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Am J Psychiatry 1957;113:583-588.
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Medical superintendent, The Langley Porter Clinic, and professor of psychiatry, University of California School of Medicine, San Francisco, Calif.

Research associate, California Department of Mental Hygiene, San Francisco, Calif.

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The causes and character of transvestism are not well understood. Hereditary and constitutional factors appear in the background of some transvestites, and there is some indication that intersex of a subtle degree may be involved. According to psychologic explanations, transvestism is the result of intense castration fears, as are homosexuality, exhibitionism, and fetishism.All agree that treatment of transvestism at present is difficult and prolonged, and results are most unsatisfactory. Most patients do not wish psychotherapy. Surgical transformation is also rejected because it plays into the patient's illusions and does not really solve the problem. In most states it is considered that mayhem statutes can be made to prohibit the use of surgical transformation.The degree of desired change varies from case to case. Some male transvestites desire breast enlargement and perhaps castration; a few insist on both castration and penotomy, with the construction of a urethra; a very few may request a plastic vagina. So far, no one has been reported to request the implantation of ovaries, fallopian tubes and uterus, although a female patient is said to have arranged for the implantation of testicles. Male parthenogenesis does not yet seem to be within the realm of possibility.Female transvestism may be more frequent than is indicated by the number of reports in the literature.It is possible that eventually castration by hormonal medication may bring about great changes in sexually deviant individuals such as transvestites and partially solve this problem. Administration of hormones, as a medication, does not run into the same legal bars as does surgery. It should be noted, however, that hormonal castration constitutes a medical decision and intervention, with quite as definite sequelae as in other medical treatments; for example prolonged hormonal medication raises the question of the danger of cancer.The treatment of choice is probably intensive, prolonged psychotherapy in suitable cases, in order to relieve tension and bring about a better adjustment; techniques may be found to make the patient more accessible to psychotherapy. So far, there are no reported successfully treated cases. Until more appropriate and successful therapies are found, present methods of treatment will continue in use.

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