Taken from

Abnormal Psychology and Modern Life (11th Edition)
by Robert C. Carson, James Neal Butcher, Susan Mineka

Transvestic Fetishism

The achievement of sexual arousal and satisfaction by "cross-dressing" -that is, dressing as a member of the opposite sex - is called transvestic fetishism. Typically, the onset of transvestism is during adolescence and involves masturbation while wearing female clothing or undergarments. Blanchard (1989, 1992) has termed the psychological motivation of transvestites autogynephilia: paraphilic sexual arousal by the thought or fantasy of being women (Blanchard 1991, 1993). The great sexologist Magnus Hirschfeld first identified a class of cross-dressing men who are sexually aroused by the image of themselves as women: "They feel attracted not by the women outside them, but by the woman inside them" (Hirschfeld, 1948, p.167). A1though some gay men dress "in drag" on occasion, they do not typically do this for sexual pleasure and hence are not transvestic fetishists. The vast majority of transvestites are heterosexual (Talamini, 1982). Transvestites may fuse the idea of being a woman with their sexual attractions toward real women in fantasies in which they are engaging in lesbian interactions (Blanchard, 1991). Buckner (1970) formulated a
description of the "ordinary' male transvestite from a survey of 262 transvestites conducted by the magazine Transvestia:[He is probably married (about two-thirds are); if he is married he probably has children (about two-thirds do). Almost all of these transvestites said they were exclusively heterosexual - in fact, the rate of "homosexuality" was less than the average for the entire population. The transvestic behavior generally consists of privately dressing clothes of a woman, at home, in secret . . . The transvestite generally does not run into trouble with the law. His cross-dressing causes difficulties for very few people besides himself and his wife.] (p. 381) This clinical picture has not changed since Buckner's report; nor,
unfortunately, has the state of knowledge about etiology, about which very little is known (Zucker & Blanchard, 1997). The following is a fairly
typical case of transvestic fetishism and illustrates both the typical early onset of transvestic fetishism and the difficulties the condition may raise
in a marriage:

Case Study, A Transvestite's Dilemma

Mr. A., a 65- year-old security guard, formerly a fishing-boat captain, is distressed about his wife's objections to his wearing a nightgown at home in
the evening, now that his youngest child has left home. His appearance and demeanor, except when he is dressing in women's clothes, are always appropriately masculine, and he is exclusively heterosexual. Occasionally, over the past five years, he has worn an inconspicuous item of female clothing even when dressed as a man, sometimes a pair of panties, sometimes an ambiguous pinkie ring. He always carries a photograph of himself dressed as a woman. His first recollection of an interest in female clothing was putting on his sister's bloomers at age 12, an act accompanied by sexual excitement. He continued periodically to put on underpants - an activity that invariably resulted in an erection, sometimes a spontaneous emission, sometimes masturbation, but never accompanied by fantasy. Although he occasionally wished to be a girl, he never fantasized himself as one. He was competitive and aggressive with other boys and always acted "masculine." During his single years he was always attracted to girls, but was shy about sex. Following his marriage at age 22, he had his first heterosexual intercourse.

His involvement with female clothes was of the same intensity even after his marriage. Beginning at age 45, after a chance exposure to a magazine called Transvestia, he began to increase his cross-dressing activity. He learned there were other men like himself, and he became more and more preoccupied with female clothing in fantasy and progressed to periodically dressing completely as a woman. More recently he has become involved in a transvestite network, writing to other transvestites contacted through the magazine and occasionally attending transvestite parties. Cross-dressing at these parties has been the only time that he has cross-dressed outside his home.

Although still committed to his marriage, sex with his wife has dwindled over the past 20 years as his waking thoughts and activities have become
increasingly centered on cross-dressing. Over time this activity has become less eroticized and more an end in itself, but it still is a source of some
sexual excitement. He always has an increased urge to dress as a woman when under stress; it has a tranquilizing effect. If particular circumstances
prevent him from cross-dressing, he feels extremely frustrated. Because of disruptions in his early life, the patient has al ways treasured the steadfastness of his wife and the order of his home. He told his wife about his cross-dressing practice when they were married, and she was accepting so long as he kept it to himself. Nevertheless, he felt guilty, particularly after he began complete cross-dressing, and periodically he
attempted to renounce the practice, throwing out all his female clothes and makeup. His children served as a barrier to his giving free rein to his
impulses. Following his retirement from fishing, and in the absence of his children, he finds himself more drawn to cross-dressing, more in conflict
with his wife, and more depressed. (Spitzer et al., 1994) 

As we have indicated, transvestic fetishism may complicate a relationship. However, like other kinds of fetishism, it causes overt harm to others only
when accompanied by such illegal acts as theft or destruction of property. This is not always the case with the other paraphilias, many of which do
contain a definite element of injury or significant risk of injury - physical or psychological - to one or more of the parties involved in a sexual encounter.


Transsexualism 

Transsexuals are adults with gender identity disorder. Many, perhaps most, transsexuals desire to change their sex, and surgical advances have made this goal partially feasible, although expensive. Transsexualism is apparently a very rare disorder. European studies suggest that approximately 1 per 30,000 adult males and 1 per 100,000 adult females seek sex reassignment surgery. Until recently, most researchers assumed that transsexualism was the adult version of childhood gender identity disorder, and indeed this is often the case. That is, many transsexuals had gender identity disorder as children (despite the fact that most children with gender identity disorder do not become transsexual), and their adult
behavior is analogous. This appears to be the case for all female-to-male transsexuals (i.e., individuals born female who become male). Virtually all
such individuals recall being extremely  tomboyish, with masculinity persisting unabated until adulthood. Most, but not all, female-to-male transsexuals are sexually attracted to women. One female-to-male transsexual had these recollections:[I have felt different as far as I can remember. Three years old. I remember wanting to be a boy. Wearing boy's clothes and wanting to do all the things boys do. I remember my mother as I was growing up saying, "Are you ever going to be a lady? Are you ever going to wear women's clothing?" These kind of things as far back as I can remember. I can remember as I got a little older always looking at women, always wanting a woman. . . I feel like a man, and I feel like my loving a woman is perfectly normal.] (Green, 1992,p. 102)

In contrast to female-to-male transsexuals, there are two kinds of male-to-female transsexuals, with very different causes and developmental
courses: homosexual and autogynephilic transsexuals (Blanchard, 1989). Homosexual transsexuals might be conceptualized as extremely feminine gay men who also wish to change their sex. In contrast, autogynephilic transsexuals appear to have a paraphilia in which their attraction is to the
image of themselves as a woman. This distinction is not currently made in the DSM. Although it may not be relevant for treatment purposes (both types of transsexuals are appropriate for sex reassignment surgery), it is fundamental for understanding the diverse psychology of male-to-female
transsexualism. A homosexual male-to-female transsexual is a genetic male who describes himself as a woman trapped in a man's body and who is sexually attracted to men. Such men seek a sex change operation in part so that as women they will have the ability to attract heterosexual male partners (Freund al., 1974). Although homosexual transsexuals are attracted to members of their own genetic sex, they resent being labeled gay because they do not feel that they belong to their genetic sex (Adams & McAnulty, 1993). Nevertheless, from an etiological standpoint homosexual transsexualism probably overlaps with ordinary homosexuality. What in rare cases causes gay
men extremely feminine to want to change their sex is not yet well
understood.

Homosexual transsexuals generally have gender identity disorder from childhood. One adult homosexual male-to-female transsexual recalled the
following: [I used to like to play with girls. I never did like to play with boys. I wanted to play jacks. I wanted to jump rope and all those things. The lady
in the schoolyard used to always tell me to go play with the boys. I found it distasteful. I wanted to play with the girls. I wanted to play the girl
games. I remember one day the teacher said, "If you play with the girls one more day, I am going to bring a dress to school and make you wear it all day long. How would you like that?" Well, I would have liked it.] (Green, 1992, p. 101

Because most children with gender identity disorder do not become transsexual adults (but instead become gay men), there must be other
important determinants of transsexualism. One study of men found that being raised in a religious Catholic family where homosexuality was condemned, coupled with cross gender behavior in boyhood, was related to transsexual rather than homosexual outcomes (Hellman et al., 8l). These investigators suggested that for these men, transsexualism was a way of being sexually involved with males while still avoiding homosexuality per se. If this is true, then homosexual transsexualism should become rarer as homosexuality becomes less stigmatized. The difference between homosexual sexualism and cross-gendered homosexuality (that is, homosexuality accompanied by behavior typical of the opposite sex) is probably more in degree than in kind. The 1990 documentary film Paris is Burning depicts gay African-American men who devote a considerable amount of time, money, and energy trying to look like beautiful women. One of the men in that film describes how he had considered but decided against a sex-change operation. Another man intends to obtain the operation when he can afford it. Although probably only the second of these two men would merit the diagnosis of transsexualism, they are clearly very similar.

Autogynephilic transsexualism (Blanchard, 1989, 1992) appears to occur only in genetic males, and its primary clinical feature is autogynephilia-a
paraphilia characterized by sexual arousal at the thought or fantasy of being a woman (Blanchard, 1991; 1993). Indeed, autogynephilic transsexuals usually report a history of transvestic fetishism, although it is not uncommon for them to deny such a history. Reasons for such denial include shame at the idea of having a "perversion' and the fact that in the past, men with transvestism could not obtain sex reassignment surgery. Some autogynephilic transsexuals may genuinely never have engaged in transvestism per se, but in most of these cases, there is other evidence for autogynephilia. For example, unlike other transvestites, autogynephilic transsexuals fantasize that they have female genitalia. Perhaps because of this fantasy, their gender dysphoria is especially acute, motivating their desire for sex reassignment surgery. Autogynephilic transsexuals may report sexual attraction either to women, both men and women, or to neither. Research has shown that these subtypes of autogynephilic transsexuals are very similar to each other and differ from homosexual transsexuals in important respects beyond their sexual orientations (R. Blanchard, 1985, 1989, 1991). Unlike homosexual transsexuals, autogynephilic transsexuals do not appear to have been especially feminine in childhood or adulthood. Autogynephilic transsexuals typically seek sex-reassignment surgery much later than homosexual transsexuals (R. Blanchard, 1994). The causes of autogynephilic transsexualism probably overlap etiologically with the causes of other paraphilias but as of yet are not well understood.

Treatment

Psychotherapy is usually not helpful in aiding transsexuals resolve their gender dysphoria (Tollison & Adams, 1979). The only treatment that has been
shown to be effective is surgical sex reassignment. Initially, transsexuals awaiting surgery are given hormone treatment. Biological men are given
estrogens to facilitate breast growth, skin softening, and shrinking of muscles. Biological women are given testosterone, which suppresses
menstruation, increases facial and body hair, and deepens the voice Typically, transsexuals must live for a lengthy period of many months with
hormonal therapy, and they generally must live for at least a year as the gender they wish to become. If they successfully complete the trial period,
they undergo surgery and continue to take hormones indefinitely. In male-to-female transsexuals, this entails removal of the penis and testes
and the creation of an artificial vagina. Moreover, they must undergo extensive electrolysis to remove their beards and body hair. They also have
to learn to raise the pitch of their voice. Female-to-male transsexuals typically are given mastectomies and hysterectomies and often other plastic
surgery to alter various facial features (such as the Adam's apple). Because relevant surgical techniques are still rather primitive and very
expensive, only a subset of female-to-male transsexuals seek an artificial penis (which is not capable of normal erection and so they must rely on
artificial supports to have intercourse anyway); the rest function sexually without a penis. As surgical techniques advance, this will very likely
change. A review of the outcome literature found that 87 percent of 220 male-to-female transsexuals had satisfactory outcomes (meaning that they did not regret their decisions), and that 97 percent of 130 female-to-male transsexuals had successful outcomes (Green & Fleming, 1990). Blanchard (1985) also reported that the majority of transsexuals are satisfied with the outcome of sex reassignment surgery, although there is variability in the degree of satisfaction. In general, those who were reasonably well adjusted before surgery do better following surgery, and those with pre-existing psychopathology are less likely to do well. In spite of the reasonably good success record for transsexual patients who are carefully
chosen, such surgery remains controversial because some professionals continue to maintain that it is inappropriate to treat psychological
disorders through drastic anatomical changes.