Transvestism - Comorbid Conditions

Mental health professionals' understanding of comorbidity in transvestism is rudimentary, largely because it has not been systematically studied. Such work would require reliable diagnostic assessments in a large group of transvestites derived from nonclinical sources and not merely based on case reports and small series. In Table 70-3, the comorbid conditions that have been reported in transvestites are enumerated; however, no data exist to suggest that any of these conditions are more or less likely in transvestites than in age-matched community samples of men who do not cross-dress.

In fact, a study of 188 non-treatment-seeking cross-dressing men who completed personality and sexual-functioning surveys were found to be nearly identical to age- and race-matched non-cross-dressing men (G. R. Brown et al. 1996). Clinicians who may evaluate distressed transvestites should nonetheless be aware of the additional conditions with which some of these patients may present.

Transvestite entertainment literature frequently includes themes of sadomasochism, female domination, and bondage in conjunction with cross-dressing activities (Buhrich and McConaghy 1976; Stoller 1975). However, only 5% of 504 transvestites surveyed by Prince and Bentler (1972) reported participating in cross-dressing while being dominated by a woman. Buhrich and McConaghy (1976) noted, nonetheless, that a fantasy interest in these activities was found to be much more likely than actual participation. Multiple paraphilias are common in those who present for treatment in tertiary referral centers, suggesting that these conditions co-occur in highly selected clinical populations (Abel 1989; Kafka 1991). Kafka (1991) observed significant comorbidity between paraphilias (including transvestic fetishism) and nonparaphiliac sexual addictions. His small sample was limited to patients with comorbid mood disorders and included one transvestite who also suffered from compulsive masturbation. It is unclear how prevalent compulsive, but conventional, sexuality is in the broader population of transvestites, although experience in nonclinical settings suggests that it is not highly prevalent (G. R. Brown 1994). Berlin has written extensively on the comorbidity and management issues in men with multiple paraphilias in forensic settings (Berlin and Meinecke 1981; Berlin and Schaerf 1985; Berlin et al. 1991).

Transvestites who present to psychiatric clinics are often in crisis as a result of family discovery of their cross-dressing or occupational difficulties arising from these activities (Wise 1990; Wise and Meyer 1980a, 1980b). The adjustment disorders they experience are generally short-lived and respond to psychotherapeutic intervention, leaving the patient and therapist to contemplate how, or whether, to address the transvestic behaviors (Wise 1987). Adjustment disorders, when left untreated, may grade imperceptibly into major mood disorders (particularly dysthymia and major depressive disorder). Kafka (1991) observed significant comorbidity between mood disorders and paraphilias in individuals seeking treatment for paraphilias.