The first question one must ask oneself is this:-
“Why should cross-dressing be treated at all?”
For the traditional definition of a mental disorder requires the presence of clear dysfunction in one or more major areas of a person’s life, e.g., occupational, interpersonal, or intrapsychic. Social deviance per se does not constitute a definition of a mental disorder warranting diagnosis and treatment and ego-syntonic behaviour which does not harm others directly never should be considered a phenomenon meriting or requiring treatment.
However, in cases where cross-dressing is felt to be ego-dystonic, by the cross-dresser, or the cross-dresser suffers from conditions which are producing problems in their own right, e.g., depression, then a case can be made for some kind of counselling or intervention.
Nevertheless, the general consensus amongst members of both the psychiatric profession and cross-dressers who have sought treatment is that it is ineffective. In fact, one of the larger surveys held, that of Brooks and Brown covering 851 transgendered men in 1994, showed that although more than 43% of cross-dressers in their survey reported having seen a mental health professional at some time in their lives, less than 5% believed that there was a cure for their transgendered behaviour. Even Robert Stoller, the bane of cross-dressers, has gone on record in Sex and Gender, Vol 1: The Development of Masculinity and Femininity (1968) as saying:-
“Although [the cross-dresser] may ask the psychiatrist to cure him of the transvestism, what he is really asking is to be cured of his pain. He generally does not consider his transvestism as painful. Quite the contrary, it is most enjoyable; what it stirs up in others is what leads to pain.”
As an aside, the more perspicacious amongst my readers will have noticed Stoller’s telling phrase: “what [cross-dressing] stirs up in others is what leads to [the cross-dresser’s] pain ”. Now I, for one, find it most interesting that Stoller, like many of his professional colleagues, is not prepared to analyse why others should feel “pain” at witnessing a cross-dresser who, after all, causes no-one any direct psychological or physiological harm. Perhaps I am being less than charitable, but to my mind Stoller spent his whole career as an excuse for excoriating those whose behaviour he felt threatened by or otherwise disapproved of. But perhaps I am being unkind in suggesting that Stoller and his kind are guilty of perverse counter-transferences?
Transvestites who have presented themselves for treatment have been met with a wide range of therapies aimed at curbing, or eliminating, the desire to cross-dress, many of which are arguably inhumane. Nevertheless the psychiatric profession has always been populated by monsters who love to inflict humiliation, pain and torture on those unfortunate enough to fall into their clutches. Earlier treatments included psychoanalysis, faradic aversion, chemical aversion and electroconvulsive therapy, whilst allegedly more modern and humane treatments have included a variety of insight-oriented psychotherapies, behavioural therapies, psychopharmacological treatments, and self-help support groups targeting self-acceptance as an outcome. Not unsurprisingly, it is the latter approach which seems to have the best outcome for cross-dressers who are troubled by their need to cross-dress, since it need involve nothing more than the self-realisation that a cross-dresser can be decent human-beings as well as valuable members of society in their own right. It is this latter approach which Agner Fog recommended in his paper Paraphilias and Therapy.
An extensive trawl of the professional literature shows that all the other methods of treatment for cross-dressing have failed in all respects to “cure’ cross-dressing and that the only real effect these have had is to increase the disquiet and any ego-dystonic aspects that occasioned the cross-dresser to present for treatment in the first place.
The manifest failure of psychoanalytical theory to explain cross-dressing, together with the obvious failure of psychotherapeutic attempts to treat or “cure” the phenomena, should have been sufficient to convince all but the most impervious to reason that the best approach to pursue is one which distinguishes between the spurious goal of curing cross-dressing and the achievable goal of addressing any ancilliary consequences and complications that may flow from the actual act of cross-dressing itself, e.g., societal, legal, financial, familial and marital issues.
In fact, as far back as 1910 Hirschfeld, when he published his seminal book The Transvestites: An Investigation of the Erotic Desire to Cross Dress, had already recognised the tenacity of transvestism and the low probability that psychotherapeutic treatments would curb the desire to cross-dress. Alternatively, he suggested that the physician reconsider his or her motivations for this treatment approach in the first place, summarising transvestism as:-
“...basically a harmless inclination by which no one is injured, [therefore], from a purely medical standpoint, nothing can be said against the actual putting on of the clothing of the opposite sex”.
Indeed, many of the motivations for psychiatric treatment are problems related to the interface between society and transvestism, and those who present for treatment appear to be experiencing “ego-dystonic transvestism”.
Hirschfeld’s attitude was echoed by that of Richard Green who, in his book The Sissy Boy Syndrome and the Development of Homosexuality (1987) encouraged mental health professionals to view the treatment for cross-gender behaviour in a broader social context, especially given that many of these forms of behaviour are characterised more by social deviance than by established definitions of mental disorder as described in the DSM-IV-TR As Green said:-
“Treatment intervention...[can be] focused on helping these people adjust to their society. What can be done to help society to adjust to these people? Can the behavioral(sic) scientist also be effective as a social activist? Can the researcher/therapist modify societal attitudes so that atypical sexual life-styles which do not infringe on the liberties of others do not cause conflict for the atypical individual?”
Which brings us straight back to the fact that one of the perennial and valid criticisms of psychiatry is that it is often utilised as a means of social control rather than as a means of genuinely addressing the real issues.
One of the more enlightened clinical models for approaching the assessment and treatment of a cross-dresser who feels the need for treatment is as follows, since it does at least try to address the societal issues and it echoes much of the more enlightened approaches towards cross-dressing suggested by Hirschfeld, Green, Fog and others:-