Transvestic disorder is a paraphilic disorder characterized by emotional distress or functional impairment due to erotic cross-dressing. Is cross-dressing a mental issue? No, it’s not. Cross-dressing is simply the act of dressing as the opposite gender. The behavior is typically practiced by cisgender, heterosexual men who wear traditionally feminine apparel like lingerie, heels, or dresses.
People don’t always cross-dress for erotic purposes. Sometimes it’s just for fun or entertainment. But the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), begins defining cross-dressing as problematic when the following two things are true: 1) it involves sexual arousal; and 2) those feelings, urges, and behaviors cause clinically significant harm to someone’s life. This harm could come in the form of guilt, shame, or functional consequences.
Transvestic Disorder DSM-5 Diagnostic Criteria
The DSM-5, published by the American Psychiatric Association (APA), states that someone must meet two criteria in order to receive a diagnosis of transvestic disorder:
- For at least six months they must experience intense and repeated sexual arousal from cross-dressing and/or the idea of cross-dressing.
- These cross-dressing fantasies and behaviors must cause emotional, social, or occupational problems.
Mental health professionals who diagnose transvestic disorder can also specify if the condition has the following features:
- With fetishism: Materials alone can cause the person to become sexually aroused. For example, someone gets turned on by touching lacy undergarments.
- With autogynephilia: The person is sexually aroused by imagining themselves to be female. They might fantasize about having female physiological functions (e.g., menstruating or lactating), engaging in stereotypical feminine behavior (e.g., wearing pink or doing embroidery), or having female anatomy (e.g., breasts).
- In a controlled environment: The person lives in a setting where they don’t have an opportunity to cross-dress (e.g., they’re institutionalized).
- In full remission: Someone hasn’t cross-dressed for at least five years even though their opportunities to do so haven’t been restricted.
Potential Signs and Symptoms of Transvestic Disorder
- Becoming erect (if male) from cross-dressing
- Difficulty maintaining penile erection with partner unless cross-dressing
- Inability to achieve sexual arousal unless wearing clothing, accessories, or other items of the opposite sex
- Playing the part of the opposite sex when cross-dressing
- Continual and powerful sexual feelings from imagining or dressing in a single article (like panties) or many articles of clothing associated with the other sex (e.g., dresses, stockings, or high heels), and/or accessories like wigs and makeup.
- Pattern of buying clothing and other items of the opposite sex, wearing them, then discarding them in an effort to put an end to cross-dressing (called “purging and acquisition” behavior)
- Serious distress in relationships or careers due to at least half a year of the cross-dressing urges and behaviors
- For men, having felt excited or fascinated by female attire before puberty
- For men, having experienced a first ejaculation while cross-dressing
- For older people, delaying masturbation in order to prolong the cross-dressing
Transvestic Disorder vs. Transvestism
Transvestic disorder is often confused with transvestism, another word for cross-dressing that’s mostly fallen out of favor. Transvestism and transvestite are both terms that are now widely considered pejorative (negative). There is nothing inherently pathological about cross-dressing. It’s a form of self-expression. In fact, humans have a long history of dressing up as the opposite gender, sometimes even for religious purposes.
But transvestic disorder should be differentiated from two other DSM-5 disorders: gender dysphoria and fetishistic disorder.
DSM-5 Transvestic Disorder vs. DSM-5 Gender Dysphoria
What is gender dysphoria? The APA calls it “the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.” So if someone’s internal experience as a woman doesn’t align with their male gender assignment at birth, they might suffer from gender dysphoria until they can peacefully reconcile their inner and outer states of being.
Is gender dysphoria a mental disorder? Some might consider gender dysphoria as more of a social disorder than a mental disorder. That’s because its internalized distress probably wouldn’t exist without gender expectations and social stigmas. And it’s generally cured by a successful transition.
The difference between transvestic disorder and gender dysphoria is that someone with transvestic disorder doesn’t necessarily feel like or want to be the opposite gender. It is possible, however, for someone with transvestic disorder to develop gender dysphoria, as they desire to play the part of the opposite sex for longer and longer periods. For these individuals, cross-dressing usually becomes less erotic over time.
Interestingly, having the fetishism specifier decreases the likelihood of gender dysphoria in men with transvestic disorder. And having the autogynephilia specifier increases the likelihood of gender dysphoria in men with transvestic disorder.
DSM-5 Transvestic Disorder vs. DSM-5 Fetishistic Disorder
Fetishistic disorder can sometimes resemble transvestic disorder when apparel and fabrics play a prominent role in someone’s sexual fantasies and behavior. In these cases, what the person is thinking about while they’re aroused is extremely important. In fetishistic disorder, the person is turned on directly by nonliving objects or nongenital body parts – not just the clothes used in cross-dressing – and this causes them significant distress. In transvestic disorder, the person is turned on by thoughts of dressing like a woman and/or being a woman.
What Triggers Cross-dressing? What Causes Transvestic Disorder?
It isn’t known exactly what triggers cross-dressing or transvestic disorder. There’s no universal cause. Sometimes the course of transvestic disorder is continuous, while at others it occurs in episodes. Cross-dressing tendencies may begin in childhood, as when a boy develops an extreme fascination with a particular item that is typically worn by women, such as lipstick or a dress. This fascination turns into excitement. And when puberty hits, cross-dressing starts to cause penile erection.
Risk Factors for Transvestic Disorder
Are there risk factors for transvestic disorder? There are certainly social and psychological risk factors. If someone doesn’t have a healthy support system, then they might fear being judged harshly for their cross-dressing. If someone doesn’t accept themselves and what turns them on, then they might feel shame or guilt about their sexual proclivities.
What Is the Prevalence of Transvestic Disorder?
Transvestic disorder is an extremely rare diagnosis, and the DSM-5 states that fewer than 3% of men report that they have ever been sexually aroused by cross-dressing. The disorder is virtually only diagnosed in men (women don’t typically suffer negative social consequences for wearing clothes traditionally associated with men), and most of them recognize themselves as heterosexual.
Treatment of Transvestic Disorder
The majority of people who cross-dress don’t have a paraphilic disorder, but if someone is experiencing severe shame, anxiety, or ridicule due to their cross-dressing tendencies, psychotherapy can help address these negative effects. The ultimate question to ask oneself is, “Is this interfering with my well-being or important areas of my life?”
In general, a therapist can help individuals find strategies to mitigate or cope with emotional distress. And approaches like cognitive behavioral therapy (CBT) can even help people improve their self-perception and self-acceptance.
If there’s an obsessive-compulsive component to someone’s cross-dressing, then they might benefit from antidepressant medication. People with relationship problems due to their cross-dressing could find a nonjudgmental space to discuss their issues through couples therapy or family therapy. Finally, social groups and support groups can give people who cross-dress a community of like-minded people to talk to for mutual benefit.