Wise (1985), who reported that the oral synthetic estrogen diethylstilbestrol (DES) decreased gender-dysphoric feelings and the urge to cross-dress in a 65-year-old transvestite who began more frequent cross-dressing while his wife was hospitalized. Intramuscular medroxyprogesterone acetate (MPA) had been effective in decreasing this patient’s cross-dressing behaviors, largely by inducing a nonspecific and precipitous decline in sexual desire and fantasies of any type. However, the complication of sterile abscesses at the MPA injection sites necessitated a switch from that agent, and a trial of DES at 1-2 mg/day was instituted. DES has antiandrogenic properties but is less potent as an antiandrogen than MPA. The patient reported a “lack of transvestic preoccupation” (Brantley and Wise 1985, p. 111), resolution of his secondary gender dysphoria, and improved mood. Treatment gains were maintained at 1-year follow-up.

Gender identity clinics frequently evaluate transvestites who develop gender-dysphoric symptoms, and some investigators have found that treatment with low-dosage estrogen preparations (e.g., ethinyl estradiol 0.05-0.10 mg/day, conjugated estrogens 1.25-2.50 mg/day) have been helpful in alleviating anxiety and tempering patients’ urgency to seek sex reassignment surgery (Blanchard and Steiner 1990; Pomeroy 1975). Early in the development of pharmacological treatment strategies for gender-dysphoric men, Newman and Stoller (1974) also noted that cross-gender hormonal treatments may be successful symptomatic treatments for patients who refused to consider, or were unresponsive to, alternative forms of treatment.

The treatment of nontranssexual gender-dysphoric men with estrogens is not universally accepted as appropriate. Morgan (1978) noted that patients may experience an increase in their desire and drive for sex reassignment after initiating estrogen treatment. While this may be true in some cases, such a response is likely consistent with an underlying diagnosis of GID. Based on her extensive experience in evaluating and treating gender-dysphoric patients in Canada, many of whom were transvestites, Steiner (1985) reported that low-dosage estrogen treatment can be safely provided after discussion of the possible risks and side effects with the patient. Patients often experience a significant reduction in their gender dysphoria and report contentment with only mild, reversible feminization. Dickey and Steiner (1990) described successful treatment of a gender-dysphoric transvestite with 1.25 mg of conjugated estrogen. The patient experienced a marked reduction in gender dysphoria, a decrease in urges to cross-dress, and an increased ability to concentrate on his work, relationships, and family life.

Patients should sign an informed consent document outlining the potential risks, benefits, and side effects of estrogen treatment. A model for this consent form was provided by Blanchard and Steiner (1990, pp. 155-158). Side effects of estrogen treatment (described more fully in the second section of this chapter) include possible elevations in liver enzymes, increased risk for prolactinoma formation, varying degrees of gynecomastia, fluid retention and potential hypertension, decreased sexual desire, redistribution of body fat to simulate the female body contour, decreased upper body muscle size and strength, decreased sperm count, and increased risk for thromboembolic events (especially in smokers). The most serious side effects appear to be related to both dose and duration of treatment and are generally not observed at the low dosages described above. Because estrogens in many forms are readily obtainable without a prescription (e.g., over-the-counter purchases in Mexico; Internet purchases from sources around the world), serum estrogen levels should be monitored, as well as liver function tests, prolactin, serum lipids, complete blood count, and blood pressure (Blanchard and Steiner 1990). It should also be noted that the presence of persistent gender dysphoria in a man with transvestism should alert the clinician to the diagnosis of GID of adulthood or GID not otherwise specified.

Antiandrogens Antiandrogens, including cyproterone acetate (CPA; not available in the United States) and MPA, have progestogenic and antigonadotropic properties resulting in both inhibition of androgen biosynthesis and inhibition of androgen action in the periphery (Hucker 1985). Additionally, CPA and MPA appear to block central androgen receptor sites that may be important in the generation of deviant sexual fantasies (Cooper 1986). Placebo-controlled trials support the use of antiandrogens for paraphilias, particularly pedophilia (Cooper 1981).

CPA was the first antiandrogen used in clinical trials for the treatment of deviant sexuality, beginning in 1966. Dosages for paraphiliac disorders range from 100 mg/day to 200 mg/day orally or 300 mg/week intramuscularly (Neumann and Kalmas 1991). Maximal treatment effect is observed by 4-6 weeks and consists of a nonspecific decrease in sexual desire, diminished erectile capacity, and decrease in, or elimination of, many paraphiliac behaviors. At higher dosages, erectile dysfunction and anorgasmia ensue. Response rates range from 75% to 80% of paraphiliac men receiving monitored treatment; placebo-controlled trials have also demonstrated CPA’s powerful treatment effects (Bradford 1988), although trials have not been conducted in homogeneous samples of transvestites.

MPA trials for the treatment of deviant sexuality also began in 1966. Numerous reports documented the effectiveness of the intramuscular form of this medication, especially in combination with psychotherapy and relapse prevention programs (Berlin and Meinecke 1981). A typical treatment regimen for hypersexuality or a severe paraphiliac disorder in a male would consist of 200 mg intramuscularly 2-3 times per week for 2 weeks, then 200 mg 1-2 times per week for 4 weeks, followed by 200 mg every 2 weeks. Thereafter, dosages would range from 100 mg once per week to once per month, depending on clinical response. Testosterone levels should be reduced to the normal female range as an initial laboratory target. Most patients will require longer-term treatment, as deviant fantasies or hypersexual desire patterns will reemerge as testosterone levels return to normal when treatment is discontinued. Long-term treatment with MPA is associated with weight gain, increases in systolic blood pressure, gallstone formation, infertility, and potential changes in glucose tolerance (Stermac 1990). Stoller (1973) reported on the successful use of MPA in nonspecifically reducing sexual drive in a gender-dysphoric transvestite, but no clinical trials have been conducted to demonstrate the efficacy of MPA treatment in transvestism.

Although antiandrogen treatment has been effective, Wise (1989) questioned the long-term utility of medications that specifically target sexual drive, in light of the expected reduction of sexual drive in aging men and the frequent dissociation of erotic sensations from the act of cross-dressing in older transvestites. Halleck (1981) discussed the ethics of antiandrogen therapy for sexual disorders, pointing out the social control aspects of “chemical castration.” Gonadotropin-releasing hormone agonists such as goserelin, triptorelin, and histrelin, primarily used in treating prostate cancer, may theoretically offer some utility in severe cases of transvestic fetishism. Advantages of these agents include 2- to 24-month durations of action after injection or implantation of a reservoir (Spitz et al. 1999). These medications essentially achieve chemical castration, with the possibility of decreasing testosterone levels to nearly zero. There are no reports to date of the use of these expensive agents in transvestism.

In addition to the medications listed in

Table 70-4, lithium carbonate has been reported to be useful in a patient who developed transvestism in the context of bipolar disorder, manic phase (Ward 1975). Ward was quick to caution, however, that no data support the use of lithium in patients with transvestism in the absence of a cycling mood disorder.

Self-Help Support Groups
A network of self-help support groups for cross-dressers has evolved over the past 35 years in the United States, Europe, South Africa, Australia, and elsewhere. With the advent of easier access to telecommunications, these groups have become more organized and accessible, even by those who never appear in public cross-dressed. For example, computer bulletin board services and Internet “chat rooms” are available for those with an interest in transvestism (e.g., “Genderline” on CompuServe). Information clearinghouses (e.g., International Foundation for Gender Education, Wayland, Massachusetts) provide both live “hotline” support and extensive literature to those who request them. Tri-Ess (Society for the Second Self) is a national “sorority” for heterosexual cross-dressers with dozens of local chapters offering both social and supportive contact for transvestites. Many of these organizations have a spouse support group (G. R. Brown 1994; G. R. Brown and Collier 1989) to assist spouses of cross-dressers as well. Numerous national and regional annual conventions for cross-dressers have also been organized over the past 20 years (e.g., Fantasia Fair, Provincetown, Massachusetts; Texas “T” Party, San Antonio, Texas; Southern Comfort, Atlanta, Georgia; “Be All” weekends in upper-Midwest cities) to provide a blend of social and didactic sessions, with extensive participation by mental health care researchers and clinicians. Those who treat transvestites often find it helpful to refer their patients to local support groups and annual conventions as part of their overall management. These groups can often offer far more help for transvestites and other transgendered persons than can be obtained in most therapists’ offices. Because they can play pivotal roles in decreasing the sense of isolation experienced by these men, the clinical algorithm (

Figure 70-1) includes them as adjunctive support sources regardless of whether the patient experiences gender dysphoria in association with cross-dressing.