Kelley Winters, Ph.D.
GID Reform Advocates
In January 2000, Peter Oiler, a married Louisiana truck driver for the Winn-Dixie grocery chain, was fired from his job after he came out of the closet to his boss,
“I told him … I’m not gay, I’m transgendered.”
“I told him I have a tendency to dress as a lady.” 
A Winn-Dixie manager explained why Peter, an exemplary employee of more than 20 years, was terminated:
“[Oiler] was doing something that was abnormal in most people’s opinion about what was accepted for a person who is a man.” 
Unfortunately, such derogatory public perceptions about cross-dressing and “abnormality” are promoted by the American Psychiatric Association in the current Diagnostic and Statistical Manual of Mental Disorders (DSM), edition IV-TR.  The diagnostic category of Transvestic Fetishism casts gender nonconformity in clothing as mental disorder and sexual deviance. Its inclusion in the DSM begs the question, should a clothing disorder merit medical nomenclature? Is cross-dressing by born-males a psychosexual wardrobe malfunction or is it simply a facet of human diversity “ubiquitous throughout human history?”
The term, transvestite, was coined by Magnus Hirschfeld in 1910 from Latin roots meaning to cross-dress. Transvestism in the DSM-III was renamed “Transvestic Fetishism” (TF) in the DSM-III-R . The very title equates cross-dressing with sexual fetishism and social stereotypes of perversion. It sexualizes a diagnosis that does not clearly require a sexual context. In fact, Hirschfeld rejected fetishism as a diagnostic label for cross-dressing that represents self-expression, erotic or not, rather than erotic focus on clothing itself. 
Cross-dressing very often represents social expression and social identity. People who identify as cross-dressers make up a large portion of the emerging transgender movement. The oldest U.S. national support organization for heterosexual cross-dressers, the Foundation for Personality Expression, was founded by Virginia Prince in the 1960s and is now known as The Society for the Second Self or Tri-Ess.  Tri-Ess describes cross-dressers as “ordinary heterosexual men with an additional feminine dimension.” Their vision emphasizes “Full personality expression, in a blending of both our masculine and feminine characteristics, in order to be all we can be.”  However, the diagnostic criteria for Transvestic Fetishism ambiguously reduces this social expression of femininity by cross-dressing males to sexual deviance.
Criterion A for Transvestic Fetishism:
Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. 
Criterion A is grammatically ambiguous.  The phrase, “sexually arousing,” could be interpreted to apply to only “fantasies” or to all three of “fantasies, sexual urges, or behaviors” with very different meaning. The first interpretation would implicate all recurrent cross-dressing behavior as sexual deviance. This interpretation is promoted in the DSM-IV Casebook,  which recommends a TF diagnosis for a male whose cross-dressing is not necessarily sexually motivated. The second would limit the diagnosis to sexually motivated cross-dressing, as did the DSM-III-R,  and imply the ackward phrase, “sexually arousing sexual urges.” Although labeled a “fetishism,” it is not clearly stated whether or not cross-dressing must be sexual in nature to qualify for diagnosis.
Moreover, coincidence is conflated with causality in the phrase “behaviors involving cross-dressing,” which requires no actual erotic motivation. This can imply that all cross-dressing by born-males is sexually motivated, whether it is or not. The resulting stereotype of sexual deviance is not limited to cross-dressers but disparages transsexual women as well. Full-time transition to a female social role could be interpreted as “behaviors involving cross-dressing” and therefore “fetishistic” under Criterion A.
In fact, transsexual and gender dysphoric individuals were specifically excluded from Tranvestic Fetishism diagnosis in the DSM-III-R  and this exclusion was removed in the DSM-IV. A major focus of the DSM-IV Subcommittee of Gender Identity Disorders was to allow concurrent diagnosis of GID and TF which was prohibited in previous editions.  A positive consequence of this change removed barriers to medical transition care for transsexual women who had been diagnosed as “transvestites.” However, it also broadened the stigma of sexual paraphilia and deviance to include many transsexual women.
Diagnosis of Transvestic Fetishism is limited to heterosexual males in Criterion A. Curiously, women and gay men are free to wear whatever clothing they chose without a label of mental illness. This criterion serves to enforce a stricter standard of conformity for straight males than women or gay men. Its double-standard not only reflects the social privilege of heterosexual males in American culture, but enforces it.  One implication is that biological males who emulate women, with their lower social status, are presumed irrational and mentally disordered, while biological females who emulate males are not. A second implication stereotypically associates femininity and cross-dressing with male homosexuality and serves to punish straight males who transgress this stereotype. Author Arlene Lev noted that the TF diagnosis is “more about sexist values and conflicts between individuals and society than they are about sexual disorders and human distress.”  This violates the definition of mental disorder given in the DSM, which specifically exclude “conflicts between the individual and society” without clinically significant dysfunction. 
Criterion B for Transvestic Fetishism:
The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Distress and impairment became central to the definition of mental disorder in the DSM-IV,  where a generic clinical significance criterion was added to all Sexual and Gender Identity disorders, including Criterion B of Transvestic Fetishism. It was an attempt to prevent false-positive diagnosis of people who do not meet the definition of mental disorder.
Unfortunately, Criterion B does not specifically define distress or impairment for the TF diagnosis. It does not allow for the existence of healthy, well-adjusted male-identified heterosexual cross-dressers. Moreover, Criterion B makes no distinction between internal clinical distress and that caused by external prejudice and discrimination. Tolerant clinicians may infer that transgender identity or expression is not inherently impairing, but that societal intolerance and prejudice are to blame for the distress and internalized shame that transpeople often suffer.  However, clinicians intolerant of gender diversity will infer the opposite: that cross-gender identity or expression by definition constitutes impairment, regardless of the individual’s happiness or well-being.
Dr. Kenneth Zucker, chair of the present DSM-V Sexual and Gender Identity Disorders work group and Dr. Raymond Blanchard, chair of the DSM-V paraphilias subcommittee, were critical of including the clinical significance criterion for Transvestic Fetishism and dismissed it as “muddled” and having “little import.” They reasoned that “individuals with TF who consult mental health professionals are presumably, in some respect, distressed or impaired by their condition.”  This circular logic is even more concerning, because “… adolescents with TF rarely self-refer. The initiative is invariably on the part of an adult.” . This implies that cross-dressing youth who are subjected to intolerance by parents or authorities are classed a priori as mentally disordered.
Ironically, the clinical significance critera for five other paraphilia diagnoses in the DSM-IV-TR, Exhibitionism Froteurism, Pedophilia, Sexual Sadism and Voyeurism, were revised with more precise wording to limit inappropriate diagnosis.  The APA apparently had no such concern for false-positive diagnosis of gender nonconforming males who meet no definition of mental disorder.
In the supporting text of the TransvesticFetishism diagnosis, behaviors that would be considered ordinary or exemplary for genetic women are presented as symptomatic of mental disorder on the basis of born genitalia and sexual orientation. These include collecting and wearing female clothes or undergarments, dressing entirely as females, wearing makeup, expressing feminine mannerisms and “body habitus,” and appearing publicly in a feminine role.  It is not clear how these same behaviors can be pathological for one group of people and not for another.
More disturbing, the supporting text lists “involvement in a transvestic subculture” among symptomatic “transvestic phenomena.” Psychiatric diagnosis on the basis of social, cultural or political affiliation evokes the darkest memories of medical abuse in American history. For example, women suffragettes who demanded the right to vote in the early 1900s were diagnosed and institutionalized with a label of “hysteria.”  Immigrants, Bolsheviks and labor organizers of the same era were labeled as socially deviant and mentally defective by psychiatric eugenicists.  In truth, transgender support organizations worldwide are a primary source of support, education and civil rights advocacy for gender variant people, families, friends and allies. Their necessity is a consequence of social intolerance, not of mental deficiency.
The Transvestic Fetishism diagnosis is currently classified as a sexual paraphilia, defined in the DSM-IV-TR as
“recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation or oneself or one’s partner, or 3) children or other nonconsenting persons” 
Sexual paraphilias in the DSM include such terribly stigmatizing disorders as Pedophilia, Exhibitionism, Fetishism, Frotteurism, Sexual Masochism, Sexual Sadism, and Voyeurism. This placement of the TF diagnosis serves to legitimize false stereotypes that unfairly associate cross-gender expression with criminal or harmful conduct.
Lacking a clear justification for the Transvestic Fetishism diagnosis according to the definition of mental disorder in the current DSM, its authors resorted to the heteronormative presumption:
“If the phylogenetic function of sexuality or eroticism is reproduction, and if its ontogenetic function is to enhance pair-bond formation and intimacy, then TF clearly is problematic at both levels of analysis.” 
This is essentially the argument used to justify the classification of homosexuality in prior editions of the Diagnostic and Statistical Manual [28-30]. In proclaiming gender role nonconformity as mental illness, the authors of Transvestic Fetishism fail to mention the role of intolerance, prejudice and sex stereotyping as barriers to intimacy and pair-bonding in a species as diverse as ours.
Speaking at the 2003 Annual Meeting of the American Psychiatric Association, Dr. Charles Moser noted, “Diagnoses should be removed if they cannot be shown to meet the definition of a mental disorder unambiguously and be substantiated by appropriate research.”  Arlene Lev concurred for the case of Transvestic Fetishism:
“transvestic fetishism is a normal human behavior transformed into a mental illness. … it should not be listed in a manual of mental disorders.” 
Perhaps Peter Oiler said it best,
“I’m tired of the closet. It’s dark and musty and I want out! I want to settle some issues I have with myself. I want to tell everyone in my situation, “you are not alone.” It doesn’t make you a weirdo to put on a dress or pants.” 
With publication of the DSM-V, it is time for the American Psychiatric Association to remove the anachronistic and sexist diagnosis of Transvestic Fetishism. Nonconformity to gender stereotypes is not mental illness; difference is not disease.
 GenderPAC, “GenderPAC National News Interviews Peter Oiler,” Feb 2001, http://www.gpac.org/archive/news/notitle.html?cmd=view&msgnum=0275
 K. Choe, American Civil Liberties Union, “Why We’re Asking Courts and Legislatures for Transgender Equality, ” Where We Are 2003: The Annual Report of the ACLU Lesbian & Gay Rights Project, Jan 2003, http://www.aclu.org/lgbt/transgender/12077pub20030101.html
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.
 V. Bullough and B. Bullough, Cross Dressing, Sex and Gender, Univ. of Pennsylvania Press, 1993, p. 18.
 American Psychiatric Associatio, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, 1987, p. 288.
 M. Hirschfeld, The Transvestites: An Investigation of the Erotic Drive to Cross Dress [Die Tranvestiten], Leipzig: Sporh, 1910; trans. M. Lombardi-Nash, Promethius Books, 1991, p. 161.
 V. Prince, R. Ekins, and D. King, Virginia Prince: Pioneer of Transgendering, Haworth Press, 2005, pp. 7-8.
 The Society for the Second Self, Inc. , http://www.tri-ess.org/
 DSM-IV-TR, 2000, p. 575.
 K. Winters (published under pen-name Katherine Wilson) and B. Hammond, “Myth, Stereotype, and Cross-Gender Identity in the DSM-IV,” Association for Women in Psychology 21st Annual Feminist Psychology Conference, Portland OR, 1996, http://www.gidreform.org/kwawp96.html.
 Spitzer, R., editor, DSM-IV Casebook, A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition), American Psychiatric Press, 1994, pp. 257-259.
[12-13] DSM-III-R, 1987, p. 289.
 Bradley, S., et al. (1991). “Interim Report of the DSM-IV Subcommittee on Gender Identity Disorders,” Archives of Sexual Behavior, Vol. 20, 1991, No. 4, p. 338.
 K. Wilson (former pen-name for Kelley Winters), “Gender as Illness: Issues of Psychiatric Classification,” 6th Annual ICTLEP Transgender Law and Employment Policy Conference, Houston, Texas, July 1997. Reprinted in Taking Sides – Clashing Views on Controversial Issues in Sex and Gender, E. Paul, Ed., Dushkin McGraw-Hill, Guilford CN, 2000, pp. 31-38. http://www.gidreform.org/kwictl97.html
 A. Lev, Transgender Emergence, Therapeutic Guidelines for Working with Gender-Variant People and Their Families, Haworth Press, 2004, p. 171.
 DSM-IV-TR, 2000, p. xxxi.
 DSM-IV, 1994, p. xxi.
 G. Brown, “Cross-Dressing Men Often Lead Double Lives,” The Menninger Letter, April, 1995, pp. 4-5.
 K. Zucker and R. Blanchard, “Transvestic Fetishism: Psychopathology and Theory,” Handbook of Sexual Deviance: Theory and Application, Guilford Press, 1997, p. 258.
 K. Zucker and S. Bradley, “Gender Identity Disorder and Tranvestic Fetishism,” eds. S. Netherton, et al., Child and Adolescent Psychological Disorders, A Comprehensive Textbook, Oxford Press, 1999, p. 386.
[22-23] DSM-IV-TR, 2000, p. 574.
 M. Mayor, “Fears and Fantasies of the anti Suffragists,” Connecticut Review 7, no. 2, April 1974, pp. 64-74.
 I. Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940. Sage House, 1997, pp. 133-177.
 DSM-IV-TR, 2000, p. 566.
 Zucker and Blanchard, 1997, p. 262.
 S. Rado, Psychoanalysis of Behavior II, Grune and Stratton, 1962.
 C. Socarides, The Overt Homosexual, Basic Books, 1962.
 R. Stoller, J. Marmor, I. Beiber, et al.,”A Symposium: Should Homosexuality be in the APA Nomenclature?” American Journal of Psychiatry, vol. 130, 1973, pp. 1208-1215,
 C. Moser and P. Kleinplatz, “DSM-IV-TR and the paraphilias: An argument for removal.” Journal of Psychology and Human Sexuality 17(3/4), also published in Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM), Eds. D. Karasic, and J. Drescher, Haworth Press, 2005, p. 106.
 Lev, 2004, p. 171.
 GenderPAC, 2001.
Copyright © 2008 Kelley Winters, GID Reform Advocates