Transvestic disorder in men is often accompanied by autogynephilia (i.e., a male’s para- philic tendency to be sexually aroused by the thought or image of himself as a woman).
Autogynephilic fantasies and behaviors may focus on the idea of exhibiting female phys- iological functions (e.g., lactation, menstruation), engaging in stereotypically feminine be- havior (e.g., knitting), or possessing female anatomy (e.g., breasts).
The prevalence of transvestic disorder is unknown. Transvestic disorder is rare in males and extremely rare in females. Fewer than 3% of males report having ever been sexually aroused by dressing in women’s attire. The percentage of individuals who have cross- dressed with sexual arousal more than once or a few times in their lifetimes would be even lower. The majority of males with transvestic disorder identify as heterosexual, although some individuals have occasional sexual interaction with other males, especially when they are cross-dressed.
In males, the first signs of transvestic disorder may begin in childhood, in the form of strong fascination with a particular item of women’s attire. Prior to puberty, cross-dress- ing produces generalized feelings of pleasurable excitement. With the arrival of puberty, dressing in women’s clothes begins to elicit penile erection and, in some cases, leads di- rectly to first ejaculation. In many cases, cross-dressing elicits less and less sexual ex- citement as the individual grows older; eventually it may produce no discernible penile response at all. The desire to cross-dress, at the same time, remains the same or grows even stronger. Individuals who report such a diminution of sexual response typically report that the sexual excitement of cross-dressing has been replaced by feelings of comfort or well-being.
In some cases, the course of transvestic disorder is continuous, and in others it is epi- sodic. It is not rare for men with transvestic disorder to lose interest in cross-dressing when they first fall in love with a woman and begin a relationship, but such abatement usually proves temporary. When the desire to cross-dress returns, so does the associated distress.
Some cases of transvestic disorder progress to gender dysphoria. The males in these cases, who may be indistinguishable from others with transvestic disorder in adolescence or early childhood, gradually develop desires to remain in the female role for longer pe- riods and to feminize their anatomy. The development of gender dysphoria is usually ac- companied by a (self-reported) reduction or elimination of sexual arousal in association with cross-dressing.
The manifestation of transvestism in penile erection and stimulation, like the manifesta- tion of other paraphilic as well as normophilic sexual interests, is most intense in adolescence and early adulthood. The severity of transvestic disorder is highest in adulthood, when the transvestic drives are most likely to conﬂict with performance in heterosexual intercourse and desires to marry and start a family. Middle—age and older men with a history of trans- vestism are less likely to present with transvestic disorder than with gender dysphoria.
Functional Consequences of Transvestic Disorder
Engaging in transvestic behaviors can interfere with, or detract from, heterosexual rela- tionships. This can be a source of distress to men who wish to maintain conventional mar— riages or romantic partnerships with women.
Fetishistic disorder. This disorder may resemble transvestic disorder, in particular, in men with fetishism who put on women’s undergarments while masturbating with them.
Distinguishing transvestic disorder depends on the individual’s specific thoughts during such activity (e.g., are there any ideas of being a woman, being like a woman, or being dressed as a woman?) and on the presence of other fetishes (e.g., soft, silky fabrics, whether these are used for garments or for something else).