Transvestic Disorder and How It Differs from Being Transgender

Phrases like "dressing as a woman" or "liking to wear clothes of the other sex" are often lumped together with very different things: genderless fashion, drag performance, certain sexual preferences and being transgender. This confusion leads to many people being stigmatised for no reason. This article separates these things clearly and explains who the diagnosis of transvestic disorder actually applies to.

This article is part of the Paraphilic Disorders series.

Four things that often get mixed up

Read more about identity in Gender identity: gender as a spectrum and its dimensions and Genderless fashion and gender expression.

Transvestic disorder in DSM-5-TR

DSM-5-TR (2022) diagnoses it when:

1. There is intense, recurrent sexual arousal from cross-dressing, shown through fantasies, urges or behaviour, lasting at least 6 months.
2. The interest causes clinically significant distress or impairment in daily life.

Clinicians may add the specifier "with fetishism" (arousal from fabrics or garments, close to a fetish) or "with autogynephilia" (arousal from thoughts or images of oneself as a woman), and may add "in a controlled environment" or "in full remission". In practice this diagnosis applies to very few people, because most people who cross-dress are not distressed by it. A Canadian survey (Joyal & Carpentier, 2017) found that about 6% of adults had experienced desires of this kind.

A preference vs a condition that needs treatment

• If cross-dressing makes you feel relaxed, happy or excited, and causes no distress and does not affect your life, it is expression or a preference, not a disorder.
• If those feelings bring intense shame, self-rejection, lost relationships, or preoccupation that harms your work, talking with a professional will help.
• Distress that comes only from society or your family not accepting you does not mean you are abnormal. It is still pain that deserves understanding care.

Why this diagnosis is contested

I want to be frank: transvestic disorder is one of the most criticised diagnoses in this group.

• The concept of autogynephilia has been criticised for describing trans women's experiences too narrowly, and it has been used to deny their identities. Scholars point out that studies have found similar feelings in women who are not transgender, which makes the clinical meaning of the concept unclear (Moser, 2010; Serano, 2010).
• The World Health Organization's ICD-11 removed the diagnoses "fetishistic transvestism" and "dual-role transvestism", because they had too little clinical usefulness and caused stigma (Krueger et al., 2017).
• ICD-11 moved gender incongruence out of the chapter on mental disorders and into the chapter on conditions related to sexual health, so that transgender people can access services without being labelled as mentally ill.
• The WPATH Standards of Care, Version 8 (SOC-8, 2022) affirm that gender diversity is not a pathology.

So if you are transgender, or exploring your identity, having felt sexually aroused when dressing does not mean your identity is not real. Gender identity is about knowing who you are, not about sexual arousal.

Assessment and care

For people who are distressed by this, care begins with an affirming, non-judgmental conversation.

• Exploring where the distress comes from: feelings about yourself, fear of being found out, conflict with a partner, or questions about identity.
• Psychotherapy and sex therapy help reduce shame and find ways of expressing yourself that feel comfortable and safe.
• Couples therapy when your partner wants to understand and adjust together. See Common couple problems and how to talk them through.
• If you have questions about identity, gender-affirming care in line with WPATH SOC-8 is more appropriate. For information on hormones, read Gender-affirming hormone therapy (GAHT): starting safely.

This condition almost never needs medication, and no treatment should aim to "change" anyone's gender identity. Conversion therapy does not work and causes harm.

Where to get help

• Talk confidentially with a clinical sexologist. See When to see a clinical sexologist.
• 1323, Thailand's free mental-health hotline (Thai language; ask for English support), if you are distressed or having thoughts of harming yourself.
• For other sexual interests outside the main groups, read Other paraphilic disorders.

Dr. Kris Clinic offers services that are welcoming to people of all genders, including clinical sexology consultations and gender-affirming hormone care, at the clinic and online, including in English, without judgment.