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the DSM does not acknowledge the existence of healthy, well-adjusted male-identified heterosexual cross-dressers
behaviors that would be ordinary or even exemplary for genetic women are presented as symptomatic of mental disorder

DSM-IV-TR: Transvestic Fetishism, 302.3
Section: Sexual and Gender Identity Disorders
SubSection: Paraphilias

Issues of Psychiatric Diagnosis of Cross-Dressers -- Kelley Winters, Ph.D.

Diagnostic Criteria (APA 1994)

  1. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
  2. 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.

Stigma of Sexual Perversion. The term, transvestite, was coined by Magnus Hirschfeld (1910) from Latin roots meaning to "cross-dress." Transvestism in the DSM-III was renamed "Transvestic Fetishism" in the DSM-III-R (APA, 1987). The very name equates crossdressing with sexual fetishism and social stereotypes of perversion. It serves to sexualize a diagnosis that does not clearly require a sexual context. Crossdressing by males very often represents a social expression of an inner sense of identity. In fact, the clinical literature cites many cases, considered diagnosable under transvestic fetishism, which present no sexual motivation for cross-dressing and by no means represent fetishism (Wise & Meyer, 1980). Worst of all, Transvestic Fetishism is classified as a sexual paraphilia, defined in the DSM-IV-TR as
    recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humilation or oneself or one's partner, or 3) children or other nonconsenting persons (p. 566).
Sexual paraphilias include such stigmatizing disorders as Pedophilia, Exhibitionism, Fetishism, Frotteurism, Sexual Masochism, Sexual Sadism, and Voyeurism. This classification serves to legitimize false stereotypes that unfairly associate cross-gender expression with criminal or harmful conduct in a most demeaning manner.

Overinclusive Diagnosis. Distress and impairment became central to the definition of mental disorder in the DSM-IV (APA, 1994, p. xxi), where a generic clinical significance criterion was added to all Sexual and Gender Identity disorders, including Transvestic Fetishism:

    The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 1994, p. 531).
Unfortunately, no specific definition of distress and impairment is given in the Transvestic Fetishism diagnosis. The DSM does not acknowledge the existence of healthy, well-adjusted male-identified heterosexual cross-dressers or attempt to differentiate them from cross-dressers who are in some way mentally disordered. These are left to the interpretation of the reader. Tolerant clinicians may infer that transgender identity or expression is not inherently impairing, but that societal intolerance and prejudice are to blame for the distress and internalized shame that transpeople often suffer (Brown, 1995). Intolerant clinicians are free to infer the opposite: that cross-gender identity or expression by definition constitutes impairment, regardless of the individual's happiness or well-being. Therefore, the Transvestic Fetishism diagnosis is not limited to ego-dystonic subjects, and it makes no distinction between legitimate clinical distress and that caused by prejudice and discrimination.

Ironically, the clinical significance criterion for five other paraphilias, Exhibitionism Froteurism, Pedophilia, Sexual Sadism and Voyeurism, in the DSM-IV-TR were revised with more precise wording to limit the inappropriate diagnosis of ego-syntonic subjects not engaged in harmful behaviors or marked interpersonal difficulty (APA, 2000, p. 574). The APA apparently extended no such concern for the consequences of overbroad diagnosis of gender nonconforming males.

Dual Standards by Sex and Sexual Orientation. Criterion A of Transvestic Fetishism limits diagnosis to heterosexual males. Curiously, women and gay men are free to wear whatever clothing they chose without a label of mental illness. This criterion serves to enforce a stricter standard of conformity for straight males than women or gay men. Its dual standard not only reflects the social privilege of heterosexual males in American culture, but promotes it. One implication is that biological males who emulate women, with their lower social status, are presumed irrational and mentally disordered, while biological females who emulate males are not. A second implication stereotypically associates femininity and cross-dressing with male homosexuality and serves to punish straight males who transgress this stereotype.

Grammatical Ambiguity. Criterion A of the Transvestic Fetishism diagnosis is grammatically ambiguous (Wilson & Hammond, 1996):

    Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. (APA, 1994, p. 531)
The phrase, "sexually arousing," could be interpreted to apply to only "fantasies" or to all three of "fantasies, sexual urges, or behaviors" with very different meaning. The first interpretation would implicate all recurrent cross-dressing behavior. This is consistent with the DSM-IV Casebook (Spitzer, ed., 1994, pp. 257-259), which recommends a TF diagnosis for a male whose crossdressing is not necessarily sexually motivated. The second would limit the diagnosis to only sexually motivated cross-dressing, as did the DSM-III-R (APA, 1987, p. 289), and imply the ackward phrase, "sexually arousing sexual urges." Although labeled a "fetishism," it is not clearly stated whether or not transvestism must be sexual in nature to qualify for diagnosis. The distinction is left to interpretation.

Pathologization of Ordinary Behaviors. In the supporting text of the Transvestic Fetishism diagnosis, behaviors that would be ordinary or even exemplary for genetic women are presented as symptomatic of mental disorder on the basis of born genitalia and sexual orientation. These include collecting and wearing female clothes or undergarments, dressing entirely as females, wearing makeup, expressing feminine mannerisms and "body habitus," and appearing publicly in a feminine role (APA, 2000, p. 574). It is not clear how these behaviors can be pathological for one group of people and not for another.

Most disturbing, the text lists "involvement in a transvestic subculture" among symptomatic "transvestic phenomena." Psychiatric diagnosis on the basis of social, cultural or political affiliation evokes the darkest memories of medical abuse in American history. For example, women suffragettes who demanded the right to vote in the early 1900s were diagnosed and institutionalized with a label of "hysteria" (Mayor, 1974). Immigrants, Bolsheviks and labor organizers of the same era were labeled as socially deviant and mentally defective by prominent psychiatric eugenicists, such as Dr. Charles Kirk Clarke, founder of the Clarke Institute of Psychiatry in Toronto, Ontario (Dowbiggin, 1997, pp. 133-177). In truth, transgender support organizations worldwide are the primary source of support, education and civil rights advocacy for gender variant people, families, friends and allies. Their necessity is a consequence of social intolerance, not of mental deficiency.

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