Even a glance at this patient's history is sufficient to suspect that a paraphilia (i.e. atypical sexual interest in objects, situations, or individuals) is present. In particular, note the presence of sexual excitement engendered by cross-dressing, which the patient nevertheless finds emotionally distressing; these meet the A and B criteria for Transvestic Disorder (TD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). There are two other potential differentials which need to be considered here: Fetishistic Disorder, and Gender Dysphoria. However, note that his sexual desires are limited to only the articles of clothing used in cross-dressing; the diagnosis of fetishistic disorder requires the presence of other fetishes as well. Gender dysphoria is excluded by the absence of desire to be of the other gender, or of an incongruence between the patient's experienced and assigned genders. As might be appreciated from the above, TD is a clinical diagnosis; routine investigation is not indicated. His management should include cognitive behavioral therapy; addition of fluoxetine will help improve the overall response to treatment. Note that hormonal therapy (for example, medical castration with LHRH) is a second line treatment for TD and should not be attempted right now. Psychosurgery no longer has a role in the treatment of paraphilias.
The American Psychiatric Association describes Transvestic Disorder (TD) as "recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing". The transvestism may involve only one type of female clothing, such as undergarments; or, at the opposite end of the spectrum, may manifest as the wearing of a complete set of inner and outer garments, along with women's wigs and makeup. Almost all patients with TD are male, with the majority being heterosexual. The incidence in the general population is unclear, with less than 3% of men reporting to have ever been sexually aroused in this manner. The etiology underlying the condition is unknown; however, it is associated with learning disabilities in some individuals, while temporal lobe abnormalities and epilepsy have been found in a few cases. It is also unclear if genetics or familial environment influence development of TD; only a minority of patients appear to have a family history of cross-dressing. Note also that the disorder can co-exist with fetishistic disorder, gender dysphoria, and autogynephilia. TD usually commences as a fascination with a particular type of female attire; this most often manifests during early childhood. Following this, the majority of patients begin to cross-dress before 10 years of age, as this gives them a sense of pleasurable excitement. After puberty, cross-dressing begins to evoke sexual feelings, and results in penile erection; this is usually followed by masturbation, after which the female clothing is removed. As the patient ages, this behavior may not necessarily result in erection; however, the desire to cross-dress may grow stronger. Note that these individuals tend to seek medical attention only if and when this pattern of behavior brings distress and interferes with normal social functioning. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines two key criteria necessary for the diagnosis of TD: - Criterion A: recurrent and intense sexual arousal from cross dressing, as manifested by fantasies, urges, or behaviors, which should have lasted for at least 6 months - Criterion B: the fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note that these patients usually do not require further investigations, unless other comorbidities are present. The treatment of TD comprises both pharmacotherapy and psychotherapy; the former aims to reduce arousal and inhibit sexual drive, via antidepressants such as the selective serotonin reuptake inhibitors (SSRI) fluoxetine, or hormonal agents such as estrogens, medroxyprogesterone acetate, LHRH agonists and antiandrogens. Cognitive behavioral therapy (CBT) is the key form of psychotherapy used; this can take the form of aversion therapy, covert sensitization techniques, or orgasmic reconditioning. Aversion therapy involves pairing the of the arousing stimulus with an aversive stimulus such as a shock or noxious odor until the paraphilic behavior no longer produces sexual arousal. On the other hand, covert sensitization techniques require the patient to fantasize regarding cross-dressing, followed by noxious thoughts such as vomiting, or being discovered by his family. Orgasmic reconditioning involves fantasizing about the paraphilic behavior while masturbating, and at the moment just before orgasm, switching the fantasy to a more acceptable stimulus, such as one's partner. Note that while psychosurgery have been used for treatment of TD in several countries, there is very little data on its efficacy or safety. In some patients, TD follows an episodic course; in others, it is continuous. In addition, some patients may go on to develop transexualism.