Transvestic fetishism

• Disease description (causes and symptoms)

  • Definition: Refers to a condition in which sexual arousal is directly associated with wearing clothing of the other sex, and as a result causes distress or functional impairment to the person or creates a possibility of harm to others (corresponding to the Transvestic Disorder category in the DSM-5). Simply wearing clothing of the other sex for role-play, acting, or self-expression rather than for sexual purposes does not constitute this disorder.
  • Causes and pathophysiology: The exact cause is not known. Psychodynamic fixation, conditioning (repetition of reinforced behaviors), and neurobiological factors related to impulse and reward circuits have been proposed.
  • Main symptoms:
    • Strong sexual arousal (fantasies, urges, or behaviors) associated with wearing clothing of the other sex, mainly clothing of the other sex.
    • Anxiety, shame, or impaired social, occupational, or interpersonal functioning resulting from this, or legal and social problems.
    • Symptoms persist over time (generally for several months or longer) and cause clinically significant distress or impairment.

• Treatment methods

  • Diagnostic approach: An interview with a psychiatrist (including assessment of sexual history, developmental history, coexisting mental disorders, and risk of self-harm or suicide), with psychological assessment if necessary.
  • Psychotherapy:
    • Cognitive behavioral therapy (CBT): Impulse-control strategies, modification of distorted beliefs, exposure and response prevention, and so on.
    • Behavioral therapy techniques: Covert sensitization, satiation, conditioned extinction techniques, and so on (applied on a case-by-case basis).
    • Psychodynamic, individual, and group therapy: Aimed at improving ego functioning, self-identity, and interpersonal relationships.
  • Medication:
    • SSRIs (selective serotonin reuptake inhibitors): May help reduce impulsivity and compulsive sexual urges.
    • Antiandrogens (e.g., luteinizing hormone-releasing hormone analogues, which suppress testosterone, or progestin preparations): Considered in severe cases in which sexual desire must be strongly suppressed (requires expert judgment and review of side effects and ethical and legal considerations).
    • Antipsychotic medications may be considered when psychotic symptoms are also present.
  • Lifestyle management and safety measures:
    • Ensure confidentiality and a safe environment, avoid situations or items that stimulate urges, and manage stress (sleep, exercise, and avoidance of alcohol and drugs).
    • Prevention of legal and social problems: Actions without consent or actions involving minors may lead to legal problems, so immediate treatment is necessary.
  • Complications and precautions:
    • Relationship problems and social stigma may occur, along with depression and anxiety; serious consequences may result if legal problems arise, such as coercive or nonconsensual acts.
    • Hormone treatment, including antiandrogens, may cause side effects such as decreased bone density, metabolic changes, and mood changes, so thorough consultation and monitoring by a specialist are necessary.
  • Prognosis:
    • Varies depending on the severity of symptoms, the presence or absence of coexisting mental disorders, and the treatment intervention and its continuity. Symptoms can be alleviated with appropriate psychotherapy and medication.

• Checkpoints before an outpatient visit (including sample questions)

  • Items and records to prepare:
    • A list of currently taken medications (prescription, over-the-counter, herbal medicines, and so on)
    • A history of previous mental health treatment or hospitalization, and records related to suicide or self-harm risk
    • A diary summarizing the time symptoms began, their frequency, triggering situations and types (fantasies, urges, or behaviors), and the effects of symptoms on daily life (work, interpersonal relationships, and so on) (if possible, covering the past several weeks)
    • Coexisting symptoms (depression, anxiety, changes in sleep, substance abuse) and previous test results (such as hormone tests)
    • Whether there have been legal problems (such as previous complaints or criminal cases)—this is important information for treatment, so report it honestly
  • Examples of what to tell the doctor during the visit:
    • “Explain specifically what thoughts and feelings you experience when wearing clothing of the other sex.”
    • “Explain, using specific examples, how the symptoms affect your daily life (work and relationships).”

• Examples of general questions to ask the doctor

  • “Can my symptoms be diagnosed as a disorder? What are the diagnostic criteria?”
  • “What treatments are recommended, and what effects and side effects can be expected?”
  • “How long will treatment take, and how likely is recurrence?”
  • “How will my privacy and confidentiality be protected during treatment?”

• Examples of condition-specific questions

  • “How do you distinguish whether my behavior is simply a hobby or a disorder requiring treatment?”
  • “How much can medications (e.g., SSRIs or antiandrogens) reduce sexual urges, and what side effects should be monitored?”

(Consultation with a psychiatrist is recommended if necessary. If there is an emergency risk, such as anticipated self-harm, harm to others, or legal problems, immediately use an emergency room or crisis counseling service.)