Transvestism as a Symptom: A Case Series.

Transvestism, commonly termed as cross-dressing, means to dress in the clothing of opposite sex. We describe a series of three cases with transvestism as one of their primary complaints. The discussion sheds light on the various ways in which transvestism as a symptom can present in Psychiatry. In the first two cases, there was lower intelligence. In first and third case, there were other paraphilia along with transvestism. Second case had co-morbid obsessive-compulsive disorder (OCD) and had good response to selective serotonin reuptake inhibitor (SSRI).

INTRODUCTION

Transvestism, commonly termed as cross-dressing, means to dress in the clothing of opposite sex. Cross-dressing is seen in varying degrees in paraphilias like dual role transvestism, fetishism and trans-sexualism. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) specifies if it is with fetishism or autogynephilia (sexually aroused by thoughts or images of self as female).[1] Multiple paraphilias co-exist in varying degrees.[2] Paraphilias are also considered part of OCD spectrum disorders.[3] Here, we describe three cases with transvestism as one of the primary complaint and in addition having other co-morbidity.

CASE REPORTS

Case 1

Seventeen-year-old male, youngest of four siblings, staying with parents and three elder sisters, was brought by mother for behavioural disturbances and anger outbursts.

Since 3 years, he stole sisters’ undergarments and used them for masturbation. This was recurrent and persistent despite warning by parents. He had started using these clothes out of curiosity, but later got arousal and gratification only on using the inner garments for genital stimulation. He sometimes dressed up in the inner garments during masturbation but it was not necessary for arousal. Other paraphilic behaviours like attempts to rub his genitals against the sister while she was asleep, watching females taking bath, exhibitionistic behaviour were also present. Gender identity was male and had sexual fantasies towards females. He denied fantasizing himself as a female during these episodes nor desire to become female.

Anger and aggressive behaviour over family members when confronted for such behaviour was present.

Patient's scholastic performance was poor since childhood and further deteriorated since 7th grade. Since 1 year, there were complaints from school that patient misbehaved with girls and tried to touch them inappropriately.

Physical examination was unremarkable. Secondary sexual characteristics were well-developed. Intelligence quotient (IQ) assessment revealed mild mental retardation (IQ-57). Ultrasonography (USG) abdomen ruled out any adrenal pathology.

Patient was diagnosed as mild MR with paraphilia and started on sodium valporate at 20 mg/kg in view of behavioural disturbances. Psychoeducation about appropriate sexual behaviour was done. At 12 weeks, family reported mild improvement in anger and no further episodes of paraphilic behaviour.

Case 2

Twenty-six-year-old, younger of two brothers from a nuclear family, was brought by mother with complaints of extreme fearfulness and avoidance of all males and dressing up in his mother's clothes while alone at home. He was scholastically poor since childhood and quit studies after 9th grade. Fearfulness for men had developed 5 years ago after a male employer he worked for used to touch patient inappropriately over his shoulders and back, against patient's wishes, though there was never any sexual contact. Since then, patient got very anxious in presence of men and constantly feared that they might try to ‘rape’ him or assault him. These thoughts were persistent and intrusive in the presence of any male. Therefore, he stopped talking to all males including his brother and would never allow any male to come close to him. Repeated hand washing in case of body contact with males was present. Patient had quit job to avoid any contact with males.

Patient repeatedly dressed up in his mother's clothes and jewellery whenever alone at home and would remain so for varying periods. This relieved his distress related to constant fear of males and gave a sense of contentment. He denied sexual arousal or fantasising being a female while cross-dressing. His gender identity was male and his sexual fantasies limited to females. There were no associated paraphilic behaviours.

Patient had extreme anxiety in the presence of a male doctor but was comfortable with a female doctor. He would try to develop subtle body contact with female doctor like hand shake, which made him relaxed. Patient had male pattern secondary sexual characteristics and borderline intelligence (IQ 78).

Patient predominantly had features of OCD and transvestic behaviour appeared as a means to alleviate anxiety rather than for sexual gratification. Patient was treated with fluoxetine upto 60 mg. Remarkable improvement in cross-dressing, fear of males and repetitive handwashing was present at 12 weeks.

Case 3

Eleven-year-old, elder of two boys from a rural nuclear family, was brought by his school teacher and mother with complaints of repeated attempts to steal girls’ and women teachers’ clothes dried outside in his boarding school. He reported excess interest in women's clothes since about 8 years of age. He would wear his aunt's, cousin's, mother's under-garments and outer-garments in privacy and felt pleasure in doing so. By 9 years of age developed erection and ejaculation while wearing them, hence stole women's clothes and hid them in trees to wear them in evening till satisfaction. He thought about wearing women's clothes most part of the day since last 3 years, likes to keep them till he ejaculates. During cross-dressing, felt like he was a woman having sex with another girl of fantasy and wished to develop female external genitalia. For these behaviours, patient was placed in a boarding school 6 months back where he jumped across to girls’ hostel for their clothes. He denied excess interest in specific body parts or in animate objects. The behaviour was recurrent and persistent despite warnings.

There were also attempts to rub against adult female passengers in crowded buses and to watch unsuspecting women taking bath. Subjectively finds them uncontrollable urges and was aware of consequences if caught and also felt guilty for his actions.

There was no history of destruction of property, harm to animals or people or bullying and stealing.

Patient was masculine and well-built; height was 150 cm, weighed 44 kg. Had well-developed secondary sexual characteristics. General physical and systemic examination was normal except for little acne on fore-head, blood pressure was 130/70.

With a diagnosis of paraphilia and precocious puberty patient was evaluated. USG abdomen and computed tomography (CT) scan were normal. Testosterone levels were higher for age but cortisol levels were normal. Patient was treated with fluoxetine up to 40 mg. Patient had no significant improvement and dropped out after 2 months.

In all three cases, there was no history of physical or sexual abuse during childhood, or family history of any psychiatric illness and prominent male figure was father.

DISCUSSION

The prevalence of transvestic disorder is unknown. In males, first signs of transvestic disorder may begin in childhood.[1] Three percent of men and 0.4% of women reported at least one episode of transvestic fetishism.[4] Majority of epidemiologic data relating to paraphilias derive from clinical populations, especially large scale studies are limited to jail inmates or sexual offenders and there are no studies in general population. It is difficult to obtain the frequency of paraphilic behaviours in non-clinical populations as individuals are reluctant to report their sexual fantasies and behaviours.

The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) distinguishes transvestism into fetishistic transvestism which is associated with sexual arousal, and dual role transvestism where there is no sexual motive for cross-dressing. In one of our cases (case 2), transvestic behaviour was not associated with sexual arousal but rather to allay the anxiety of obsessive thoughts. Hence, this could be an example of dual role transvestism secondary to OCD. However, so far, there is no distinction of primary and secondary transvestism in literature.

Recent studies suggest that paraphilics “cross-over” from one paraphilic behaviour to another and multiple paraphilias co-exist, as noted in our patients[2] The third patient also had autogynephilia as noted in DSM-5.[1]

There are no studies to show direct correlation between intelligence and paraphilia. Sexually deviant behaviour has been associated with higher[5] or lower intelligence.[6] Here, case 1 and 2 had onset at later age and also had lower IQ. Lower intelligence may be the cause of delayed onset of symptoms in adolescence or early adulthood.[7] In case 3, although the onset was in childhood, it was in a precocious adolescent. It is possible that persons with low intelligence may have poor impulse control and cannot alter gratification.

Paraphilias are also considered as part of OCD spectrum disorders.[3] In case 2, there appears to be no apparent link between the theme of obsessive thoughts and transvestic compulsive acts.

There are no guidelines for the treatment of sexual paraphilias. There is some support for the use of serotonergic drugs.[78] Escitalopram.[9] sertraline and also lithium[10] have been used. Two of our patients were started on fluoxetine. Of these, the patient with co-morbid OCD had significant clinical improvement in both compulsions and paraphilia. Another case in which mood stabilisers were given due to associated aggressive behaviour had significant improvement in both symptoms. Hence, in selected cases of paraphilia this group of drugs may be effective, especially when associated with other co-morbidity.

CONCLUSION

A patient presenting to Psychiatrist with transvestism could be suffering from different disorders. Careful evaluation with special reference to other paraphilias and co-morbid disorders is necessary. SSRI's are the most commonly used pharmacotherapy. Treatment is likely to be effective when transvestism is associated with other co-morbidities.