Ten Reasons Why the Transvestic Disorder Diagnosis in the DSM-5 Has Got to Go

Kelley Winters, Ph.D.
GID Reform Advocates

The classification of gender diversity and nonconformity to birth-assigned gender roles as mental illness by the American Psychiatric Association (APA) has drawn growing protest and outrage from transpeople and and allies worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the APA, is regarded as the medical and social definition of mental disorder throughout North America and strongly influences international diagnostic nomenclature. The fifth edition of the manual, the DSM-5, is in development and scheduled for publication in 2013. While the diagnostic category of Gender Identity Disorder (GID) has garnered most of the controversy, a second category of so-called Transvestic Fetishism (TF) has harmed transwomen, including transsexual women, as well as male-to-female crossdressers, dual gender and gender nonconforming people since the earliest days of the DSM. Trans and LGB advocates have been inexplicably quiet about the TF category, even after the APA proposed to expand the category in the DSM-5, renamed Transvestic Disorder, to implicate gender nonconforming people of all sexes and all sexual orientations.

The proposed DSM-5 diagnosis of Transvestic Disorder, even worse than its predecessor Transvestic Fetishism, labels gender expression not stereotypically associated with assigned birth sex as inherently pathological and sexually deviant. The diagnosis is punitive and scientifically capricious, serving to punish social and sexual gender nonconformity and enforce binary stereotypes of assigned birth sex. Here are ten reasons why the Transvestic Disorder diagnosis should be eliminated entirely from the DSM-5.

1. Diagnosis of Diversity

The World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association, (HBIGDA), publishes recognized standards of medical transition care for those who need it. In May, 2010, WPATH issued the following pivotal statement on de-psychopathologisation of gender variance,

The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The [psychopathologisation] of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being. WPATH urges governmental and medical professional organizations to review their policies and practices to eliminate stigma toward gender-variant people. 

Gender expression that differs from social expectations of assigned birth sex does not meet any medical or scientific definition of mental pathology. Difference is not disease.

2. Stigma of Sexual Deviance

Transvestic Disorder is classified as a “paraphilic” sexual disorder, grouped with diagnoses of such harmful behaviors as pedophilia and exhibitionism. The resulting stereotypes of sexual deviance deny human dignity and civil justice to transgender and gender variant people, including transsexual individuals, who consequently lose their jobs, homes, families, children, freedoms and access to public accommodation.

In the United States, these false stereotypes were exemplified in a full-page newspaper ad campaign in 2008 by Focus on the Family, a political extremist group opposed to civil rights for transpeople in the state of Colorado. A transwoman was depicted in a photo as a disheveled suspicious male in dirty work boots, lurking in a women’s restroom as a little girl stepped out of a stall. The ad contained the headline, “Colorado Just Opened Its Bathrooms to Either Sex!” with the phrase, “sexual predator.” The association of transwomen with sexual predation and threat to children was in reference to the association of transwomen with “paraphilia” in the DSM.

3. Denial of Civil Justice

In the DSM-III, the APA stated, “The crucial issue in determining whether or not homosexuality per se should be regarded as a mental disorder is not the etiology of the condition, but its consequences and the definition of mental disorder.” Tragically, the APA has neglected to apply this same logic to the consequences of psychopathologization of gender variance and nonconformity.

For example, Andrea Lafferty, of the extremist Traditional Values Coalition, exploited the TF and GID diagnostic categories to oppose national employment nondiscrimination legislation for GLBTQ Americans in a CBS News interview this year. Lafferty cited the APA while repeating that transpeople have “a serious mental disorder” and represent a threat to children. In fact, the current TF and GID nomenclature have played a pivotal role in the ongoing defeat of the Employment Nondiscrimination Act (ENDA) in the U.S. Congress, as opponents have focused on sensational false stereotypes of mental illness and sexual deviance rather than direct attack against gay and lesbian people.

4. Pathologization of Ordinary Behaviors.

The supporting text of the Transvestic Fetishism diagnosis describes behaviors that would be ordinary or even exemplary for cisgender women as symptomatic of mental disorder for transgender women and gender nonconforming males. These include wearing female clothing, dressing entirely as females, wearing makeup, expressing feminine mannerisms and appearing publicly in a feminine role. The text goes so far as to list “involvement in a transvestic subculture” among pathological “transvestic phenomena.” It is not clear how the very same behaviors and social/political affiliations can be pathological for one group of people and not for others.

5. Harm to Transsexual Women

The proposed Transvestic Disorder category is not limited to crossdressers or male-identified people. It also targets transsexual women with a specifier of “autogynephilia,” a deeply offensive label that sexualizes ordinary and customary social gender expression and promotes a poorly supported and socially defamatory theory that transsexual women transition to satisfy a sexual fetish rather than attain harmony with their experienced gender identity. The label of Transvestic Fetishism has also been used to deny medical transition treatment for transsexual indivicuals who need it. For example, the diagnosis was cited by Federal attorneys against Ms. Rhiannon O’Donnabhainn in her recent landmark case in U.S. Tax Court. They used the TF category to promote a false stereotype of fetishism to argue that corrective transition surgeries for transsexual women are not medically necessary.

6. Harm to Transmen

In June of this year, the phrase “in a male,” in reference to birth-assigned sex, was removed from criterion A for the proposed Transvestic Disorder without explanation. As a result, transmen and masculine or butch women may now be implicated with Transvestic Disorder because of the clothes they wear. A new specifier of “with autoandrophilia” was added to the diagnostic criteria to target transsexual men, much as the specifier of “autogynephilia” would target and defame transsexual women.

7. Harm to Non-erotically Motivated Crossdressers

Ambiguous language in Criterion A of the APA Transvestic Disorder proposal implicates sexual expression “involving” crossdressing, without evidence of causation. Thus, virtually any gender expression among bigender, dual-gender or genderqueer people that is coincident with any kind of a sex life may be inferred as diagnosable, whether erotically motivated or not.

It is apparent that DSM authors have long intended for the TF diagnosis to implicate non-erotic or ambiguously erotic crossdressing as a fetishistic psychopathology. For example, the DSM-IV Casebook recommended a Transvestic Fetishism diagnosis for a male-identified subject whose crossdressing was not necessarily sexually motivated.

8. Harm to Erotically Motivated Crossdressers

Crossdressing that is erotically motivated is a benign consensual sexual expression that does not rise to the definition of mental illness. There is no scientific justification for labeling this behavior as mentally or sexually pathological. The DSM-IV-TR states, “Neither deviant behavior … nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of dysfunction…”

9. Harm to Ego-Dystonic (self-unaccepting) Crossdressers

The APA proposal for Transvestic Disorder, pathologizes ego-dystonic crossdressers, who are distressed by internalized shame and societal transphobia, very much as the previous diagnosis of Ego-Dystonic Homosexuality in the DSM-III pathologized victims of social homophobia. Ego-Dystonic Homosexuality was removed entirely from the DSM-III-R in 1987, because it inexorably associated all same sex orientation with pathology and because “almost all people who are homosexual first go through a phase in which their homosexuality is ego-dystonic.” The very same logic should apply to the Transvestic Disorder diagnosis in the DSM-5. It would be tragic for the APA to perpetuate a diagnosis so analogous to Ego-Dystonic Homosexuality of the last century.

10. Implicit Endorsement of Gender-Reparative Therapies

In 2008, the American Psychiatric Association (APA) released public statements that, “…the DSM is a diagnostic manual and does not provide treatment recommendations or guidelines.” In fact, however, diagnostic nomenclature and treatment are inseparably related. The efficacy of all drug and psychotherapy treatments are judged according to specific diagnostic criteria listed in the DSM and ICD. The diagnostic criteria for the proposed Transvestic Disorder in the DSM-5 favor gender-reparative therapies that serve to repress gender nonconforming fantasies, urges and behaviors, described in criterion A. Bigender, dual gender or gender variant individuals who are not shamed into repression but are distressed by external societal intolerance, would perpetually meet the criteria regardless of how happy and functional they might otherwise be.
It is time to call upon the APA leadership to reject the proposed diagnostic category of Transvestic Disorder and remove nomenclature from the DSM that casts crossdressing and gender role nonconformity in themselves as mental disorder.

Appendix A: DSM-IV-TR Diagnostic Criteria for Transvestic Fetishism
(APA 2000)

A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. 

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 

Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity 

Appendix B: Proposed DSM-5 Diagnostic Criteria for Transvestic Disorder
(APA 2010)

A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross-dressing. 

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.: 

Specify if:  

With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments) 

With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female) 

With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male) 

Specify if: 

In Remission (During the Past Six Months, No Signs or Symptoms of the Disorder Were Present) 

In a Controlled Environment 


American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Washington, D.C., p. 426.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C., p. xxii.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., pp. xxxi, 574-5.

American Psychiatric Association (2008), “APA STATEMENT ON GID AND THE DSM-V,” http://www.psych.org/MainMenu/Research/DSMIV/DSMV/APAStatements/APAStatementonGIDandTheDSMV.aspx , May 23

American Psychiatric Association (2010) “DSM-5 Development; Proposed Revisions, 302.3
Transvestic Fetishism,”

Blanchard, R. (1989). “The Classification and Labeling of Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 18 n. 4, p. 322-323.

Cordes, N., CBS News (2010). “Washington Unplugged,” April 20 http://www.cbsnews.com/video/watch/?id=6414895n (audio excerpts of Andrea Lafferty, of the Traditional Values Coalition, repeating slurs of mental disorder are available at http://www.gidreform.org/cbslafferty1.mp3 )

DeCuypere, G., Knudson G., & Bockting, W. (2010). “Response of the World Professional Association for Transgender Health to the Proposed DSM 5 Criteria for Gender Incongruence,” http://www.wpath.org/documents/WPATH%20Reaction%20to%20the%20proposed%20DSM%20-%20Final.pdf

Focus on the Family Action (2008). Colorado Springs, CO, http://www.citizenlink.com. Photo available online at http://www.gidreform.org/2008FOFsb2006.jpg

Lev, A., Alie, L., Ansara, Y., Deutsch, M., Dickey, L., Ehrbar, R., Ehrensaft, D., Green, J., Meier, S., Richmond, K., Susset, F., Winters, K. (2010). Professionals Concerned With Gender Diagnoses in the DSM Statement on Transvestic Disorder in the DSM-5, http://gidconcern.wordpress.com/statement-on-transvestic-disorder-in-the-dsm-5/

Serano, J. (2009). “Autogynephilia’ and the psychological sexualization of MtF transgenderism,” International Foundation for Gender Education 2009 Conference, Alexandria VA, March, http://ai.eecs.umich.edu/people/conway/TS/IFGE2009/Disordered_No_More.html#Julia

Spitzer, R., editor (1994), DSM-IV Casebook, A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition), American Psychiatric Press, pp. 257-259.

Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the Struggle for Dignity. CO: GID Reform Advocates, pp. 33-43.

Winters, K., (2010). “A Taxing Question of Medical Necessity,” GID Reform Advocates Essay Series on Gender Diagnoses in the DSM-V, Feb 6, http://www.gidreform.org/blog2010Feb06.html

Winters, K. (2010). “Comments on the Proposed Revision to 302.3 Transvestic Fetishism,” http://www.gidreform.org/201004APATFkwB.pdf

World Professional Association for Transgender Health (2010). “Statement Urging the De-psychopathologisation of Gender Variance,” http://wpath.org/

About Kelley
Dr. Kelley Winters is a writer and consultant on issues of gender diversity in medical and public policy. She is the author of Gender Madness in American Psychiatry: Essays from the Struggle for Dignity (2008) and a past member of the International Advisory Panel for the World Professional Association for Transgender Health (WPATH) Standards of Care, the Global Action for Trans* Equality (GATE) Expert Working Group, and the Advisory Boards for TransYouth Family Allies (TYFA). She was recognized in the 2013 Trans 100 Inaugural List for work supporting the transgender community in the US. Kelley has presented papers and presentations on gender policy issues at annual conventions of the American Psychiatric Association, the American Psychological Association, the American Counseling Association and the Association of Women in Psychology. Kelley wanders the highways of America in an old Mazda, ever in search of comfort food.

8 Responses to Ten Reasons Why the Transvestic Disorder Diagnosis in the DSM-5 Has Got to Go

  1. Pingback: Trans and Mental Health: “… But It Shouldn’t Matter If I Was.” « Dented Blue Mercedes

  2. Pingback: Ten Reasons Why the Transvestic Disorder Diagnosis in the DSM-5 Has Got to Go

  3. Jasper Gregory says:

    Kelley, I thought that part of the rationale for introducing the Paraphilic Disorders was to depathologize consensual fetish which be labeled a paraphilia but not a disorder.
    I saw a sex positive dsm reform site speak out in favor of this from a legal standpoint.

    • gidreform says:

      The Devil is in the details. While Dr. Blanchard did make a distinction between paraphilia and “paraphilic disorder” in his proposed titles for the DSM-5, he failed to reflect this in his diagnostic criteria for “transvestic disorder” or other paraphilic categories. At the heart of the issue, he did not correct the clinical significance criterion to exclude victimization by societal prejudice. Therefore, a well adjusted gender nonconforming child or adult bullied in the schoolyard or fired from a job are labeled mentally ill, because their victimization represents “impairment” under his Criterion B:

      “B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

      Historically, Blanchard and Zucker have made just this argument to dismiss the clinical significance criterion for transvestic fetishism as of “little import,” (1997) clearly implicating nonconformity to gender stereotypes of assigned birth sex, in itself, as mental pathology. Therefore, Blanchard’s clarifications in the titles may be positive on the surface but are in title only. He did not change the definition of his proposed diagnostic criteria accordingly, and therefore did not actually depathologize consentual fetishistic crossdressing. Even if he had corrected Criterion B., he has not explained why ego dystonic crossdressers, who have internalized societal shame about their gender nonconformity, should be classified as mentally disordered, while ego-dystonic cisgender gay and lesbian people very clearly are not (since 1987; see points #9 and #10 of this essay).

      The central issue remains unanswered; Dr. Blanchard never justified why crossdressing or gender expression that differs from assigned birth role, erotic or not, should ever be classified as mental illness in the first place. Please join me in calling for the complete removal of Dr. Blanchard’s “Transvestic Disorder” category from the DSM-5. Difference is not disease. Nonconformity is not pathology.

  4. Joe Shaffer says:

    I agree Transvestic Disorder has got to go.

  5. Pingback: The Complicated Question Of Diagnosing Transgender Identities | Political Analytical – Insight and Analysis on Politics and Reason

  6. Pingback: DSM-5 Plays Sleight of Hand With Trans Diagnosis | Care2 Causes

  7. Pingback: Trans* People And Mental Illness | Today I Am A Man

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