Transvestic fetishism

Transvestism, also known as paraphilic transvestism, transvestic fetishism, heterosexual transvestism, or erotic crossdressing, among other synonyms, is a paraphilia in which a person, generally a heterosexual male, experiences sexual arousal and enjoyment with crossdressing as the opposite sex.^{[1][10][3][4]} Men with transvestism experience pleasurable feelings with crossdressing and often also view themselves in the mirror and masturbate and orgasm when they crossdress.^{[1][3][11][12]} They usually crossdress episodically, for instance once a week in most individuals.^[1] Although typically done privately and in secret at least at first, some progress to crossdressing in public or crossdressing all the time.^[1][3][13] When excessive or problematic, for instance causing distress or impairment, transvestism is defined as a mental disorder and can be diagnosed as transvestic disorder.^[1][2]

Transvestism is a paraphilia.^[1] Two distinct and often difficult-to-distinguish subtypes of transvestism exist: one involving fetishism (sexual arousal with certain items of female clothing) and the other involving autogynephilia (sexual arousal with the thought or image of being female).^[1][5][2] These two types often occur together and seem to be closely related.^[1][12][5] They are both erotic target location errors, and when transvestism is related to autogynephilia, it is additionally defined as an erotic target identity inversion.^[12][14][15] Most cases of transvestism involve autogynephilia.^[1][5][2] Transvestism often co-occurs with other paraphilias, for instance fetishism and sadomasochism.^[1][2] It can also sometimes be associated with gender dysphoria and can evolve into being transgender and transitioning.^{[1][12][13][2]} While various theories exist, the causes of transvestism are unknown.^[1][3] The onset of transvestism is usually in childhood or adolescence.^[1][2][16]

Data and information on treatment of transvestism are very limited and treatment of the condition is not necessarily indicated.^[1][3] In any case, management strategies can include psychotherapy and certain kinds of medications to reduce sex drive.^[3][8][9][4] These medications can include serotonergic antidepressants, dopamine antagonists, and antiandrogens, among others.^[3][8][9][4] Medications for transvestism can have side effects and risks.^[8][9][3] Transvestism is thought to be unchangeable, analogously to normal sexual orientations, and is considered to be a chronic and lifelong disposition.^[1][12] The condition can result in sexual, relationship, familial, and occupational difficulties.^[1][2]

Transvestism has been observed and documented since ancient times.^[3] The term transvestism was coined by German sexologist Magnus Hirschfeld in 1910.^{[17][3][18][19]} The concept of autogynephilia, which is believed to underlie most cases of transvestism, was introduced in 1989 by Canadian sexologist Ray Blanchard.^[1][17][2] It is thought that around 2 to 3% of men have transvestism.^[1][12][20] Transvestism, and paraphilias in general, are rare in women, although cases of transvestism in women have been reported.^{[1][14][12][2][21][22]} Rare cases of homeovestism (sexual arousal to wearing same-sex clothing) in gay men have also been reported.^[14][12][11] A subculture surrounding transvestism has existed for many decades, for instance the crossdressing magazine Transvestia and the crossdressing organization Tri-Ess (Society for the Second Self).^[13][23] A number of famous individuals with transvestism or heterosexual crossdressing are known, such as Virginia Prince and Louise Lawrence.^{[24][25][13][26][27]} Many crossdressers would identify or be referred to as (non-transitioning) transgender today.^{[28][29][27][30][31]}

Signs, symptoms, and characteristics

Men with transvestism experience sexual arousal and enjoyment from crossdressing and have desires or urges to crossdress.^[1][32][2] They report that crossdressing results not only in sexual excitement, but also feelings of well-being, calm, comfort, relaxation, thrill, coziness, and ease.^{[33][1][3][11]} Feelings of sensuality, elegance, and beauty are also reported.^[34] Adolescent and adult males with transvestism crossdress in a number of different ways.^[1] They wear female clothes episodically and/or masturbate, they sometimes wear female clothes, such as undergarments, under their male clothes, and they often crossdress more fully when they are able to do so.^[1][2] Men with transvestism may crossdress with only one or two items of female clothing, for instance undergarments, or crossdress with complete female outfits.^[2] They can also use wigs, makeup, and accessories in addition to clothes to more fully simulate the appearance of being a woman.^[34][33][2] In one study, 83% of men with transvestism crossdressed at least once a week.^[1][35]

Most males with transvestism started crossdressing in private and secret.^[1] The clothes they wore usually belonged to a female relative.^[1] Female undergarments were frequently the first types of clothes that were worn.^[1] Prior to puberty, crossdressing is not necessarily experienced as sexual or sexually arousing but as exciting and pleasurable in a more generalized way.^[1][3][2] It often starts as strong fascination with a certain item of women's clothing or with women's clothing in general.^[3][2] After the onset of puberty, crossdressing usually results in sexual arousal and often leads to masturbation and orgasm.^[1][3][2] With puberty, crossdressing may result in the first ejaculation in some cases.^[2] In a large survey of men with transvestism, crossdressing resulted in sexual excitement and orgasm nearly always in 21%, often in 19%, occasionally in 32%, rarely in 12%, and never in 9%.^[16] However, most men with transvestism still enjoy crossdressing when masturbation is not possible.^[16] Some may avoid masturbation to prolong crossdressing sessions and positive feelings.^[3][2] Following orgasm, men with transvestism often temporarily lose their desire to crossdress.^[1] There is frequently a strong desire to remove the clothing following orgasm.^[7] Feelings of disgust and revulsion with respect to their crossdressing may occur at this time.^[1] Men with transvestism will often progress to crossdressing in public.^[11][13] In large surveys, 71% had crossdressed in public, 8 to 14% frequently crossdressed in public, 23 to 48% did so occasionally, and 38 to 69% did so rarely.^[16] In one study, 21% had progressed to crossdressing in public prior to 20 years of age and most had been crossdressing for at least several years.^[11][13] A small number of men with transvestism may progress to wearing female clothes full-time or for extended intervals.^[13][13]

Transvestism usually onsets during childhood before puberty.^[1][2] There are case reports of boys as young as 2 years old who have desired to wear female clothes and have developed penile erections upon doing so.^[1] In large surveys of American men with transvestism, 54 to 66% reported starting crossdressing before age 10, 29 to 37% between the age of 10 to 20, and 5 to 8% after the age of 20.^[1][16] In other smaller studies of crossdressing men, about 50% have reported crossdressing before age 7, a majority before age 9, and almost all before age 13.^[1] Their first episodes of crossdressing were usually undertaken by their own initiative, whereas less commonly they were undertaken at the suggestion of female relatives or caregivers.^[1] The peak of transvestic interests, behavior, and sexual arousal occurs during early adulthood.^[3][2] The severity of pathological transvestism is greatest in adulthood, when the disposition conflicts with other-directed sexuoromantic relations and with desires to marry and/or start a family.^[2]

Men with transvestism frequently report that the sexual arousal with crossdressing gradually decreases in intensity and frequency with time and older age.^{[1][3][13][2]} The initially intense sexual excitement is said to be replaced only by feelings of comfort, well-being, and relaxation.^[3][11][2] Some men with transvestism report that the sexual arousal eventually goes away completely.^[1][3][2] However, sexual arousal can often still be measured in men with transvestism who deny sexual arousal using clinical phallometry.^[1][15][36] Despite sexual arousal diminishing with time, the desire to crossdress often remains the same or becomes even stronger.^[2] Sexual arousal with crossdressing is often experienced as unacceptable, unwanted, ego-dystonic, and/or bothersome in men with transvestism.^{[12][3][37][4][34]} Men with transvestism very often downplay or deny experiencing sexual arousal with crossdressing, likely due to shame and desire to look better socially.^{[38][12][15][34]} In one study, more than half of individuals reporting sexual arousal with crossdressing found this to be unacceptable for themselves.^[1][37] Oftentimes men with transvestism downplay eroticism as a motive for crossdressing and instead assert that it is a way to express the feminine sides of their personalities or identities (i.e., the "girl within").^[12][13]

Men with transvestism usually have one or more full female outfits.^[1] Some men with transvestism can have more than 20 full female outfits.^[34] The average time to owning a full female outfit after starting crossdressing was 15 years in one study.^[11][13] Men with transvestism tend to prefer clothing styles worn by younger women, that are sexually provocative, or that were in fashion during their own youth.^[1][33] Examples include lingerie/bras and panties, sleepwear, short skirts and dresses, low-cut blouses, girdles, garter belts, nylon stockings/pantyhose, and high heels.^[33] Many can take 1 to 2 hours to crossdress and apply makeup during a session.^[34] Men with transvestism will often attempt to abandon crossdressing and will purge their collections of female clothing.^[1][34][2] As many as 60 to 80% of men with transvestism report having purged their clothes.^[34][16] Attempts at ceasing crossdressing are generally unsuccessful, and these men will eventually obtain new female clothing and start crossdressing again.^[1][2] Reports of shame and guilt related to crossdressing are significant, with a rate of 22% in one study, yet most do not wish to stop crossdressing, with a rate of only 1% in the same study.^[34] Cycles of purging and reacquisition of women's clothing is often a signal of clinically significant distress.^[2]

Crossdressing in men with transvestism may be precipitated by psychological tension, stress, or boredom, and may be used to help improve feelings of depression and anxiety.^[1][5][4] In this way, crossdressing may be viewed as a coping strategy.^[4] It is plausible that some non-paraphilic individuals may use regular sex in similar ways.^[1] Episodes of crossdressing can also be triggered by seeing preferred women's clothing.^[35]

In large studies, 80 to 83% of women whose husbands had transvestism were aware of it, although only 27 to 32% knew before marriage.^[3][4][16] Attitudes towards their husband's transvestism varied, with "completely antagonistic" in 19 to 20%, "mixed view" in 47 to 57%, and "completely accepting" in 23 to 28%.^[3][4][16] Wives may complain that the solitary sexual satisfaction of their crossdressing husbands can be detrimental to their marital sexual fulfillment.^[4][16][2] This can lead to relationship difficulties.^[2] Men with transvestism who have accepting female partners will sometimes have sexual intercourse with their partners while crossdressed.^[1][2] In one study, rates of sex with women while crossdressed ranged from 36 to 62%.^[35] Some men may have difficulties sustaining an erection during sex with a woman unless crossdressed.^[3][2] Sometimes men with transvestism fantasize that they are in a lesbian relationship with their female partners.^[1] When men with transvestism fall in love and enter relationships with new female partners, their desire to crossdress sometimes temporarily diminishes or disappears, though it eventually returns later.^{[1][15][39][2]}

Men with transvestism often develop cross-gender feelings and identities.^{[1][15][13][16][40]} They often develop gender-related self-representations that are multifaceted or consist of multiple coexisting selves; that is, both masculine and feminine sides.^[15][13] Most men with transvestism report experiencing a partial, preferential, or even complete cross-gender female identity, especially when crossdressed.^[1][41] In large surveys, 69 to 74% felt like they were a "man with a feminine side" and 12 to 17% felt like a "woman trapped in a man's body", whereas 9 to 12% attributed their crossdressing merely to "fetishism".^[20][16][40] Additionally, 28 to 56% reported preferring their feminine self and 12 to 60% equally preferred their masculine and feminine selves, whereas 11 to 29% preferred their masculine self.^[41][16][40] Men with transvestism sometimes adopt a feminine name for their feminine selves or for when they are crossdressed.^[11][13] There is indication of considerable time being required for development of cross-gender identity in men with transvestism.^[11][38] In one study, adoption of a feminine name happened after an average of 21 years of crossdressing.^[11][13] In addition to crossdressing, many men with transvestism are interested in physical feminization and use or express a desire to use feminizing hormone therapy.^[1][12][7] In large surveys, 9 to 25% of men with transvestism were currently on hormone therapy or had previously taken hormone therapy and 43 to 50% wanted to use hormone therapy in the future, whereas 41 to 48% were not interested in taking hormones.^{[1][12][41][16]} Besides cross-gender feelings and identification, transvestism can sometimes progress to gender dysphoria and more substantial gender transition.^{[1][38][41][2]}

In terms of behavioral traits, men with transvestism rarely describe themselves as having been feminine in childhood or adolescence and few report having been called "sissies".^[1][2] They generally have male-typical hobbies and interests, engage in rough-and-tumble play, participate in sports, and prefer boys rather than girls as friends.^[1] Many of them have however reported envying girls.^[1] In adulthood, men with transvestism are typically unremarkably masculine when not crossdressed.^[4][13] However, 78% of men with transvestism have self-described themselves as having "marked femininity".^[13] Men with transvestism are usually heterosexual and report sexual attraction to women.^[4][14] In large surveys, 86 to 89% identified as heterosexual and sexual interest in women was average or above average in 74 to 86%.^{[41][3][13][40][16][37]} Conversely, 7 to 9% identified as bisexual and 1% identified as homosexual, while 1 to 5% identified as asexual.^[16] In a survey of almost 2,500 Swedish adults, there were no instances of main or exclusive focus on men with respect to sexual attraction or intercourse.^[37]

Although most men with transvestism identify as heterosexual, a subset of men with the disposition occasionally engage in sexual activity with other men while crossdressed or fantasize about doing so.^{[1][11][39][7][4]} In large studies, 17 to 32% of men with transvestism reported homosexual experiences or engaging in sex with men while crossdressed, despite only 8 to 10% identifying as bisexual or homosexual.^{[11][35][13][16][40][37]} Men with transvestism who have same-sex sexual experiences are grouped under the umbrella term "men who have sex with men" (MSM) and are at increased risk for sexually transmitted infections from unprotected anal sex such as the human immunodeficiency virus (HIV).^[42][43]

In terms of demographic features, men with transvestism resemble other men in most respects.^[1] This includes number of siblings, number of children, relationship rates, socioeconomic status, and overall life satisfaction, all of which have been unremarkably different from those of other men.^[1] In one study, 78% were currently married or had been married.^[13][40] However, men with transvestism have been found to be more likely to report separation from parents in childhood, be easily sexually aroused, masturbate and use pornography more often, and have same-sex sexual experiences.^[1][3] Higher education levels and professional and technical occupations appear to be overrepresented in men with transvestism.^[1]

Many men with transvestism enjoy forced feminization, fantasy scenarios or narratives in which a person is forced to undergo feminization, for example being forced to wear feminine clothes or develop feminine physical characteristics.^[1][13] Forced feminization is often encountered in fiction written by and for men with transvestism.^[1][13] Other themes include being transformed into a woman full-time, having reasons that justify a need to become a beautiful or seductive female, and engaging in sexual or romantic relationships with lesbians and men.^[13] Such themes provide insight into what men with transvestism find most rewarding and erotic.^[13]

Transvestism differs from certain other paraphilias in that there is a lack of harm, a lack of dysfunction, and a relative acceptance of the disposition.^[4]

Classification

Transvestism can be divided into two subtypes, with fetishism (sexually aroused by "fabrics, materials, or garments") and with autogynephilia (sexually aroused by "thoughts or images of self as female").^[1][5][2] In those with fetishism, for instance for bras and panties, the interest and focus is on specific articles of feminine clothing themselves and the properties of those items, although the items may still be worn.^{[1][5][12][2]} Conversely, in those with autogynephilia, the key aim is in becoming a woman or simulating the appearance of a woman, with the clothing merely acting as an aid to this fantasy.^{[1][38][12][33][5][2]} Transvestism can also occur with both fetishism and autogynephilia simultaneously, and this is in fact the case for roughly half of men with transvestism.^[1] In a study of men with transvestism, 11% acknowledged fetishism but denied autogynephilia, 32% acknowledged autogynephilia but denied fetishism, 49% acknowledged both fetishism and autogynephilia, and 7% denied both.^[1][5] Hence, in terms of total rates in this study, 81% acknowledged autogynephilia and 60% acknowledged fetishism, while 7% acknowledged neither.^[1][5] In other studies, 33 to 59% of fetishists also had transvestism and 20 to 78% of those with transvestism also had fetishism.^[12] Fetishists who use female clothes in a fetishistic way but are not genuinely transvestic have sometimes been referred to as "pseudo-transvestites" or "pseudo-crossdressers".^[12]

Fetishism is an erotic target location error similarly to transvestism.^[12][44] Fetishism and transvestism are thought to be closely related and present together on an etiological continuum.^[1][12] In fetishism, among the most common fetish objects are extensions of the human body, such as items of women's clothing or footwear.^[12] Others common fetish objects include specific female body parts, like breasts, and objects of a particular texture or special material, like rubber, plastic, or leather.^[12] It has been noted that the latter fetish objects tend to have a texture similar to that of human skin.^[12] In one study of male fetishists, the most frequent fetish objects were clothing (58%), rubber items (23%), footwear (15%), and body parts (15%).^[12] Fetishists treat their fetish objects much the same way they would treat human sexual partners.^[12] As examples, fetishists seek close physical contact with their fetish objects by wearing them or lying on them, gaze at them, fondle them, rub themselves against them, suck on them, and insert them into body cavities.^[12] Some men with transvestism who also have fetishism may be inclined to damage or destroy their clothes after use, for instance cutting them, burning them, or ripping them up.^[12][5] Paraphilias tend to cluster, and this may be a manifestation of co-occurring sexual sadism towards their fetishistic objects (and hence sexuoromantic targets) in some individuals.^[12] Kurt Freund compared men with transvestism with men with fetishism proper and found that the two groups did not differ in their fetishistic interests or their responses to preferred fetishistic stimuli.^[12][45][46] He concluded that men with transvestism are truly fetishistic and that men with transvestism and fetishists proper are difficult to distinguish.^[45][12][46]

Crossdressing in men with transvestism is usually, though not always, accompanied by the fantasy of being female; that is, with autogynephilia.^[1][2] It is thought that autogynephilia is the motivation for crossdressing in these men and that autogynephilia underlies most cases of transvestism.^[14][1][11] The women's clothes used are sexually arousing primarily as symbols of one's femininity rather necessarily than as specific fetishes.^[4] Transvestism is the most common manifestation of autogynephilia.^[14][11][47] This is likely related to the fact that crossdressing is an easy, temporary, and inexpensive means of making oneself look more like a woman.^[14] Some men with transvestism additionally fantasize about having female physical features, for instance breasts or a vagina, which is termed anatomic autogynephilia.^[14][11][2] Men with transvestism sometimes have other types of autogynephilia as well, such as behavioral autogynephilia and physiological autogynephilia.^[11][2] It is thought, however, that transvestic autogynephilia is the predominant type of autogynephilia in men with transvestism.^[11] The desire of some men with transvestism for physical feminization via hormone therapy without undergoing sex reassignment surgery or living full-time as a woman has been referred to as partial autogynephilia.^[12][48][49] Aside from their obvious sexual or erotic component, autogynephilia and transvestism can also be conceptualized as encompassing feelings and elements of romantic love, such as desire for closeness and bonding, much the same as normal other-directed sexual orientations like gynephilia (attraction to females).^[41][20][39]

Sex with men in men with transvestism is theorized not to be due to true or genuine androphilia (as in homosexuality or bisexuality), but instead to be a manifestation of behavioral autogynephilia and by extension of pseudoandrophilia or autogynephilic interpersonal fantasy—that is, fulfilling the autogynephilic sexual fantasy of having sex as a woman with a man.^{[11][38][39][47][50][51]} In people with autogynephilia, attraction to men is frequently limited or absent despite sexual interest in men, and sex with men is often arousing in fantasy but experienced as unappealing in practice.^[52] In terms of relations with women, the phenomenon of temporarily diminished interest in transvestism when entering relationships with new female partners is believed to relate to the fact that autogynephilia and alloerotic (other-focused) gynephilia appear to compete in men with transvestism.^[15][39]

A further two-type categorization of men with transvestism based on frequency and intensity has been proposed by Neil Buhrich and Neil McConaghy, and this categorization has been widely adopted.^[1][13] The categories are nuclear crossdressers and marginal crossdressers.^[1][13] Nuclear crossdressers crossdress episodically and do not seek physical feminization, whereas marginal crossdressers crossdress more extensively and either desire or undergo physical feminization with hormone therapy or surgery.^[1][13] Nuclear crossdressers are described as psychologically satisfied with their gender and sexual identity as males, whereas marginal crossdressers are not.^[3][13] Nuclear crossdressers crossdress less frequently, crossdress completely at a later age, and are less likely to crossdress in public compared to marginal crossdressers.^[1][13] They also report less childhood feminine behaviors, earlier and more sexual activity with female partners, and are taller and higher in social status than marginal crossdressers.^[1][13] It has been suggested that these differences may represent a selection effect, wherein marginal crossdressers go further in their efforts based on how convincingly they believe they could pass as female and the amount of social status they could lose if they became noticeably feminized.^[1]

Comorbidity

Paraphilias tend to co-occur or cluster, and transvestism is often comorbid with one or more other paraphilias.^{[1][38][12][41][2]} More than 100 different paraphilias have been described in the literature.^{[53][54][55][56][57][58]} Transvestism has been found to be strongly associated with other paraphilias, like fetishism, sadomasochism, exhibitionism, and voyeurism.^[3][41] In studies, co-occurring fetishism has been reported in 55 to 59%, sadomasochism in 14 to 35%, voyeurism in 33%, frotteurism in 28%, toucherism in 22%, exhibitionism in 17 to 36%, sexual contact with prepubertal girls (not necessarily due to pedophilia) in 11 to 20%, and rape (not necessarily due to biastophilia) in 6%.^{[1][12][13][37]} Other co-occurring paraphilias have included gynandromorphophilia, zoophilia, obscene phone calling, and autoerotic asphyxiation, among others.^{[12][4][13][59][39][2][60]} Transvestism has also been reported to co-occur with other erotic target location errors and identity inversions, such as pedovestism, autopedophilia, and apotemnophilia.^{[12][1][15][61][14]} In one study, about half of the men with transvestism had one or more co-occurring paraphilias.^[1] Some of these comorbid paraphilias may involve behavior that is potentially illegal.^[1] Aside from other paraphilias, transvestism has also been associated with hypersexuality.^[3]

Information about comorbid psychiatric disorders in men with transvestism is limited and conflicting.^[1] One study found that men with transvestism were no more likely to report a current psychiatric disorder than other men and their mental health ratings were similar.^[1] There was however a non-significant trend toward a higher degree of illicit drug use (though not necessarily indicating substance abuse).^[1] In a study of men with transvestism from clinical samples, personality and sexual functioning scores were unremarkable, but neuroticism was elevated.^[1] In another study, one of men with transvestism who had not sought treatment for their condition, elevated rates of depression and alcohol dependence were observed.^[1] In addition to psychiatric disorders, paraphilias, including transvestism, have been reported at higher-than-expected rates in people with autistic spectrum disorders in a number of studies, suggesting a potential association with autistic characteristics as well.^[62][63][64]

Most men with transvestism develop some form of cross-gender feelings and identification, for instance dual masculine and feminine selves or more extensive feminine identity, analogously to the cross-gender identities in transgender people.^{[1][38][15][13][16][40]} Moreover, transvestism can sometimes progress to feelings of gender dysphoria, full gender transition, and transgender identity.^{[1][38][41][2]} Distinguishing between isolated transvestism and transvestism with gender dysphoria can be difficult, and the diagnoses of transvestism and gender dysphoria are not mutually exclusive.^[1][2] When both are present, both diagnoses should be given.^[2] It is difficult to predict which men with transvestism will progress to gender dysphoria.^[2] Oftentimes such men are indistinguishable in childhood or adolescence from other men with transvestism.^[2] Middle-aged and older men with transvestism are more likely to present with gender dysphoria.^[2] The presence of autogynephilia, especially anatomic autogynephilia (e.g., desire for breasts or a vagina),^[14][11] has been strongly positively associated with unwavering female identity, gender dysphoria, and desire for gender transition in men with transvestism, whereas the presence of fetishism has been negatively associated with gender dysphoria.^[5][65][2] Those that experience sexual arousal with crossdressing as unwanted or bothersome also show higher levels of gender dysphoria.^[4] In large surveys of men with transvestism, 14 to 17% said they would elect for sex reassignment surgery if it were possible, 34% would elect for sex reassignment surgery if they were younger,^[34][16] and 11% were presenting full-time as women.^[12][41] No definitive statistics are available, but it has been estimated, based on observations of men with transvestism who have participated in crossdressing clubs, that fewer than 5% ultimately progress to fully transitioning and being transgender or transsexual.^[13]

In addition to a small subset of men with transvestism progressing to transitioning and transgender identity, a number of other findings also link men with transvestism with a subset of transgender women.^[38][12][41] According to the DSM-5, late-onset gender dysphoria in adolescent and adult natal males is preceded by "transvestic behavior with sexual excitement" in many cases.^[66] In studies of transgender women, majorities of individuals report sexual arousal with crossdressing and/or cross-gender fantasy.^[39][38] This includes rates of 73 to 89% among non-androphilic transgender women and rates of 10 to 40% among transgender women who are androphilic (exclusively attracted to males).^[39][38] It has been theorized that non-androphilic transgender women are often miscategorized as androphilic and this accounts for the elevated rates in androphilic groups.^[38][11] In line with all of the preceding, many transgender women could also meet diagnostic criteria for transvestism, and many transgender women previously identified as crossdressers or transvestites.^[41][47][7] With hormonal transition and reduction of sex drive in transgender women, sexual arousal to crossdressing or cross-gender fantasy usually diminishes or disappears.^[39][38] Transvestism and gender dysphoria have also been reported to co-occur in families.^[14][67]

Although the notions that autogynephilia is a paraphilia and is the underlying motivation of most cases of transvestism in men are widely accepted and limitedly controversial, the situation is different in the case of transgender women.^{[1][38][2][6]} It has been said that no one denies the existence of autogynephilic arousal (i.e., sexual arousal with crossdressing or cross-gender fantasy) in transgender women or that some transgender women transition due to autogynephilia.^[38][11][68] However, the notion that autogynephilia serves as the motive for transitioning in all non-androphilic transgender women, as proposed by Ray Blanchard's etiological typology of transgender women and supporters like Anne Lawrence and J. Michael Bailey, is extremely controversial and heavily contested by many transgender women and academics.^{[38][69][70][71][68]} Critiques have been lobbied at this theory on a variety of grounds, and alternative theories of autogynephilic arousal have been proposed by some academics.^[70][71][68] Examples of such critiques and theories include those by Charles Allen Moser,^[68] Jaimie Veale and colleagues' identity–defense model of gender variance,^[72][73] and Julia Serano's embodiment fantasies model.^[70][71] In any case, some transgender women, as well as some non-transitioning autogynephiles, identify with the concept of autogynephilia and feel that it accurately describes their experiences.^{[39][38][69][74][75][73][76]} In a 2012 online survey of transgender women asked about Blanchard's typology and autogynephilia, 16% responded positively, 32% gave neutral responses, and 52% responded negatively.^[38][75] It is important for clinical professionals of transgender women to be aware of the highly controversial and potentially offensive nature of autogynephilia.^[41]

Causes

Transvestism is defined as a paraphilia; that is, as an atypical sexual propensity.^[1][41] It is considered to be a form of autogynephilia, to be an erotic target location error and erotic target identity inversion, and to be a self-directed form of male heterosexuality or gynephilia (sexual attraction to women).^[41][1][14] Transvestism has been defined as a paraphilia and/or paraphilic disorder in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization's International Classification of Diseases (ICD).^[1][41]

Various theories about the etiology of transvestism exist.^[3][1] Many theorists have proposed psychological origins, like behavioral and reinforcement theory (as in classical conditioning), familial and parental considerations and relationships, sexual abuse in childhood, and psychoanalytical explanations largely related to castration anxiety.^[3][12] Robert Stoller suggested that transvestism was often due to mothers or other female caregivers who forced their boys to crossdress in order to humiliate them or undermine their masculinity.^[1][12] Richard L. Schott theorized that transvestism might in part be due to an especially close mother–child relationship, together with an absent father and often no older brothers.^[1][12][77] These theories are contradicted by data and/or are no longer widely accepted.^[1] Behavioral theorists have proposed that the development of fetishism is due to classical conditioning, wherein an inanimate object is paired with the experience of sexual stimulation, and something similar may be happening in transvestism.^[12] Experimental studies have found that fetishism-like responses for women's boots can be conditioned and extinguished in a laboratory study, which lends a degree of support to this view.^[12][78][79]

Knowledge about possible biological causes of transvestism is lacking.^[3] Transvestism and related conditions like gender dysphoria have been reported to co-occur in families, which is consistent with potential genetic predisposition to transvestism, but this has not been clearly demonstrated.^[1][12] High co-occurrence of transvestism in monozygotic and dizygotic twin pairs has been reported, but this could be either due to genetic or psychosocial influences.^[1] There have been case reports of transvestism with temporal lobe epilepsy and head injury.^[12]

Some academics, such as Charles Allen Moser, have denied that transvestism and autogynephilia are paraphilias or have dismissed the concept of paraphilias altogether.^{[41][68][80][81]} Additionally, some crossdressers and theorists have proposed alternative models in which disturbances in gender identity or gender variance primarily underlie transvestism and autogynephilia.^[12][72] Under this model, it is maintained that the associated erotic desires and behaviors in people with transvestism and autogynephilia are secondary to and a byproduct of gender variance.^[12][72] Moreover, some of these academics, such as Jaimie Veale and Julia Serano, have contended that people with gender variance related to transvestism and autogynephilia are on an etiological continuum with gender variance related to homosexual men and androphilic transgender women.^{[72][70][71][73]} However, alternative theories have difficulty explaining why transvestism and autogynephilia co-occur at high rates with other paraphilias, among other issues.^[47][38][41]

Consequent to inadequate studies and evidence, there is presently no scientific consensus about the etiology of transvestism, and no theoretical explanations for the condition have been widely accepted.^[1][6]

Diagnosis

When excessive or problematic, transvestism has been defined as a psychiatric diagnosis, including in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (as transvestic disorder) and the International Classification of Diseases, 10th Edition (ICD-10) (as fetishistic transvestism).^[1][2] The diagnosis can be given regardless of sex or sexual orientation.^[1] In the ICD-10, it can be given regardless of clinically significant distress or functional impairment, whereas in the DSM-5, significant distress or functional impairment is required.^[1] In the ICD-10, the diagnoses of transvestism and transsexualism are not mutually exclusive.^[1] There is no firm division between these diagnoses, and it is thought that there is a continuous spectrum of symptomatology between them.^[1][38]

The diagnostic criteria for transvestic disorder in the DSM-5 (2013) and DSM-5-TR (2022) are as follows:^[3][82][2]

Criterion A: Over a period of at least 6 months, recurrent and intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or behaviors.

Criterion 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: If sexually aroused by fabrics, materials, or garments.

With autogynephilia: If sexually aroused by thoughts or images of self as female.

Specify if:

In controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in voyeuristic behavior are restricted.

In full remission: [DSM-5-only: The individual has not acted on the urges with a nonconsenting person, and] [t]here has been no distress or impairment in social, occupational or other areas of functioning, for at least 5 years while in an uncontrolled environment.

Transvestism is diagnosed via thorough clinical interview and other psychological assessment methods.^[3][4] This focuses on crossdressing and its relationship with sexual arousal.^[3] Past personal history should also be reviewed.^[3] No specific diagnostic tests for transvestism exist.^[3] Physiological measures of sexual arousal such as phallometry may be useful in the evaluation of transvestism,^[4] although the usefulness in diagnosis has not been clearly established.^[3] The essential diagnostic features of transvestism are recurrent, intensely arousing sexual fantasies, urges, or behaviors involving crossdressing.^[1][2] The diagnosis is not warranted if transvestism is not accompanied by clinically significant distress or impairment.^[2]

Two subtypes of transvestism have been defined in the DSM-5, including with fetishism, when sexual arousal is to "fabrics, materials, or garments", and with autogynephilia, when sexual arousal is to "thoughts or images of self as female".^[1] It can be difficult to distinguish between transvestism and fetishism for items of women's clothing.^[1][12][5] The with autogynephilia specifier is only applied to males; the female analogue, autoandrophilia (sexual arousal and attraction to the thought of oneself as male), has been reported rarely and is thought to be less common.^[1][14] The autogynephilic and autoandrophilic subtypes are considered to be erotic target location errors, conditions in which a person is sexually attracted to oneself as the sex they are oriented towards.^[12][14] Ray Blanchard, who was chair of the DSM-5 paraphilias working group, said that he doesn't think autoandrophilia in women actually exists, and that if sexual arousal in women with crossdressing does exist, it's rare.^[83][5] He remarked that the diagnosis of transvestism allowing women to be diagnosed was simply to avoid accusations of sexism.^[83]

The ICD-10 diagnosis of fetishistic transvestism, as well as the ICD-10 diagnoses of sadomasochism, fetishism, and dual-role transvestism, were all removed in the ICD-11.^[84][65] This was towards the aim of depathologization.^[65] These conditions are consensual or solitary activities, do not inherently result in harm to oneself or others, and are not necessarily distressing or impairing.^[65] Hence, they were deemed to lack clinical relevance and public health significance.^[85][65] Instead of being defined as mental disorders, they may be more accurately viewed as variants in sexuality and/or gender expression.^[65] In any case, the new diagnostic category of "other paraphilic disorder involving solitary behaviour or consenting individuals" in the ICD-11 can be used instead of fetishistic transvestism if the condition is associated with marked distress or functional impairment.^[85][84] The distress should however not be exclusively based on rejection or fear of rejection by other people, in which psychotherapy is instead indicated.^[84]

Differential diagnoses for transvestism include simple fetishism for women's clothing and gender dysphoria or transgenderism.^[1] However, these diagnoses are not distinctly separated, and may be viewed as points on a continuous spectrum of symptomatology.^[1] Another differential diagnosis is dual-role transvestism, which is not a paraphilia and explicitly excludes sexual arousal.^[1][7] Dual-role transvestism involves crossdressing to temporarily experience membership of being the opposite sex but without sexual arousal or desire for gender transition.^[1] However, many men with transvestism may be misdiagnosed as having dual-role transvestism.^[1] This is because men with transvestism often deny experiencing sexual arousal with crossdressing, yet this arousal is frequently still detectable with phallometry.^[1][36] It has been stated that dual-role transvestism is rarely, if ever, actually applicable to non-homosexual males.^[39]

Changes over time

The formal diagnosis of transvestism has changed over time.^[3][5][6] Transvestism was included in the DSM-I (1952) under the diagnosis "sexual deviation", with "transvestism" as a type specifier,^[86][6] and then in the DSM-II (1968) under the category "sexual deviations", with the subdvision "transvetitism".^[87][6] Transvestism was included in the "Psychosexual Disorders" chapter of the DSM-III (1980) under the paraphilias category.^[88][6] As with other diagnoses in the DSM, this was the first time that the diagnosis of transvestism was thoroughly described or given explicit diagnostic criteria.^[88] Whereas the DSM-III used the term "transvestism", the DSM-III-R introduced the term "transvestic fetishism", but otherwise there was very little change in the diagnosis between these versions.^{[89][5][3][6]} The term "transvestic fetishism" was also used in the DSM-IV^[90][3] and the DSM-IV-TR.^[91] The name change was likely made to help disambiguate the term "transvestism", which had also been used to refer to crossdressing in homosexual men (drag queens) and had historically been used to refer to transsexuals (now transgender people).^[5][3]

The DSM-5 returned to using the term "transvestism" and also distinguished between transvestism and transvestic disorder, similarly to the case for other paraphilias.^[82][3] Transvestism is defined as a paraphilia, whereas transvestic disorder is defined as a paraphilic disorder (i.e., a paraphilia that is excessive and/or problematic and rises to the level of being a disorder). [...]^[5] However, one of the DSM-5 specifiers denotes whether transvestism occurs with fetishism.^[3] The previous term "transvestic fetishism" had been criticized as conflating two distinct paraphilias (transvestism and fetishism) and emphasizing one (fetishism) at the expense of the other (transvestism).^[5][3] The diagnosis of transvestism was largely unchanged in the DSM-5-TR compared to the DSM-5.^[2]

In the DSM-IV, transvestism was limited to heterosexual men, but this restriction was removed in the DSM-5 and the diagnosis was opened up to men and women with the disposition and regardless of sexual orientation.^[1] However, individuals with transvestism are almost always male and heterosexual.^{[4][92][13][16]} In the DSM-III, transvestism and gender identity disorder of adolescence or adulthood were mutually exclusive, and the latter diagnosis was given to cases of transvestism that had progressed to exhibiting gender dysphoria.^[6] Conversely, in the DSM-IV, transvestism was given a new specifier of with gender dysphoria.^[6] The specifiers with autogynephilia and with fetishism for transvestism in the DSM-5 replaced the earlier specifier of with gender dysphoria in the DSM-IV and DSM-IV-TR.^[5] It was however also previously noted in the DSM-IV-TR that the diagnosis of transvestic fetishism was often due to autogynephilia.^[4] The inclusion of the with autogynephilia specifier in the DSM-5 was opposed by the World Professional Association for Transgender Health (WPATH).^[6][93][94]

Treatment

Information about treatment of transvestism is very scarce.^[1][3] Most men with transvestism do not seek nor desire treatment for their condition.^{[1][3][4][13]} Treatment is also not necessarily indicated.^[1] When treatment is sought, it is often due to pressure from others, for example family members and sometimes employers.^[13]

Psychotherapy has been suggested for treatment of transvestism, including relapse prevention, harm reduction, mindfulness, emotional regulation, dialectical behavior therapy, psychodynamic therapy, cognitive-behavioral therapy, acceptance and commitment therapy, and supportive therapy.^[3][1][4] However, these treatments for transvestism are not currently evidence-based, largely lacking even supporting case reports.^[3][4] It has been stated that attempts to remove the desire to crossdress with psychotherapy have invariably been unsuccessful.^[1] In any case, psychotherapy to help control the frequency of crossdressing, negative thinking and feelings related to crossdressing, or social consequences may be useful.^[1] Including spouses and family members in psychotherapy, alone or in group therapy, may also be valuable.^[1][3] Psychoeducation by clinicians may be helpful.^[3] Self-help, support groups, and social support organizations and societies for people with transvestism or crossdressing may be helpful as well.^[3][1][4] One such example is Tri-Ess (Society for the Second Self), the largest such organization.^[3][4] Self-help books for transvestism are mostly unavailable.^[3][4]

A limited number of case reports and series exist of treating problematic transvestism with medications.^[3][8][9][4] These include serotonergic antidepressants like fluoxetine, sertraline, escitalopram, clomipramine, and phenelzine, the anxiolytic buspirone, the mood stabilizer lithium, the antidopaminergic antipsychotic pimozide,^[95] the progestogenic antiandrogens cyproterone acetate and medroxyprogesterone acetate at very high doses, the gonadotropin-releasing hormone agonist leuprorelin, and the estrogen diethylstilbestrol.^[3][8][9][4] Combination therapy, for instance with a serotonergic antidepressant and a progestogenic antiandrogen, can also be tried.^[8] Hormonal agents should be reserved for extreme cases.^[3] Many of these treatments are thought to work by suppressing sex drive and sexual arousal.^[8][9] However, reports of effectiveness are anecdotal.^[1] Moreover, medication treatments can have side effects and risks, sometimes serious, like decreased bone strength with antiandrogens.^[8][9][3]

Dopaminergic medications have been reported to induce or worsen transvestism and other paraphilias in case reports.^[96] In the case of transvestism, this has included levodopa, ropinirole, lisuride, selegiline, pergolide, and pramipexole.^[96] In one instance, a man with Parkinson's disease was treated with the dopamine-elevating MAO-B inhibitor selegiline and developed transvestism and hypersexuality.^[3][4][97] He had no prior history of crossdressing or desire to do so.^[3][97] His transvestism resolved upon discontinuation of selegiline.^[3][4][97] Other paraphilias and hypersexuality have also been found to be induced or exacerbated with dopamine agonists and other dopaminergic agents in men with Parkinson's disease.^[97][96] Dopamine antagonists have been reported to be effective in ameliorating symptoms of such paraphilic exacerbations in case reports.^[96][97] Besides dopamine agonists, dopamine releasing agents, like amphetamines, have been reported to induce or worsen transvestism in case instances.^[34][98][99]

Although men with transvestism don't usually seek treatment, those who develop gender dysphoria and a transgender identity frequently seek treatment in the form of medical gender transition with hormone therapy and surgical procedures.^[1]

Prognosis

Transvestism is a chronic and lifelong condition.^[1] Paraphilias like transvestism, as with normal other-directed sexual orientations, appear to be immutable in adulthood.^[12] The course of transvestism can be continuous or episodic.^[2] In episodic cases, the intensity of transvestism fluctuates and occasionally there may be temporary remissions.^[1][2] Transvestism often has a progressive course, resulting in the desire for crossdressing more frequently, extensively, and/or publicly.^[1] In some cases, it can develop into gender dysphoria and being transgender.^[1] Men with transvestism often report social consequences and difficulties.^[1] These include divorce, marital problems, opposition by family, relationship problems with men and women, and occupational challenges.^[1]

Epidemiology

The vast majority of people with transvestism are male.^[1][2] In a population-based study in Sweden, 2.8% of men reported at least one episode of sexual arousal with crossdressing.^[1][2][37] In another study, of German male volunteers, 7.4% of individuals reported a history of sexual arousal with crossdressing acts or fantasies.^[1] In this sample, only 1.9% described these experiences as intensely arousing, and almost all denied distress.^[1] A review of the data from 10 additional studies concluded that likely 2 to 3% of men (with a range of 2.0 to 10.9%) have experienced sexual arousal with crossdressing.^[1][12][20]

With the exception of masochism, paraphilias are thought to be very rare in women and are much less common than in men.^{[21][22][12][14]} In the Swedish population-based study in which 2.8% of men reported at least one episode of sexual arousal with crossdressing, 0.4% of women also did so.^[1][37] Other population studies have also found small numbers of women reporting transvestism.^[14] However, it is unclear whether these instances in women represent genuine transvestism rather than something superficially similar.^[1][14] Transvestism in women is extremely rare and almost unknown, with only a few published case reports existing.^{[1][14][12][3][2][50][76]}

Ray Blanchard has said that autogynephilia does not occur in cisgender women or occurs rarely in these individuals.^[17][68] However, two surveys, by Charles Allen Moser and Jaimie Veale and colleagues, claimed that autogynephilia (including autogynephilic homeovestism) occurs at high rates in cisgender women.^{[38][39][14][68][100][101]} In the study by Moser, almost all of the women (90%) were heterosexual.^[100] These studies have been criticized as having methodological limitations, and, owing to lack of measurement sophistication, obtaining responses that may have merely superficially resembled autogynephilia.^{[38][11][39][102]} Rather than measuring autogynephilia, it has been argued that they may have measured sexual arousal caused by anticipation from a romantic evening or sexual encounter.^{[38][11][39][102][14]} A subsequent study by J. Michael Bailey and colleagues using Blanchard's original Core Autogynephilia Scale found low scores for autogynephilia in cisgender women and men compared to crossdressers and other autogynephiles.^[103] The findings have been challenged and criticized by certain academics including Moser, Veale, and Julia Serano however, and more research is needed to further clarify the question of whether genuine autogynephilia occurs or not in cisgender women.^{[104][105][106]}

Transvestism has principally been described in Western cultures.^[1] It is unknown whether the phenomenon is more prevalent in Western cultures or if it is merely more visible in these cultures.^[1]

History and terminology

The term transvestism, from the Latin "trans" (across, over) and "vestitus" (dress, dressed, clothed), literally means crossdressing.^[3] The terms transvestism and transvestite (crossdresser) were introduced by gay German sexologist Magnus Hirschfeld in his 1910 book, Die Transvestiten: Eine Untersuchung über den Erotischen Verkleidungstrieb (Transvestites: The Erotic Drive to Cross-Dress).^{[17][3][18][19]} However, records of transvestic behavior and crossdressing date back to the Bible and Ancient Greece.^[3] The terms transvestism and transvestite, as coined by Hirschfeld, were originally not specific to erotic crossdressing, but were applied to all individuals who crossdressed, as well as to transsexuals or transgender people.^[17][13] He sometimes used the terms extreme transvestites or total transvestites to refer to what would subsequently be called transsexuals.^{[107][108][109]} Hirschfeld briefly coined the term transsexual in 1923, but it was not widely used until later on.^[65][110] Transvestism and transsexualism were not distinguished as separate diagnostic categories until the 1950s, which occurred through the work of German-American endocrinologist and sexologist Harry Benjamin.^{[13][65][111][112][113]}

Hirschfeld, in 1918, was the first to observe that some male crossdressers are sexually aroused by the thought or image of themselves as women.^{[17][114][115]} He referred to this phenomenon as automonosexuality (sexual arousal strictly from oneself), and referred to individuals with the disposition as automonosexuals or automonosexual transvestites.^{[17][114][116][115]} Hirschfeld was also the first to distinguish these individuals from homosexual men.^[17][50] The English-French sexologist Havelock Ellis subsequently observed this phenomenon and referred to it as sexo-aesthetic inversion in 1913 and as eonism (after 18th-century French crossdresser Chevalier d'Éon) in 1928.^{[114][17][65][117][118][119]} Other researchers, such as Otto Fenichel and H. Taylor Buckner, observed the phenomenon as well.^[17] The full-time heterosexual male erotic crossdresser Virginia Prince coined and used the term femmiphilia, or love of the feminine, to refer to the phenomenon and described herself and others as femmiphiles by the mid-1960s.^{[24][120][121][40][122]} She preferred the term femmiphile over transvestite as the latter term had been used too indiscriminately, for instance to refer to crossdressing for any reason.^[24][121] Prince wished to highlight the motive for crossdressing in erotic heterosexual crossdressers like herself, as well as the differences between these crossdressers and others like homosexual men, drag queens, and transgender women who crossdressed for different reasons.^{[24][120][121][122]} However, Prince also had the central explanation that crossdressing was to express the feminine self and maintained that sexual factors played only a minor role.^[13]

In 1982, the Czech-Canadian sexologist Kurt Freund distinguished between two types of cross-gender identity, one related to homosexuality and another preceded by transvestism and related to what he referred to as cross-gender fetishism.^[17][123] In 1989, Canadian sexologist Ray Blanchard, a protégé of Freund, coined the term autogynephilia (Greek "auto" (self), "gyne" (woman), "philia" (love) and literally "love of oneself as a woman") to describe the phenomenon of sexual arousal to oneself as a woman.^[17][114] Blanchard conceptualized autogynephilia as a paraphilia representing self-directed male heterosexuality.^[17][114] He decided to coin the term after encountering a gender dysphoric patient named Philip, who was sexually aroused by the fantasy of having a female body (including breasts, a vagina, and soft skin), but unlike most of Blanchard's similar patients, was not sexually interested in dressing in female clothes.^[17] Blanchard realized that prior terms, like transvestism and cross-gender fetishism, were inadequate or poorly descriptive, so he introduced autogynephilia as a new term to use instead.^[17] Subsequently, in 1991, Blanchard defined four distinct types of autogynephilia that he had observed clinically—transvestic, behavioral, physiologic, and anatomic.^[47][124] Consequently, transvestism became defined as a subtype of autogynephilia, and is now also known as transvestic autogynephilia.^{[47][124][33]} The term autogynephilia was subsequently included as a descriptor and specifier for the diagnosis of transvestism or transvestic fetishism in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders,^[1][5] including in the DSM-IV-TR (2000),^[91] the DSM-5 (2013),^[82] and the DSM-5-TR (2022).^[2]

Virginia Prince conducted major studies into men with transvestism, which were published in 1972 and 1997.^{[24][25][40][16]} Her first publication in this area was in 1957.^{[24][125][126]} She also founded the Foundation for Full Personality Expression (FPE), which eventually became Tri-Ess (Society for the Second Self), started the magazine Transvestia in 1960, and was an activist for promoting understanding and destigmatization of men with transvestism.^[24][25][13]

The first literature use of the term autoandrophilia was in 1995.^[12][127] Homeovestism, sexual interest in wearing certain kinds of same-gender clothing, and a phenomenon consistent with the concept of autoandrophilia, was observed in homosexual men and first described in the 1970s by George Zavitzianos.^{[14][12][11][61][128][129]} The first clear report of autoandrophilia, a case report of anatomic autoandrophilia in a homosexual man without mention of homeovestism, was reported by Anne Lawrence in 2009.^[14][130] The first and among the only, published cases of transvestism in women were reported by Emil Gutheil in 1930 and Robert Stoller in 1982.^{[12][50][76][131][132]}

Transvestism has also been referred to under a variety of other names besides transvestism, including transvestitism, transvestic fetishism, fetishistic transvestism, transvestic disorder, paraphilic transvestism, femmiphilic transvestism, heterosexual transvestism, transvestic autogynephilia, sartorial autogynephilia, erotic crossdressing, and sexual crossdressing, among others.^{[1][10][3][5][6][133][76]} Today, the term transvestite is considered derogatory, and has fallen out of fashion in favor of the word crossdresser.^{[134][135][136][137][138][139]} However, some crossdressers have reclaimed the word transvestite.^[139] Some people who would previously be called "transvestites" or "crossdressers" would be referred to as (non-transitioning) transgender people today.^{[28][29][27][30][31]}

Society and culture

Notable cases

Virginia Prince was a full-time heterosexual male crossdresser and one of the most famous such individuals of the 20th century.^[25][27] She founded the crossdressing magazine Transvestia, the crossdressing organization Tri-Ess (Society for the Second Self), and conducted major studies of men with transvestism.^[25] Other famous heterosexual male crossdressers involved in the crossdressing community include Louise Lawrence and Edythe Ferguson.^[26][27]

Some individuals who have described a history of sexual arousal with crossdressing, for instance in autobiographies, have gone on to transition and become transgender women.^{[44][69][140]} Some of these cases have been reviewed by Anne Lawrence.^[44] They include Lawrence herself,^[39][141] Deirdre McCloskey^[142] Kate Bornstein,^[44] Renée Richards,^[44][143] and Katherine Cummings,^[44][144] among others.^[44]

A number of paraphilic serial killers have been reported to have transvestism, including Dennis Rader^[59] Ed Gein,^{[145][146][147]} Gerard John Schaefer^[59] Jerry Brudos,^[145][148] and Richard Speck,^[149][150] as well as others.^[151][152]

Media representations

Transvestism has been portrayed in the media and popular culture, often in highly stigmatizing ways.^{[153][154][155][156][157]}

Media representations of transvestism include Denise Bryson (David Duchovny) in Twin Peaks (1991),^[154] Norman Bates (Anthony Perkins) in Psycho (1960),^[146] Paul Smecker (Willem Dafoe) in The Boondock Saints (1999),^[154][153] and Galaxia (Woody Harrelson) in Anger Management (2003).^[155][156]

Books about transvestism have been published, for instance Helen Boyd's My Husband Betty: Love, Sex, and Life with a Crossdresser (2003), Boyd's She's Not The Man I Married: My Life with a Transgender Husband (2007),^[158][159] and Richard J. Novic's Alice in Genderland: A Crossdresser Comes of Age (2005), among others.^[160]

References