Marital partners of transvestites are more likely than their husbands to seek treatment from a psychiatrist (G. R. Brown 1994). In Prince and Bentler’s (1972) survey of 504 subscribers to a transvestite journal, most of whom were themselves middle-aged transvestites, only about 24% had ever sought psychiatric treatment, whereas 38% of 106 women in committed relationships with cross-dressers had received mental health treatment sometime in their lives (G. R. Brown 1994). Early studies of wives of transvestites focused on small clinical samples. In them, wives were categorized as having low self-esteem and “moral masochism” (Stoller 1967). These women have also been described as having character styles rich in dependency and, therefore, as “settling” for a cross-dressing mate as an alternative preferable to the pain of loss and loneliness (Wise et al. 1981).

Spouses interviewed in nonclinical settings are a more varied group than those treated by Stoller, Wise, and colleagues. The average participant in a nonclinical study is likely to be a 40-year-old, Caucasian, once-married woman with some college education and is more likely than her same-age peers to be both firstborn and childless (G. R. Brown 1994, 1998). These spouses are no more likely to have had homosexual experiences or to report substance use problems than are women in the general population (G. R. Brown 1994). Approximately half have allowed cross-dressing in the bedroom on at least one occasion, and 25% report having experienced sexual arousal by their husband’s cross-dressing (G. R. Brown 1994). Those who discover their husband’s cross-dressing accidentally are more likely to have significant problems requiring clinical attention (G. R. Brown 1990b, 1994, 1998; G. R. Brown and Collier 1989; Talamini 1982). Prince and Bentler (1972) reported that 36% of transvestites who were divorced cited cross-dressing as at least one of the contributing factors to their divorce, most often in the context of their not having revealed their transvestism before marriage. On the other hand, women who were informed of their mate’s cross-dressing prior to becoming involved in a committed relationship display a wide range of acceptance of such behaviors, often adjusting to, or becoming accepting of, his transvestism (G. R. Brown 1994; Docter 1988). Hirschfeld also appreciated the importance of disclosure, instructing the transvestites he saw to inform their wives of their cross-dressing activities (Hirschfeld 1910). With the advent of organized social and support groups for transgendered men (e.g., Boulton and Park Society, Tri-Ess, International Foundation for Gender Education), some spouses become active in the cross-gender subculture along with their husbands. This could include going to national conventions, shopping with him while he is “en femme,” buying him women’s clothes, and helping him to apply makeup. These women, termed “high acceptors” (G. R. Brown 1994), generally do not report for psychiatric treatment.

Wise (1987) cautioned that therapists should never “actively encourage [wives] to tolerate or participate in their spouse’s fetishistic activities” (p. 234). However, because the alternative may be divorce or separation (seriously considered by 32% of women because of their husband’s cross-dressing; G. R. Brown 1998), this approach seems both judgmental and unnecessarily limiting of treatment options for the therapist engaged in conjoint therapy (Peo 1988). Wise did advise therapists to avoid “the value judgment that transvestite behavior is wrong or harmless” pending therapists’ arriving at a full appreciation of the relationship issues and characterological features of the partners (Wise 1987, p. 645).

Spouses who do seek clinical treatment or self-help support group involvement raise a number of questions and issues in four major domains of which the treating psychiatrist should be aware. These are listed in

Table 70-5. Many of these questions are readily amenable to didactic intervention, based on what is currently known of transvestism.

Others, however, are best managed in the context of a psychotherapeutic relationship (G. R. Brown 1998; Cairns 1997). Group intervention has also been shown to be very beneficial, even if organized by spouses of men involved in transvestite social clubs (G. R. Brown 1994; G. R. Brown and Collier 1989). Nationally distributed newsletters for spouses of transgendered men also serve a helpful role in reducing the isolation experienced by some women (e.g., Partners Newsletter, Boulton and Park Society, San Antonio, Texas; SPICE, Little Rock, Arkansas).