A professional defense of crossdressing

[CJ]

Hi all,

I came across this page while surfing for info and thought it would stimulate discussion. I considered posting this in the Transgender Topics area of the forum but decided against it as not everyone here has access to that area and I wanted to give this the greatest exposure possible. The thesis statement of the article (and it could've been used as a subtitle) is the following: The rationale for pathologizing a coping skill is questionable.

(The web page is here: The Diagnostic Dilemmas of Transvestitism but I've copied it in its entirety below.)


The formal citation for the present paper is:

Moser, C. & Kleinplatz, P.J. (2002). Transvestic fetishism: Psychopathology or iatrogenic artifact? New Jersey Psychologist, 52(2) 16-17.



Transvestic Fetishism: Psychopathology or Iatrogenic Artifact?



By

Charles Moser, Ph.D., M.D.*
Professor of Sexology
Institute for Advanced Study of Human Sexuality
San Francisco, CA

and

Peggy J. Kleinplatz, Ph.D.
School of Psychology
University of Ottawa
Ottawa, Ontario
Canada






*To whom correspondence is to be addressed

Charles Moser, Ph.D., M.D.
45 Castro Street, #125
San Francisco, CA 94114

Docx2@ix.netcom.com


Transvestic Fetishism: Psychopathology or Iatrogenic Artifact?

The act of wearing the stereotypic articles of clothing of the other sex is known as cross-dressing. Obtaining erotic enjoyment from the process of cross-dressing is known as transvestism. The cross-cultural (Ford & Beach, 1951) and trans-historical (Bullough & Bullough, 1977) records indicate that cross-dressing is not rare. However, whether erotic arousal from cross-dressing exists cross-culturally and trans-historically is much more difficult to ascertain. Little attention has been paid to subjective erotic arousal experienced during sexual acts. It is easier to observe behavior than to discern individual motivation.

Magnus Hirschfeld coined the term "transvestism" in 1910 (Bullough & Bullough, 1977). Havelock Ellis (1936) termed the same phenomena "Eonism," but included individuals that would now be considered "effeminate homosexuals" and those with gender dysphoria. Kinsey did not ask questions about cross-dressing (Gebhard & Johnson, 1979) and defined transvestism only as cross-dressing (Kinsey, Pomeroy, Martin & Gebhard, 1953).

Benjamin (1966) described a continuum between those who cross-dress for erotic reasons and those who dress as an expression of gender identity (e.g. transsexuals). There are many different varieties of individuals who cross-dress. They include (but are not limited to) "drag queens" (and "kings"), the transgendered, transsexuals, transvestites, "she-males," female impersonators (also known as gender illusionists), and some "psychotic" individuals who believe that they are members of the other sex.

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) is considered by many to be the definitive authority on the diagnosis of mental disorders. This reference text is revised regularly and purports to be factually correct, reflect new information available, and be up-to-date. It classifies unusual and strong sexual interests (i.e., paraphilias) as psychopathological. The DSM states it is "…supported by an extensive empirical foundation" (APA, 2000, p. xxiii). However, there is no objective support in the literature for the belief that these sexual interests stem from psychopathology or constitute a form of psychopathology per se. Except for historical precedent, why should strong sexual interests (unusual or otherwise) be diagnosed as mental disorders? (See Moser [2001] for a critique of the concept of "paraphilia.") A reevaluation of the entire paraphilia section of the DSM (2000) is in order, but the present paper will be focused on discussion of Transvestic Fetishism (TF), the DSM term for transvestism.

The current edition of the DSM (APA, 2000) continues to list TF as a mental disorder, although the latest research available does not support the inclusion of this diagnosis. Brown, Wise, Costa, Herbst, Fagan and Schmidt (1996, p. 265) conclude, "Cross-dressers…are virtually indistinguishable from non-cross-dressers." This statement takes on added importance because Wise and Schmidt were members of the DSM-IV-TR (2000) Sexual and Gender Identity Disorders Text Revision Work Group, (i.e., the committee responsible for revising this section of the DSM).

The diagnostic criteria define this disorder as occurring specifically among heterosexual men. Neither women nor homosexual men are likely to receive this diagnosis. This reflects on how narrowly masculinity is defined in this culture and on the cultural context in which the diagnostic process is embedded.

To illustrate the problems with this diagnosis, consider the following case:

Mr. A is a 40-year-old man, married for 15 years, with no children, who works as a truck driver. He seeks psychotherapy for depression characterized by dysphoric mood, anhedonia, insomnia, fatigue, and feelings of hopelessness. The current episode began one month ago. He reports the precipitating events include the possibility that he may be fired and that his wife is considering divorce. You make a diagnosis of Major Depressive Episode.

Now assume that the same patient is sitting in your office while cross-dressed. He describes a history of erotic arousal when dressed in female attire, but now finds cross-dressing is calming. His employer discovered his cross-dressing - (in private, not while on the job) - from a co-worker in whom Mr. A confided. His employer states he must act "to preserve the company image." His wife always disliked the cross-dressing and feels the behavior "must be sick"; she does not want to endure the embarrassment its revelation may bring. Mr. A reports cross-dressing overall has had a positive effect on his life. He admits that having to keep it secret has been stressful and he had periods of self-loathing in the past because he thought cross-dressing was sick. Over time and with the help of several transvestite support groups, these problems have been resolved. How will your diagnosis, treatment plan and goals change with this new information?

According to the DSM (APA, 2000), in order to make a diagnosis of TF, both of the following criteria must be met:

A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other areas of functioning. (APA, 2000, p.575)

To be a mental disorder, the sexual interest in cross-dressing must cause either distress or impairment. It is dubious if TF qualifies as a mental disorder or how it should be classified, if it does not cause distress or impairment. The criteria of distress and impairment will be examined separately.

Distress

Mr. A is distressed about his job and marriage, but not about his cross-dressing. Although he did experience some distress in the past, this now appears resolved. The diagnostic criteria do not say that the distress had to occur in the last six months; only a six month duration is needed. If it is meant literally, then Mr. A has an incurable condition, even if none of the "signs" or "symptoms" is currently present. If the criterion is sexual excitement in the last six months, then he does not meet the diagnostic criteria for TF.

The DSM indicates that the motive underlying the cross-dressing can change in character and that the sexual arousal may disappear. In these cases, it is suggested that, "…the cross-dressing becomes an antidote for anxiety or depression or contributes to a sense of peace and calm" (APA, 2000, p. 574-5). Should this behavior, which can be regarded as adaptive rather than distressing, be construed as psychopathological? The rationale for pathologizing a coping skill is questionable.

Impairment

While his employer and wife may have a problem with his sexual interest, Mr. A apparently does not. His impairment, if any, comes from the fact that his job and marriage are in jeopardy. If he was unable to perform the duties of his job (e.g., he was too busy dressing to actual drive the truck), then this dysfunction may qualify for a diagnosis of mental disorder. If we accept that his problems arise from the societal attitudes he is forced to endure, then we must question whether a diagnosis of psychopathology is valid. If TF is a mental disorder, we imply that women or African Americans, who also experience problems arising from discrimination, are similarly subject to diagnosis.

When non-paraphilic (normophilic) individuals are distressed or even dysfunctional because of an inability to find accepting and supporting partners, they are not defined as having psychosexual disorders. We do not assume that individuals are mentally disordered if potential partners reject them because the former are fat, poor, or even ugly. Why does being rejected for non-standard sexual interests imply a mental disorder?

Common concerns that some therapists use as reasons to treat TF:

* "It is compulsive." The patient feels driven to cross-dressing and reports that it diminishes his distress. Heterosexual coitus or masturbation usually does not seem to evoke the same concerns even though many people feel driven to the acts and report that they decrease distress. Although any behavior can be compulsive, cross-dressing rarely meets the DSM criteria for a compulsion. If it does qualify, then another diagnosis would be more appropriate, because compulsion is not part of the diagnostic criteria of TF.

* "The individual cross-dresses to decrease anxiety." Why should one abandon coping skills that work? Why are some adaptive behaviors regarded as better than others? Admittedly, any behavior might be deleterious for some, but (aside from the category of the paraphilias) it is not typically the behavior that is identified as the problem (e.g., washing one's hands until raw may be a compulsion, but it is not a hand-washing disorder).

* "The cross-dresser is unable to engage in sexual activity without cross-dressing." Many heterosexuals are unable to engage in sexual activity with same sex partners or with unappealing partners. However, we are not inclined to pathologize those whose sexual preferences and aversions conform to the "norm". Uncommon behavior is not necessarily pathological and conventional behavior is not necessarily healthy.

* "The patient requests help to extinguish the behavior." Clinicians play a large role in determining which problems are targeted for treatment. Just because patients wish to modify their sexual interests does not necessarily mean that clinicians should attempt to do so. Most therapists would not try to eradicate homosexuality. The presenting problem (e.g., depression, anxiety, substance abuse) can have no relationship to the sexual interest. Even if a relationship exists, it is not clear if the problem is causing the sexual interest, if the sexual interest is causing the problem, if the sexual interest is causing different problems, or some combination of these.

* When should a therapist deal with the cross-dressing? A patient's sexuality can be an appropriate focus of therapy. Some individuals may need help integrating their sexual interests into their lives. Even if their sexual interests are problematic, the best treatment may entail referral to support groups or assistance in how to manage the problems generated by the interest.

Conclusion

In the case presented, the therapist might be "seduced" into attempting to extinguish Mr. A's cross-dressing behavior, despite its adaptive value. The focus on his TF, with the concomitant de-emphasis of his other problems may lead to iatrogenic problems. He may be deprived of focused treatment for his depression, marital therapy, or even a referral to an attorney to defend his interests in a "wrongful termination" suit.

There is no empirical evidence that TF is problematic, let alone a mental disorder. Even if it does qualify as a disorder, the interpretation and application of the diagnostic criteria lack consistency and clarity; that is the reliability and validity of the diagnosis remain dubious.

We have criticized the Soviet and Chinese mental health establishments for pathologizing those with unconventional political beliefs; we should not make an analogous mistake concerning those who have unconventional sexual interests.




References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revised). Washington, DC: American Psychiatric Association.

Benjamin, H. (1966). The transsexual phenomenon. New York: Julian Press.

Brown, G.R., Wise, T.N., Costa, P.T., Herbst, J.H., Fagan, P.J., & Schmidt, C.W. (1996). Personality Characteristics and Sexual Functioning of 188 Cross-Dressing Men. The Journal of Nervous and Mental Disorders 184, 265-273.

Bullough, V.L., & Bullough, B. (1977). Sin, sickness, and sanity. New York: New American Library.

Ellis, H. (1936). Studies in the Psychology of Sex, (Vol. III, Part 2). New York: Random House.

Ford, C.S., & Beach, F.A. (1951). Patterns of sexual behavior. New York: Harper & Row, Publishers.

Gebhard, P.H., & Johnson, A.B. (1979). The Kinsey data: Marginal tabulations of the 1938-1963 interviews conducted by the Institute for Sex Research. Philadelphia, PA: W. B. Saunders Company.

Kinsey, A.C., Pomeroy, W.C., Martin, C.E., & Gebhard, P.H. (1953). Sexual behavior in the human female. Philadelphia, PA: W. B. Saunders Company.

Moser, C. (2001) Paraphilia: Another Confused Sexological Concept. In: P. J. Kleinplatz (Ed.) New directions in sex therapy: Innovations and alternatives (pp. 91-108), Philadelphia: Brunner-Routledge.

[DonnaT]

1. pathology -- the branch of medical science that studies the causes and nature and effects of diseases
2. pathology -- any deviation from a healthy or normal condition

iatrogenic -- Resulting from the professional activities of physicians, or, more broadly, from the activities of health professionals. Originally applied to disorders induced in the patient by autosuggestion based on a physician's examination, manner, or discussion, the term is currently applied to any undesirable condition in a patient occurring as the result of treatment by a physician (or other health professional), especially to infections acquired by the patient during the course of treatment.

[DonnaT]

Seems to be well written, and I can't find fault with what was written.

What is missing is recommendation(s) for changing the DSM.

Would they recommend the section of TF removed as a pathology/mental disorder, much like the removal of homosexual as a pathology/mental disorder, which is now labeled Dyshomophilia?

Transvestic Fetishism:
A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
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 Gender Dysphoria: if the person has persistent discomfort with gender role or identity.

Seems weird that this disorder is limited to heterosexual males. Apparently, women and gay men are free to wear whatever they chose without a diagnosis of mental illness.

Additionally, the language at A seems to be quite ambiguous. For example, would a heterosexual male, having recurrent, intense sexually arousing fantasies over a period of at least 6 months qualify as the first step in the diagnosis of TF, or would it also have to involve cross-dressing?

Or, as another example, would the behaviors involving cross-dressing need be "intense sexually arousing" behaviors?

[JoAnnDallas]

This is a good report, that shows that there is nothing wrong with cross dressing. It may in fact be theupedical, in many cases. I am saving a copy of this posting for my files.

[JoAnnDallas]

The diagnostic criteria define this disorder as occurring specifically among heterosexual men. Neither women nor homosexual men are likely to receive this diagnosis.

Does this mean that it's OK for a gay man to crossdress??

[CJ]

JoAnn wrote: Does this mean that it's OK for a gay man to crossdress??

Donna wrote: Apparently, women and gay men are free to wear whatever they chose without a diagnosis of mental illness.

I've often thought about all this and it seems to me that there's a difference between crossdressing as an end in itself (which, arguably, is the type of CD'ing practiced by heterosexual males) and crossdressing as a means to something else (say, to attract a male, in the case of a gay male who crossdresses). Mind you, this is just speculation. And a very non-professional one, at that. This is where gender identity and sexual orientation intersect. If you, as a heterosexual male, dress because the act itself gives you sexual and emotional satisfaction, it's not the same as when you dress for the purpose of attracting a member of the opposite gender. I say "gender" and not "sex" because a man who dresses as a woman has, statistically speaking, a better chance of attracting another man, regardless of his sexual orientation--if his aim is to attract a partner.

I'm not sure that most heterosexual males who crossdress have such a goal in mind. They may be flattered by the attention, mind you, just because it's a sign that their passing skills are adequate, but attracting another man is not their main motive--if they truly are heterosexual. Gay males, on the other hand, may have this goal in mind. That is, assuming they're interested in pursuing a sexual relationship at all. It could be that, as is the case for some heterosexual crossdressers, some gay crossdressers have little interest in sexual intimacy with another person.

As to Donna's objection, I think that heterosexual male crossdressing gets more of a bum rap (and a diagnosis of mental illness) than do gay male or female crossdressing because the latter two are somehow less of a "perversion" of the sexual instinct. Again, because a gay male may do this in order to attract a partner, and women have fought (sometimes bitterly) for the cultural freedom to wear what they choose.

Also, it's important to remember that "wearing what you please" and "passing yourself off as a member of the opposite sex" are not the same thing. Far from it. Some bearded dude walking down the street in a leather jacket and Doc Martens but wearing some type of skirt will not be thought of by the majority of people as being as, uh, "troubled," as will a male who's trying to pretend he's a female.

As to the article itself, I agree with Donna that the authors should not have shied away from recommending bringing the DSM into the 21st century. Of course, we're only a half dozen years into that century, so it's certainly not too late to hope that this will, eventually, come to pass.

Anyway, thanks for the replies, folks. I enjoyed this article and I'm glad you did, too.

Love,
CJ

[Jacky]

Would be interesting to read an article like this one written by a prof.etc that crossdresses himself,after all some of the feelings are not explainable unless you have experienced them yourself.But then I suppose its looked at as being biased.
As to drag Queens and cross dressers,Ive tried to explain to my wife what the difference is, although they might look the same to ordinary folk,they are actually two completely different people,the one likes women and the other likes men.How much more difference can there be?
That is why I enjoy reading what you girls say as we know how we feel,and do not hve to explain it.
Love Jacky

[Kyra]

Thanks CJ,

A very well written piece, indeed. I agree with Donna, The only fault I found was a missing recommendation. Still a good read, though.

Thanks again.

Hugs,
Kyra

[Marlena Dahlstrom]

As to Donna's objection, I think that heterosexual male crossdressing gets more of a bum rap (and a diagnosis of mental illness) than do gay male or female crossdressing because the latter two are somehow less of a "perversion" of the sexual instinct. Again, because a gay male may do this in order to attract a partner, and women have fought (sometimes bitterly) for the cultural freedom to wear what they choose.

For what it's worth, Vern and Bonnie Bulloughs excellent "Cross Dressing, Sex, and Gender" has a chapter on both the "medicalization" of trans-ness that occurred in the 20th century and how various pyschological theories (up through the 1980s) about crossdressing and transsexuality were far more reflective of unsubstantiated theory (primarily Freudian, even though Freud actually never addressed trans-ness) and pervasive societal attitudes than actual research.

Those biases are still reflected in the DSM, with the sort of logical inconsistencies that Donna T. notes. Because female CDs couldn'texist, researchers were blind to the evidence that they actually do, even if their style of CDing differs. (I just finished the excellent "Butch is a Noun," and the way S. Bear Bergman lyricizes over getting hir first dress shirt and tie equals the sort comments I've heard from MTFs buying their first dress. Disclaimer: There are as many varieties of butches as CDs, so Bergman is only representative of one of them.)

[Virginia]

I wish to NOT coop this thread but............. a couple of things,
First, Jackie, if you read this you will find that as in the case of crossdressers, as has been stated, most, MOST are heterosexual males - granted, as CJ referenced, there can and I would assume (having never met one) but that there are probably, gay crossdressers! Uh, like at times I may consider myself a male lesbian.
Second, most and again I know a few and I know that there are exceptions, but, most FI's would rather be considered heterosexual, male, entertainers and that is all they are, entertainers.
Someone started a thread a year or more ago asking (now I remember it was I) anyway, asking what you would do if you were out, dressed, at a "social function" and a guy asked you to dance? Yes I realize a lot of images enter your minds, "is he gay," "does he read you or maybe not?", "does he know you personally and is just being "nice"?" For that matter what if it were a "GG" that asks you to dance all previous scenarios aside?
No, we are not nuts!!!!! We are blessed with a "gift" that is just not understood ---------------------------- YET!!!!!!
Go Forth Woman and BE!
Virginia

[Bethany]

I wish to NOT coop this thread but............. a couple of things,
First, Jackie, if you read this you will find that as in the case of crossdressers, as has been stated, most, MOST are heterosexual males - granted, as CJ referenced, there can and I would assume (having never met one) but that there are probably, gay crossdressers! Uh, like at times I may consider myself a male lesbian.
Second, most and again I know a few and I know that there are exceptions, but, most FI's would rather be considered heterosexual, male, entertainers and that is all they are, entertainers.
Someone started a thread a year or more ago asking (now I remember it was I) anyway, asking what you would do if you were out, dressed, at a "social function" and a guy asked you to dance? Yes I realize a lot of images enter your minds, "is he gay," "does he read you or maybe not?", "does he know you personally and is just being "nice"?" For that matter what if it were a "GG" that asks you to dance all previous scenarios aside?
No, we are not nuts!!!!! We are blessed with a "gift" that is just not understood ---------------------------- YET!!!!!!
Go Forth Woman and BE!
Virginia

Well, both my wife and I dance with men all the time at social functions, we like dancing, it is fun, and it can be nice to be held close by a man. That does NOT mean we go home with them! It is ok to express your femininity, and it is not teasing to dance with someone...
My wife and I are monogamous, but when we are at a party or club, we enjoy ourselves, there is nothing wrong with that, as long as we go home togeather.

[Virginia]

Thanks Bethany!
I had brought up the question as I was going to a somewhat formal affair and I was curious as to what my sisters here had to say about that situation arising. Well, I had your "approach" in mind. I was asked to dance by a gentleman and I came out of the chair like it had a spring in it. I was and am Virginia and I was asked very politely and I accepted graciously like a lady should - an unaccompanied lady at that! It was an awesome feeling to be held and whirled around the floor.
I said it then and I will say it now - gotta watch those gay guys, they can charm your panties off and they are perfect gentlemen as well, so you have to be the perfect lady! It takes practice and a positive acceptance of yourself. I can assure you if you are in a social situation and look, act and project as "just a guy in a dress" that is how you will be treated!!!!!
Love,
Virginia

[Absaroka]

The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

And that is where all the trouble starts. A great many mental illnesses have that sentence. Originally it was put there to keep the Crossdresser ( or any number of other people) who are not unhappy free of any diagnosis. It bears repeating, the crossdresser who is happy or at least not terribly disturbed by there crossdressing does not warrant a diagnosis according to the DSM.

The problem arises with the societal reaction to the crossdressing (or other harmless behavior) Often the crossdresser is not distressed by the dresssing so much as the societal reaction. Or they buy into the reaction to the extent that they blame their unhappiness on the crossdressing rather than the societal reaction.

I suppose there are people who's crossdressing interferes with their life. We see posts here from time to time about is it addictive and so forth. I'm not about to make blanket statements about all crossdressers.

Radical therapy (which I haven't heard about since the 70's) used to say that most psychiatric problems were due to societies enforcement of expectations, custom and so on. I don't buy that completely. But there is often truth to this. A disturbed society will produce disturbed members of the society.

Obesity is a wonderful example. There are very sound reasons to want to not be obese. Health is a big one. Another one is that it can limit ones choice of activity. Mountain climbing and running marathons are not options that are open anymore, although of course the person in question may have no desire to do these things.

But then we get into the stigma of obesity. the feeling that it renders a person somehow "less than". And lo and behold now the obese person has two problems. One a physical one and one an emotional one of feeling shame over their body and appearance. Some will move from this into a rebellion, a sort of "fat is good" philosophy. I think this is mistaken. I would say rather that they were good people with a problem to be addressed. But human nature is often too complicated for that.

Psychiatry has a real problem with much of the population. There are those who are unequivocally mentally ill and who can be helped. At one time I fit into this category. But there are many who are having trouble navigating through complex issues in life who may be in need of help from many quarters but who do not deserve an actual diagnosis.

I have always been very greatful for my therapist, who has taken an approach of "lets talk about this, evaluate it in terms of it's impact and potential impact on your life" rather than making any judgements about it being desirable or undesirable. And believe me there have been other topics where he has made his feelings very clear about something being either desirable or undesirable.

Absaroka