History

Fact Explanation
Cross dressing In an individual with transvestic fetishism cross dressing can begins soon after puberty. Initially cross dressing is done only in private, but later on it maybe done in public as well. Most often cross dressing of undergarments under the cover of normal male outer-garments is practiced. [1]
Sexual arousal by cross dressing Fetishism is sexual arousal by inanimate objects. In Transvestic fetishism , sexual arousal in a heterosexual male, is achieved by garments, material and fabric associated with the opposite gender. cross dressing is the preferred or only means of sexual arousal. According to DSM-IV, diagnosis of transvestic fetishism requires, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing, in a heterosexual male, over a period of at least 6 months,[1]
Distress or impairment due to sexual preference According to DSM-IV, the fantasies, sexual urges, or behaviors associated to transvestic fetishism cause distress which is clinically significant or impairment in social, occupational, or other important areas of functioning [1][2]
Autogynephilia Autogynephilia is sexual arousal by thought or image of self as female. Some individuals with transvestic fetishism also experience autogynephilia. [1][3]
References
  1. BLANCHARD RAY. The DSM Diagnostic Criteria for Transvestic Fetishism. Arch Sex Behav [online] December, 39(2):363-372 [viewed 22 July 2014] Available from: doi:10.1007/s10508-009-9541-3
  2. KRUEGER RB, KAPLAN MS. Paraphilic diagnoses in DSM-5. Isr J Psychiatry Relat Sci [online] 2012, 49(4):248-54 [viewed 21 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23585461
  3. VELAYUDHAN R, KHALEEL A, SANKAR N, KUMAR M, KAZHUNGIL F, RAGHURAM TM. Fetishistic Transvestism in a Patient with Mental Retardation and Psychosis Indian J Psychol Med [online] 2014, 36(2):198-200 [viewed 21 July 2014] Available from: doi:10.4103/0253-7176.130995

Examination

Fact Explanation
Mental State Examination: Appearance and Behaviour Appearance is normal and masculine in most affected individuals as cross dressing is done only in secret by most. Even those who cross dress in public tend to be restricted to cross dressing of undergarments with normal male outer clothing. But some individuals may not take precautions against discovery.Complete cross dressing of female garments is observed in very few individuals.[1]
Mental State Examination: Speech Speech will be coherent, rational and appropriate. [2]
Mental State Examination: Mood Mood maybe euthymic or dysphoric, if the person has significant distress due to his sexual reference. Also mood maybe dysthymic if patient has associated depression, anxiety or obsessive compulsive disorder.[3][4]
Mental State Examination: Thoughts No abnormalities of form or content of though will be apparent, except in those who have other associated psychiatric disorders. Obsessive thoughts maybe present in some with co-morbid obsessive compulsive disorder.[2][3]
Mental State Examination: Perceptions No perceptual abnormalities are associated with transvestic fetishism.[1]
Mental State Examination: cognitive functions Orientation,attention,concentration and memory will be within normal range.[1]
Mental State Examination: Insight Insight is variable, with most having some insight that the condition is abnormal and some having complete insight including insight regarding symptoms,awareness of having a mental disorder, and need for treatment.[4]
References
  1. KRUEGER RB, KAPLAN MS. Paraphilic diagnoses in DSM-5. Isr J Psychiatry Relat Sci [online] 2012, 49(4):248-54 [viewed 21 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23585461
  2. Blanchard, R. (2010). The DSM diagnostic criteria for transvestic fetishism. Archives of Sexual Behavior, 39(2), 363-372. [viewed 21 July 2014] Available from: http://akikos-planet.cocolog-nifty.com/blog/files/the_dsm_diagnostic_criteria_for_transvestic_fetishism.pdf
  3. USMANI MA, K GAUR R, AHMAD AZMI S, GANGWAR S. Treatment of transvestic fetishism with fluoxetine: a case report. Iran J Psychiatry Behav Sci [online] 2012 Fall, 6(2):100-1 [viewed 21 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24644490
  4. LÅNGSTRöM NIKLAS, ZUCKER KENNETH J.. Transvestic Fetishism in the General Population. Journal of Sex & Marital Therapy [online] 2005 March, 31(2):87-95 [viewed 22 July 2014] Available from: doi:10.1080/00926230590477934

Differential Diagnoses

Fact Explanation
Gender identity disorder (transsexualism) The person affected by this disorder has the conviction of being the opposite sex to that indicated by the external genitalia. Cross dressing is characteristic in individuals with transsexualism, but the difference lies in the fact that they gain no sexual arousal by cross dressing.Also transsexuals wish to alter their physical appearance and external genitalia to that of the opposite sex. Both men and women may be affected, though most are men. According to DSM- IV, a strong persistent cross-gender identification is observed in affected individuals, but it is not merely a desire for any perceived cultural advantages of being the other sex. In children, the disturbance is manifested by four (or more) of the following symptoms- Repeatedly stated desire to be, or insistence that he or she is, the other sex, in boys, preference for cross-dressing or simulating female attire; In girls, insistence on wearing only stereotypical masculine clothing, strong and persistent preferences for cross-sex roles in make believe play or persistent fantasies of being the other sex, intense desire to participate in the stereotypical games and pastimes of the other sex, or strong preference for playmates of the other sex. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.[1][2][3]
Fetishism An inanimate object is the preferred or only mean of achieving sexual arousal in fetishism. Most often this is observed in heterosexual males and the objects involved are female undergarments or other feminine attire like high heeled shoes.[2][4]
Obsessive compulsive disorder An individual with obsessive compulsive disorder may have obsessive thoughts or compulsions along the theme of transvestism or fetishism or there maybe co-morbid obsessive compulsive disorder in individuals with transvestic fetishism.[5]
Schizophrenia Delusions may result in transvestism and transsexualism and cross dressing maybe seen in schizophrenia. Fetishism may also be observed in schizophrenic individuals.[4]
References
  1. Zucker, K. J. (2000). Gender identity disorder. In Handbook of developmental psychopathology (pp. 671-686). Springer US. [viewed 22 July 2014] Available from: http://66.199.228.237/boundary/SA/SA_Chapter.pdf#page=401
  2. Blanchard, R. (2010). The DSM diagnostic criteria for transvestic fetishism. Archives of Sexual Behavior, 39(2), 363-372. [viewed 22 July 2014] Available from: http://akikos-planet.cocolog-nifty.com/blog/files/the_dsm_diagnostic_criteria_for_transvestic_fetishism.pdf
  3. LÅNGSTRöM NIKLAS, ZUCKER KENNETH J.. Transvestic Fetishism in the General Population. Journal of Sex & Marital Therapy [online] 2005 March, 31(2):87-95 [viewed 22 July 2014] Available from: doi:10.1080/00926230590477934
  4. VELAYUDHAN R, KHALEEL A, SANKAR N, KUMAR M, KAZHUNGIL F, RAGHURAM TM. Fetishistic Transvestism in a Patient with Mental Retardation and Psychosis Indian J Psychol Med [online] 2014, 36(2):198-200 [viewed 22 July 2014] Available from: doi:10.4103/0253-7176.130995
  5. USMANI MA, K GAUR R, AHMAD AZMI S, GANGWAR S. Treatment of transvestic fetishism with fluoxetine: a case report. Iran J Psychiatry Behav Sci [online] 2012 Fall, 6(2):100-1 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24644490

Management - General Measures

Fact Explanation
Dignose and treat other mental disorders Transvestic fetishism and especially cross dressing maybe a manifestation of other mental disorder like anxiety or depression with the abnormal behavior manifested as an outlet to stress or anxiety.[1][2][3]
Improve normal sexual functioning Disorders of sexual preference maybe a manifestation due to poor satisfaction of normal sexual relationships.Sexual counseling will help with difficulties in forming or maintaining healthy relationships with the opposite sex.[4]
Providing healthy and adaptive coping mechanisms Assessment of role of abnormal sexual relationship in patient's life needs to be done as abnormal behaviors of the disorder maybe a coping mechanism to counteract loneliness , anxiety or depression. Better coping strategies should be introduced and encouraged.[4][5]
Ensuring support and motivation The individual's motivation for treatment is variable ,but essential, therefore it needs to be sustained with the help of the partner and by giving insight in to disorder and need for treatment.[4][5]
References
  1. BLANCHARD RAY. The DSM Diagnostic Criteria for Transvestic Fetishism. Arch Sex Behav [online] December, 39(2):363-372 [viewed 22 July 2014] Available from: doi:10.1007/s10508-009-9541-3
  2. VELAYUDHAN R, KHALEEL A, SANKAR N, KUMAR M, KAZHUNGIL F, RAGHURAM TM. Fetishistic Transvestism in a Patient with Mental Retardation and Psychosis Indian J Psychol Med [online] 2014, 36(2):198-200 [viewed 22 July 2014] Available from: doi:10.4103/0253-7176.130995
  3. LÅNGSTRöM NIKLAS, ZUCKER KENNETH J.. Transvestic Fetishism in the General Population. Journal of Sex & Marital Therapy [online] 2005 March, 31(2):87-95 [viewed 22 July 2014] Available from: doi:10.1080/00926230590477934
  4. BRANDON S. Management of sexual deviation. Br Med J [online] 1975 Jul 19, 3(5976):149-51 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1139263
  5. CHANG HL, CHOW CC. The treatment of fetishism in an adolescent with attention deficit hyperactivity disorder. Chang Gung Med J [online] 2011 Jul-Aug, 34(4):440-3 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21880200

Management - Specific Treatments

Fact Explanation
Anti androgens and oestrogen Abnormal levels of androgen may contribute to inappropriate sexual arousal therefore these drugs can be used to reduce the sexual drive.[1][4]
Serotonin selective reuptake inhibitors (SSRIs) SSRIs are effective at reducing behaviors associated with fetishism and other paraphilias. They are also effective in co-morbid obsessive compulsive disorder.[1][2]
Psychotherapy Psychoanalysis, psychodynamic psychotherapy and supportive psychotherapy is used though efficacy is not proven to be high. [1] Psychotherapy is aimed at modifying rather than eliminating the fetishistic behavior.[3][4]
Behavioral therapy A variety of behavioral therapies like aversive conditioning, covert sensitization and cognitive behavior therapy can be tried.[1] Cognitive and behavior therapy as well as rational emotive therapy may improve the fetish behavior.Teaching the patient to translate his fetish sexual excitement to a more socially accepted behavior is the major treatment goal. [3][4]
References
  1. VELAYUDHAN R, KHALEEL A, SANKAR N, KUMAR M, KAZHUNGIL F, RAGHURAM TM. Fetishistic Transvestism in a Patient with Mental Retardation and Psychosis Indian J Psychol Med [online] 2014, 36(2):198-200 [viewed 22 July 2014] Available from: doi:10.4103/0253-7176.130995
  2. USMANI MA, K GAUR R, AHMAD AZMI S, GANGWAR S. Treatment of transvestic fetishism with fluoxetine: a case report. Iran J Psychiatry Behav Sci [online] 2012 Fall, 6(2):100-1 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24644490
  3. CHANG HL, CHOW CC. The treatment of fetishism in an adolescent with attention deficit hyperactivity disorder. Chang Gung Med J [online] 2011 Jul-Aug, 34(4):440-3 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21880200
  4. BRANDON S. Management of sexual deviation. Br Med J [online] 1975 Jul 19, 3(5976):149-51 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1139263