Fetishistic behavior without fetishistic disorder. Use of a fetish object for sexual arousal quence would not meet criteria for fetishistic disorder, as the threshold required by Crite- rion B would not be met. For example, an individual whose sexual partner either shares or can successfully incorporate his interest in caressing, smelling, or licking feet or toes as an important element of foreplay would not be diagnosed with fetishistic disorder; nor would an individual who prefers, and is not distressed or impaired by, solitary sexual be- havior associated with wearing rubber garments or leather boots.
Fetishistic disorder may co-occur with other paraphilic disorders as well as hypersexual- ity. Rarely, fetishistic disorder may be associated with neurological conditions.
Diagnostic Criteria 302.3 (F65.1)
A. Over a period of at least 6 months. recurrent and intense sexual arousal from cross- dressing, as manifested by fantasies, urges, or behaviors.
B. The fantasies. sexual urges. or behaviors cause clinically significant distress or impair- ment in social. occupational, or other important areas of functioning.
Specify if:
Wlth fetishism: If sexually aroused by fabrics, materials, or garments.
With autogynephllia: If sexually aroused by thoughts or images of self as female.
Specify it:
In a controiled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to cross-dress are restricted.
In full remisslon: There has been no distress or impairment in social, occupational, or other areas of functioning for at least 5 years while in an uncontrolled environment.
The presence of fetishism decreases the likelihood of gender dysphoria in men with trans- vestic disorder. The presence of autogynephilia increases the likelihood of gender dyspho- ria in men with transvestic disorder.
The diagnosis of transvestic disorder does not apply to all individuals who dress as the op- posite sex, even those who do so habitually. It applies to individuals whose cross-dressing or thoughts of cross-dressing are always or often accompanied by sexual excitement (Cri- terion A) and who are emotionally distressed by this pattern or feel it impairs social or in- terpersonal functioning (Criterion B). The cross-dressing may involve only one or two articles of clothing (e.g., for men, it may pertain only to women’s undergarments), or it may involve dressing completely in the inner and outer garments of the other sex and (in men) may include the use of women’s wigs and make-up. Transvestic disorder is nearly exclusively reported in males. Sexual arousal, in its most obvious form of penile erection, may co-occur with cross-dressing in various ways. In younger males, cross-dressing often leads to masturbation, following which any female clothing is removed. Older males often learn to avoid masturbating or doing anything to stimulate the penis so that the avoidance of ejaculation allows them to prolong their cross-dressing session. Males with female part- ners sometimes complete a cross-dressing session by having intercourse with their part- ners, and some have difficulty maintaining a sufficient erection for intercourse without cross-dressing (or private fantasies of cross-dressing).
Clinical assessment of distress or impairment, like clinical assessment of transvestic sexual arousal, is usually dependent on the individual’s self—report. The pattern of behav- ior "purging and acquisition” often signifies the presence of distress in individuals with transvestic disorder. During this behavioral pattern, an individual (usually a man) who has spent a great deal of money on women’s clothes and other apparel (e.g., shoes, wigs) discards the items (i.e., purges them) in an effort to overcome urges to cross-dress, and then begins acquiring a woman’s wardrobe all over again.