CASE
Management of a case of transvestic fetishism
Soumitra Ghosh, Dhrubajyoti Bhuyan1
Associate Professor, 1Assistant Professor, Department of Psychiatry, Assam Medical College Hospital, Dibrugarh, Assam, India
Abstract
This case report describes a 22 year old boy presenting with a history of wearing female garments for sexual arousal. He was treated successfully with the help of behaviour therapy.
Ghosh S, Bhuyan D. Management of a case of transvestic fetishism. Dysphrenia. 2012;3:181-2. Epub 2012 Mar 20.
Keywords: Paraphilia. Cross-dressing. Behaviour therapy. Aversion.
Correspondence: dr.dhrubajyoti@gmail.com
Received on 5 February 2012. Accepted on 20 March 2012.
Introduction
Transvestism nowadays called transvestic fetishism is a type of paraphilia involving cross-dressing by a male in women’s attire to obtain sexual excitement.[1] The disorder has been classically described in the heterosexual males and this diagnosis is not made if cross-dressing occurs exclusively during the course of gender identity disorder. Obtaining erotic enjoyment from the process of cross-dressing is the hallmark of the disorder.[2] The disorder typically starts at childhood or early adolescent with cross-dressing. The initial experience may involve partial or total cross-dressing and partial cross-dressing often is seen to progress to complete cross-dressing. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines transvestic fetishism as recurrent, intense sexually arousing fantasies, sexual urges or behaviours involving cross-dressing in a heterosexual male for a period of over six months causing significant distress or impairment in social, occupational or other important functioning.[1] The causes of transvestic fetishism are not well understood.[3] The causes may be many. Theories explaining transvestic phenomenon may range from old psychodynamic to the newer biological theories. Based on the theoretical construct the treatment modalities are also different, starting from psychodynamic psychotherapy to pharmacotherapy. Pennington[4] advocated pharmacotherapy with drugs like chrorpromazine and meprobamate. Many authors advocated treatment with selective serotonin reuptake inhibitors (SSRIs). Behaviour therapy in the form of aversion is also practiced with variable results.[5] Behaviour therapy is based on the principles of learning theory, mainly reward and punishment. Here is an attempt to depict the usefulness of aversion therapy in the treatment of transvestism.
Case history
A 22 year old boy belonging to a lower socioeconomic class, presented to psychiatric outpatient department (OPD) of a tertiary care teaching hospital on 21st of December 2005 with the history of sexual arousal by thinking and wearing of female garments from the age of 12–13 years. As reported by the patient at the age of 12–13 years, one day one of his aunts put him a skirt for fun and according to him he had arousal on wearing the skirt and since then he started wearing female garments in-between to have sexual arousal. He started enjoying and fantasising with the female dresses. After each episode of such cross-dressing he used to masturbate to have gratification. He started practicing this at home and also in his hostel usually when alone. However he never identifies or wishes to be a member of opposite sex. With the increasing fear of being detected by his friends and family members, he started having distress about his habit of cross-dressing and he revealed it to his parents who brought him to the psychiatric OPD. On examination he was found to have normal physical and sexual development and a heterosexual orientation but he was found to be concerned more with gratification by cross-dressing rather than having physical relationship.
Management
After obtaining consent and proper education and information about the nature of the illness to the patient, behaviour therapy in the form of aversion was started. The technique involved use of aversion with the help of behaviour therapy machine to reduce the abnormal sexual urges. The first session was started on 30th December 2005 and initially behaviour therapy was conducted at daily basis. The patient was asked to wear female dress in separate room to have sexual arousal. Therapist sat in a separate room with the aversion machine and electrodes with the long wire tied to one of the legs of the patient who was in the next room. At the height of the arousal he was asked to ring a bell as an indicator, on hearing the bell the therapist applied the mild electrical stimulus with the help of the behaviour therapy machine. Later on the sessions were spaced at weekly and then fortnightly interval. The improvement was measured in visual analogue scale and after 14 sessions the patient had 70% improvement and started to have normal arousal. After 25th session, the patient had normal arousal and so the aversion was stopped. But after stopping the aversion, patient again started having abnormal arousal with cross-dressing. So it was restarted. However after 32 sessions, patient’s abnormal arousal subsided. After completion of the therapy he had four follow ups and he rates his improvement as satisfactory and no episodes of cross-dressing or arousal with thinking about female dresses have been reported since then.
Discussion
Transvestic fetishism in a broad sense may cover a wide range of cross-dressing and sexual behaviour and feeling. The transvestic behaviour may range from dressing up with clothes of opposite sex, without obvious deviant sexual behaviour from cross-dressing with gender identity.[3] In our case, the transvestic behaviour was not associated with any other deviant sexual behaviour or gender identity or altered sexual orientation. According to Karpman[6] only a small portion of male transvestics are homosexual. The cause of transvestic fetishism is also not known but several theories have been proposed starting from psychological to biological theories. Female psychosexual functioning in a male brain produced by some biochemical malfunctioning in the centre of bisexual development antagonistic to the gender represented by the gonads may be the cause of transvestism.[2] According to psychodynamics transvestism is because of intense castration anxiety while behaviourists posit that it is a learned behaviour.[3]
There is no general consensus about the treatment of transvestic fetishism and treatment is difficult and prolonged and options vary from pharmacotherapy to non-pharmacotherapeutic interventions.[3] Many have used various pharmacological agents for the treatment of this condition. There have been case reports of management of such cases with pharamacological agents like nialamide, chlorpromazine and meprobamate with complete negation of transvestic symptoms and a return to normal behaviour.[4] However many advocate the use of behavioural therapies to such cases.
Behaviour therapy is a term used to describe a number of psychotherapeutic measures varying from aversive conditioning to desensitisation with all having a common theoretical basis.[5] The disorders of sexual behaviour that can be treated with the help of behaviour therapy include impotence, frigidity, voyeurism, fetishism, exhibitionism, homosexuality and transvestism.[5] The rationale behind such type of treatment is that these behaviours are acquired through the principles of learning and therefore these behaviours can also be eliminated by the process of learning either by extinction or inhibition.[5]
The use of aversion therapy (chemical or electrical) is not new. Davies and Morgenstern[7] report an unsuccessful attempt to treat a transvestite patient by apomorphine aversion conditioning. It is impossible however to ascertain any possible effects of this therapy on the patient because of the marked organic syndrome involved. Raymond[8] also used aversive conditioning to patients with fetishism with mixed results. In our case aversive conditioning was found to be quite effective and after repeated follow ups after completion of the therapy patient was found to be better and with no reported episodes of cross-dressing.
Further reading
Hirschfeld M. Sexual anomalies and perversions. 2nd ed. Haire N, editor. London: Encyclopaedic Press; 1952.
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association 2000.
2. Moser C, Kleinplatz PJ. Transvestic fetishism: psychopathology or iatrogenic artifact? New Jersey Psychologist [Internet]. 2002 [cited 2012 Mar 20];52:16-7. Available from:http://home.netcom.com/~docx2/tf.html
3. Bowman KM, Engle B. Medicolegal aspects of transvestism. Am J Psychiatry. 1957;113:583-8.
4. Pennington VM. Treatment in transvestism. Am J Psychiatry. 1960;117:250-1.
5. Rachman S. Sexual disorders and behavior therapy. Am J Psychiatry. 1961;118:235-40.
6. Karpman B. Dream life in a case of transvestism, with particular attention to the problem of latent homosexuality. J Nerv Ment Dis. 1947;106:292-337.
7. Davies BM, Morgenstern FS. A case of cysticercosis, temporal lobe epilepsy, and transvestism. J Neurol Neurosurg Psychiatry. 1960;23:247-9.
8. Raymond MJ. Aversion therapy for sexual deviations. Br J Psychiatry. 1969;115:979-80.
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