Should Transvestic Fetishism Be Classified in DSM 5? Recommendations from the WPATH Consensus Process for Revision of the Diagnosis of Transvestic Fetishism

ABSTRACT

The World Professional Association for Transgender Health (WPATH) conducted a consensus process in order to develop recommendations for the refinement of diagnoses for Gender Identity Disorders and Transvestic Fetishism for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). This article is the report of the work group on Transvestic Fetishism. It reviews the history of the diagnosis of Transvestic Fetishism in the DSM, the current DSM-IV-TR classification, and the prevalence and characteristics of the phenomenon of transvestic fetishism. The problems with the current diagnostic classification are reviewed. Based on the consensus process, a new diagnostic label and diagnostic criteria are presented. The new diagnosis is Transvestic Disorder, defined by two criteria: (a) recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing and (b) the fantasies, sexual urges, or behaviors are causing clinical distress or impairment in important areas of psychological functioning; that is, the distress is not solely due to external prejudice, stigma, or oppression.

KEYWORDS:

• Transvestic fetishism
• psychiatric classification
• Diagnostic and Statistical Manual of Mental Disorders (DSM)

The World Professional Association for Transgender Health created a work group in 2009 to review the DSM diagnosis of Transvestic Fetishism as part of a larger consensus project to contribute to the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5; Knudson, De Cuypere, & Bockting, 2010). The results of this process for Gender Identity Disorders are presented in a special issue of the International Journal of Transgenderism (2010, vol. 12, no. 2). This article is the report of the work group on Transvestic Fetishism. It includes input from attendees of the WPATH biennial symposium of June 2009.

TRANSVESTIC FETISHISM IN THE DSM: A HISTORICAL OVERVIEW

The first edition of the Diagnostic and Statistical Manual appeared in 1952 and was 128 pages in length, whereas the DSM-IV-TR (American Psychiatric Association, 2000), the version currently used, is 943 pages. The purpose of DSM-I (1952) was to unify and modernize competing systems that were used to classify disturbances of mental functioning in the first half of the twentieth century (in the United States). DSM-I made an explicit distinction between psychiatric and neurological disorders and classified psychiatric disorders primarily as occurring with or without organic brain disturbance. The provision of a unifying and reliable classification system of psychiatric disorders is still a primary intent of the DSM (Hyman, 2010; Blashfield, Flanagan, & Raley, 2010). With the publication of the DSM-III in 1980, the DSM classification system changed drastically. DSM-III introduced the use of extensive diagnostic criteria, a multiaxial system (5 axes), and a descriptive approach rather than an etiology-based approach. This approach was retained in DSM-IV. The next installment of the DSM, the DSM 5, is currently under development, and the work has sparked tremendous debate about what diagnoses to include, combine, omit, or alter. However, one thing that few are arguing for is to abolish the whole DSM altogether (Wakefield, 2010; Zucker, 2010). Furthermore, while the debate about what diagnoses and criteria to include will continue for some time, most users expect that DSM 5 will remain organized upon the use of diagnostic criteria (used dimensionally or categorically) to classify psychiatric disorders, a multiaxial system (5 axes), and a descriptive approach.

As a consequence, one important question regarding the DSM 5 classification of Transvestic Fetishism is whether the criteria used to diagnose this phenomenon as a mental disorder are reliable and valid. An even more fundamental question is whether Transvestic Fetishism should be included in the DSM 5 as a mental disorder. A review of the history of the DSM classifications of Transvestic Fetishism will provide a helpful perspective to guide future classification and selection of criteria.

In DSM-I (1952) Transvestic Festishism ¹ was classified as an example of “000-x63 Sexual Deviation” and defined as “deviant sexuality which is not symptomatic of more extensive syndromes, such as schizophrenic and obsessional reactions” (p. 38). The Sexual Deviation category was classified as a subgroup of the personality disorders, which implied that Transvestic Fetishism was a lifelong dysfunctional personality structure, resulting in a typical behavior pattern with little or no stress (DSM-I, 1952). Of note, the DSM-II defined personality disorders as a typical behavior pattern without clear mental or emotional symptoms (DSM-I, 1952, p. 34). This classification of Transvestic Fetishism did not change significantly with the publication of DSM-II (1968). The condition was still classified as a sexual deviation, and the sexual deviations remained classified as a subgroup of the personality disorders. The DSM-II (1968) emphasized that at the core of Transvestic Fetishism was a lack of attraction to people of the opposite sex but, instead, attraction for sexual acts not associated with coitus or for “coitus performed under bizarre circumstances” (p. 44).

In the DSM-III (1980), the psychiatric classification of Transvestic Fetishism changed drastically. No longer was it considered a personality disorder but, rather, an Axis I disorder under the category of Paraphilias. There were a number of ramifications from this new classification. First, with Transvestic Fetishism defined as an Axis I disorder, the implication was that it was caused by psychological factors (DSM-III, 1980, p. 261). Second, the classification of Transvestic Fetishism as a paraphilia implied that “unusual or bizarre imagery or acts are necessary for sexual excitement (for at least 6 months). Such imagery or acts tend to be insistently and involuntarily repetitive and, generally, involve either (1) preference for use of a nonhuman object for sexual arousal, (2) repetitive sexual activity with humans involving real or simulated suffering or humiliation, or (3) repetitive sexual activity with nonconsenting partners” (DSM-III, 1980, p. 266).

Very little change was made in the DSM-III-R (1987), with the exception that it was no longer assumed that the sexual disorders were caused by psychological factors. Furthermore, Transvestic Fetishism in the DSM-III (1980, p. 288) was applicable only to heterosexual males and was not to be diagnosed in cases in which the disturbance had evolved into Gender Identity Disorder of Adolescence or Adulthood. The primary revision in the DSM-IV (1994, p. 531) was the need to specify if a person with Transvestic Fetishism also had gender dysphoria.

This review of how Transvestic Fetishism has been classified in each subsequent revision of the DSM reflects the continuity of this classification as a mental disorder. Over the years, the American Psychiatric Association has changed its conceptualization of the nature of this disorder from a personality disorder (in DSM-I and DSM-II) to an Axis I sexual disorder, that is, a paraphilia characterized by two core dimensions: the transvestic behavior, which refers to cross-dressing, and the fetishistic feature, which reflects the sexual focus (Wheeler, Newring, & Draper, 2008). See Table 1 for an overview of the classification of Transvestic Fetishism in the DSM.)

TABLE 1 Brief Overview of the Classification of Transvestic Fetishism in the DSM

DSM	Category	Subgroup	Group	Specifiers
I (1952)	Transvestism	Sexual Deviations	Personality Disorders	None
II (1968)	Transvestism	Sexual Deviations	Personality Disorders and Certain Other Nonpsychotic Disorders	None
III (1980)	Transvestism	Paraphilias	Psychosexual Disorders	None
III-R (1987)	Transvestic Fetishism	Paraphilias	Sexual Disorders	None
IV (1994)	Transvestic Fetishism	Paraphilias	Sexual and Gender Identity Disorders	With gender dysphoria
IV-TR (2000)	Transvestic Fetishism	Paraphilias	Sexual and Gender Identity Disorders	With gender dysphoria
V (proposed by Blanchard)	Transvestic Disorder	Paraphilias	Sexual Disorders (without the Gender Identity Disorders, which are classified as a separate group)	With fetishism
				With autogynephilia
V (proposed by WPATH	Transvestic Disorder	Paraphilias	Sexual Disorders	None

THE CURRENT CLASSIFICATION OF TRANSVESTIC FETISHISM IN DSM-IV-TR

Transvestic Fetishism is classified in DSM-IV-TR (2000) as a paraphilia and is defined in this text as involving cross-dressing by a man in women's attire (p. 574). Further specified in DSM-IV-TR (2000) is this viewpoint:

In many or most cases sexual arousal is produced by the accompanying thought or image of the person as a female (referred to as autogynephilia). These images can range from being a woman with female genitalia to that of a view of the self fully dressed as a woman with no real attention to the genitalia. Women's garments are arousing primarily as symbols of the individual's femininity, not as fetishes with specific objective properties (e.g., objects made of rubber). Usually, the male with Transvestic Fetishism keeps a collection of female clothes that he intermittently uses to cross-dress. This disorder has been described only in heterosexual males. Transvestic Fetishism is not diagnosed when cross-dressing occurs exclusively during the course of Gender Identity Disorder. When not cross-dressed, the male with Transvestic Fetishism is usually remarkably masculine. (p. 574)

The DSM-IV-TR (2000) adds that Transvestic Fetishism has some correlation with Masochism. DSM-IV-TR also states that Transvestic Fetishism often develops as an antidote (or coping strategy) for anxiety or depression and fuels a sense of ease and calm. In some men it is also associated with gender dysphoria or the development of gender dysphoria.

Table 2 provides an overview of the specific operational diagnostic criteria of Transvestic Fetishism in DSM-IV-TR (2000). Because a differential diagnosis with Gender Identity Disorder is important, Table 3 specifies the operational diagnostic criteria of Gender Identity Disorder. Although DSM-IV-TR states that the diagnosis of Transvestic Fetishism is not given when cross-dressing happens only during the course of Gender Identity Disorder (p. 574), it also states that it is possible to give both diagnoses when the criteria for both mental disorders are fulfilled. This inconsistent classification signals that confusion exists with regard to the specifier “With Gender Dysphoria” in the diagnosis of Transvestic Fetishism (as has been signaled by Blanchard, 2010). It is not clear how to differentiate Transvestic Fetishism with Gender Dysphoria from the diagnosis of Gender Identity Disorder or from Gender Identity Disorder Not Otherwise Specified. Nevertheless, the DSM-IV-TR classifies Transvestic Fetishism as a mental disorder and as a paraphilia. Although, the DSM IV-TR identifies Transvestic Fetishism as an abnormal sexual behavior, the experience of distress remains a necessary condition to meet criteria for the diagnosis of Transvestic Fetishism. Therefore, the current classification indicates that without distress, Transvestic Fetishism should not be classified as a mental disorder per se (see also Blanchard, 2010, p. 366).

TABLE 2 Diagnostic Criteria for 302.3 Transvestic Fetishism in DSM-IV-TR

A. Over a period of at least six months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

With gender dysphoria: if the person has persistent discomfort with gender role or identity.

TABLE 3 Diagnostic Criteria for Gender Identity Disorder in DSM-IV-TR

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being of the other sex).

In children, the disturbance is manifested by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is, the other sex

(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical          masculine clothing

(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the          other sex

(4) intense desire to participate in the stereotypical games and pastimes of the other sex

(5) strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as the stated desire to be the other sex,      frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has      the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are      disgusting and will disappear or assertion that it would be better not to have a penis, or aversion toward      rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating      in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts      or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of      primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically      alter sexual characteristics to stimulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:

302.6 Gender Identity Disorder in Children

302.85 Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals)

Sexually Attracted to Males

Sexually Attracted to Females

Sexually Attracted to Both

Sexually Attracted to Neither

TABLE 4 WPATH Proposed Diagnostic Criteria for 302.3 Transvestic Disorder

Category: Paraphilias

A. Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.

B. The fantasies, sexual urges, or behaviors are causing clinical distress or impairment in important areas of psychological functioning. The distress is not solely due to external prejudice, stigma, or oppression.

Exclude: Gender dysphoria

THE PREVALENCE AND DEVELOPMENTAL COURSE OF TRANSVESTIC FETISHISM

Transvestic Fetishism is not common. In a recent study of 2,450 adult Swedes, the prevalence of transvestic behavior, defined as ever having experienced sexual arousal from cross-dressing behavior, was 2.8% for males and 0.4% for females (Langström & Zucker, 2005). While this definition is not synonymous with a diagnosis of Transvestic Fetishism, the rates suggest that cross-dressing associated with sexual arousal is not rare, albeit not frequent, and is not an exclusively male phenomenon.

Although it can be argued that the etiology or development of Transvestic Fetishism is not relevant for a descriptive classification of mental disorders, attention to its development is justified in this context in light of the heated controversy over the role of autogynephilia and “erotic target localization error” in the development of Transvestic Fetishism and gender dysphoria and the proposed consequences for the DSM 5 (e.g., see Blanchard, 2010; Cohen-Kettenis & Pfäfflin, 2010; Lawrence, 2009, 2010a, 2010b; Moser, & Kleinplatz, 2002; Nuttbrock et al., 2010a, 2010b). Blanchard has argued that the phenomenon behind most transvestic behavior is either autogynephilia, that is, sexual arousal stemming from the fantasy of being a woman or fetishism, that is, sexual arousal in response to female clothing (Blanchard, 2010). While there is a correlation between these phenomena, they are clearly not isomorphic (Moser, 2010a; Serano, 2010). Freund, Blanchard, and Lawrence have argued that the phenomenon of transvestism constitutes an erotic target location error, that is, men have transferred their sexual attraction to female bodies to female clothing and to their own bodies (Lawrence, 2009, 2010a, 2010b).

However, there is no scientific consensus as to the etiology of Transvestic Fetishism. Valid data about the determinants and processes that cause Transvestic Fetishism are still lacking (Wheeler et al. 2008). In particular, there are no prospective longitudinal developmental studies. It also remains unclear to what extent the distress that is reported by some adults with Transvestic Fetishism is caused intrinsically by this condition or is a consequence of the social stigma or relationship conflict attached to the behavior. However, it is important to remember that many persons report no distress from cross-dressing (Langström & Zucker, 2005).

Due to our lack of knowledge about the development of Transvestic Fetishism and taking into account the descriptive nature and empirical basis of the DSM, the DSM 5 should exclude such concepts as autogynephilia as operational diagnostic criteria or specifiers (Cohen-Kettenis & Pfäfflin, 2010).

PROBLEMS WITH THE CURRENT CLASSIFICATION OF TRANSVESTIC FETISHISM IN DSM-IV-TR

An important guiding principle of the revision for DSM 5 is to ensure that diagnostic criteria have empirically established reliability and validity (Hyman, 2010). Based on this guiding principle, there are a number of questions that must be answered regarding the DSM IV-TR classification of Transvestic Fetishism in order to appropriately revise it for inclusion in the DSM 5. These questions include

1.	Is Transvestic Fetishism a mental disorder?
2.	Should the diagnosis be categorical or dimensional?
3.	Should Transvestic Fetishism be classified as an Axis I or an Axis II disorder?
4.	Should the duration of 6 months be used as an operational diagnostic criterion?
5.	Should the diagnosis Transvestic Fetishism be limited to heterosexual males?

The first question is obviously the most important one. The label Transvestic Fetishism implies that the phenomenon of cross-dressing for the purpose of sexual arousal is inherently a disorder, even though the existing diagnosis requires the presence of distress or impairment. The major goal of any revision of the diagnosis of Transvestic Fetishism should be to provide a stronger distinction between atypical sexual behavior and a mental disorder. On one hand, it is important to depathologize sexual behaviors and urges that have for years been categorically defined as disordered (e.g., cross-dressing). On the other hand, professionals and distressed individuals require the ability to define situations in which the behavior has become problematic and requires intervention (e.g., excessive or self-destructive forms of cross-dressing). The search for a balance in these competing needs has been the goal of the WPATH consensus process for Gender Identity Disorder as well (Knudson et al., 2010). Blanchard's recommendation to change the name of the diagnosis to Transvestic Disorder is a step in this direction (Blanchard, 2010). He phrases his view as follows:

A paraphilia is any powerful and persistent sexual interest other than sexual interest in copulatory or precopulatory sexual behavior with phenotypically normal consenting, human partners … A paraphilic disorder is a paraphilia that causes impairment or distress. One would ascertain a paraphilia (determine whether it is present or absent according to common signs or symptoms) but diagnose a paraphilic disorder (determine whether the paraphilia is distressing the patient or impairing his [or her] psychosocial functioning). In my proposal for Transvestic Disorder, criterion A is an ascertainment criterion that identifies the patient as transvestic according to traditional indicators of transvestism, and criterion B is a diagnostic criterion that classifies the patient's condition as a psychiatric disorder on the grounds of distress or impairment. (Blanchard, 2010, p. 367)

(For some critical comments on the difference between transvestic behavior and Transvestic Disorder and the so-called process of ascertainment, see Moser, 2010b; O’Donohue, 2010).

Until recently, the next two questions have not received much attention. It seems that at the moment, the implicit consensus from experts is that a categorical diagnosis is preferred and that the classification of Transvestic Fetishism should remain an Axis I disorder despite the DSM-IV-TR description that better fits a chronic personality disorder (i.e., it usually starts in childhood or early adolescence and lasts during life). This perspective is maintained in the DSM 5 work group's proposal for a classification of Transvestic Disorder, albeit with the acknowledgment that these issues deserve more attention (Blanchard, 2010).

The criterion of a 6-month duration, added in DSM-III-R (Blanchard, 2010), remains arbitrary. Perhaps it was inserted to reduce the probability of false positive diagnoses or based on some implicit, and still unknown, idea about the development of sexual desires and attractions as acute mental states (Blanchard, 2010, p. 365). In our interpretation this means that the DSM has the view that an atypical sexual orientation should be a trait and not a mental state of short duration. It may be beneficial to exclude this criterion altogether (see also Blanchard, 2010, for some interesting suggestions to move the criterion of 6 months to the B criterion). Finally, based on the fact that there is empirical evidence that some homosexual males and females experience sexual arousal in response to cross-dressing, the restriction of the diagnosis to heterosexual males is no longer empirically tenable (Langström & Zucker, 2005).

NEED FOR EMPIRICAL TESTING

Despite much controversy, confusion, and unsolved problems that characterize the debate about whether Transvestic Fetishism should be retained in the DSM 5, it appears likely that Transvestic Fetishism will be retained in the DSM 5 as a mental disorder (e.g., Blanchard, 2010, Wheeler et al., 2008). As a consequence, the question then becomes what are the most reliable and valid diagnostic criteria. According to Moser (2009) and Hyman (2010), not reliability but validity is the most important issue for the revision of this diagnosis. Only conditions that are mental disorders should be included in a diagnostic and statistical manual of mental disorders. The inclusion of other mental conditions or social behaviors in the DSM leads to a misuse of psychiatry for social and judicial policies (Singy, 2010; Wakefield, 2010). However, if it is assumed that Transvestic Fetishism is a harmful dysfunction, ² it belongs in the DSM 5. This assumption cannot be taken for granted but, instead, needs to be empirically tested to justify the inclusion (or exclusion) of Transvestic Fetishism or Transvestic Disorder in the DSM. Precisely, this empirical validation process deserves more attention in the current debates on DSM 5.

WPATH’S RECOMMENDATION FOR DSM 5

Based on an analysis of the literature regarding Transvestic Fetishism and a review of the various DSM diagnostic criteria of Transvestic Fetishism and the Paraphilias in general, (Blanchard, 2010; Gijs & Brewaeys, 2007; Lawrence, 2009; Wheeler, et al., 2008; Zucker & Blanchard, 1997), the WPATH consensus process work group on Transvestic Fetishism proposes the following diagnostic criteria for DSM 5 (see also Table 4): (a) recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing and (b) the fantasies, sexual urges, or behaviors are causing clinical distress or impairment in important areas of psychological functioning. The distress is not solely due to external prejudice, stigma or oppression.

Our proposal is quite similar to that of what the DSM work group under the leadership of Blanchard recently proposed (Blanchard, 2010), which can be found in Table 5. Most importantly, we also recommend that the name of the disorder be changed to Transvestic Disorder to make clear that it does not apply to all transvestic behavior or interests. Blanchard proposes to not use gender dysphoria as an exclusion criterion but, instead, to use Transvestic Disorder and Gender Identity Disorder as two separate diagnoses, which can both be given if the diagnostic criteria for both are fulfilled.

TABLE 5 Blanchard's Proposed Diagnostic Criteria for Transvestic Disorder

A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

With Fetishism (Sexually Aroused by Fabrics, Materials,    or Garments)

With Autogynephilia (Sexually Aroused by Thought or    Image of Self as Female)

The most important difference between the WPATH work group's proposal and the American Psychiatric Association DSM 5 work group's proposal concerns the specifiers. Blanchard (2010) argues that in light of the need for differentiating subtypes of Transvestic Disorder, and based on the available empirical evidence, that two specifiers should be used: With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments) and With Autogynephilia (Sexually Aroused by the Thought or Image of Self as Female). Although, these are certainly legitimate proposals (see also Lawrence, 2010a), there is in our opinion not enough solid empirical evidence to include these specifiers (Gijs, 2007; Gijs & Brewaeys, 2007; see also Serano, 2010).

Notes

1. For the sake of clarity and ease, in the context of this paper, no distinction is made between the various terms (e.g., Transvestism and Transvestic Fetishism) that have been used in the different versions of the DSM. For a review of detailed changes in the various versions of the DSM, the reader is referred to Blanchard (2010).

2. A harmful dysfunction is defined by Wakefield (2010) as follows: “In sum, a mental disorder is a harmful mental dysfunction. If this view of a harmful dysfunction is correct, then a society's categories of mental disorder [offer] two pieces of information. First, they indicate a value judgment that society considers the condition negative or harmful. Second, they make the factual claim that the harm is due to a failure of the mind to work as designed” (p. 290).