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LETTERS TO EDITOR  
Year : 2019  |  Volume : 61  |  Issue : 2  |  Page : 217-218
Fetishistic transvestism with ectodermal dysplasia: A case report


1 Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Department of Psychiatry, Dr. S N Medical College, Jodhpur, Rajasthan, India., India

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Date of Web Publication11-Mar-2019
 

How to cite this article:
Rohilla J, Nebhinani N, Suthar N. Fetishistic transvestism with ectodermal dysplasia: A case report. Indian J Psychiatry 2019;61:217-8

How to cite this URL:
Rohilla J, Nebhinani N, Suthar N. Fetishistic transvestism with ectodermal dysplasia: A case report. Indian J Psychiatry [serial online] 2019 [cited 2019 Aug 17];61:217-8. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/2/217/253838




Sir,

Ectodermal dysplasia is heritable heterogeneous group of disorders with variable degree of abnormal development and function of hair, teeth, nails, and glands.[1] Association of ectodermal dysplasia in children with intellectual disability and attention deficit hyperactive disorders has been reported.[2] With our best efforts, we could not find any literature on cooccurrence of ectodermal dysplasia with transvestitism.

A 26-year-old unmarried male came for psychiatric consultation after his father found him wearing female undergarment on two occasions in the last month and advised him to get medical help. The patient reported that this behavior started 7 years ago; but he is finding himself to be distressed because of this behavior and interference in his academic and social functioning for the last 3 years. The patient did not consult before because of stigma about the nature of problem and uncertainty about availability of any treatment in medical science. He was diagnosed with ectodermal dysplasia in childhood at the age of 5 years. His current physical examination was unremarkable except nail abnormality (thick and brittle) and sparse hair on face, body, and scalp with well-developed other secondary sexual characteristics of male. Childhood history revealed that bullying for his appearance being like a girl and having doubt on his potency and ability to procreate in future. Sexual history revealed that he started masturbation around the age of 10 years mostly while taking bath by rubbing his genitalia on the floor. At the age of 16 years, he started putting clothes on his head to have feeling of long hair on head and used to wear female vest, to imagine himself as a woman to get for better arousal and orgasm during masturbation. Three years back, he also started watching a lot of multi-media content (videos, blogs, articles, and movies) about transformed women (male-to-female [MTF]), their life before and after procedure. Since the last year, for getting better erection during masturbation, he also started doing makeup in front of the mirror by changing hairstyles and wearing different types of female clothing. In stressful situation this behavior used to increase but after acting on these fantasies, he used to feel sad and regretful for next few days along with low self-confidence and difficulty in facing with people around. Hence, he himself reported as being trapped in this vicious cycle and wanted to get rid of all this fantasies and related behavior.

He denied fantasizing himself as a female other than during sexual act or any feeling of being a member of opposite sex (female) or thoughts of himself as a female trapped inside male body. He considered his identity as a male and had sexual fantasies towards female although it does not get him arousal enough to ejaculate. He rejected the idea of living life like an MTF or homosexual male. According to him, the reason for psychiatric consultation was to decrease such thoughts, behavior, subsequent distress and low mood.

In a Swedish population-based study, the prevalence of transvestic fetishism is reported 2.8% in men and 0.4% in women and majority of them (85.7%) had exclusive heterosexual orientation while none of them reported exclusive homosexual orientation.[3] We could not find any global or Indian data on prevalence of transvestic fetishism. After ruling out differential diagnoses of transsexuality and dual-role transvestism, index case was diagnosed with fetishistic transvestism according to the International Statistical Classification of Diseases and Related Health Problems-10th revision. After detailed evaluation, final diagnosis of fetishist transvestism with ectodermal dysplasia was made, and treatment was planned after discussing case in departmental case conference.

Treatment involved initial two supportive sessions to address low self-esteem, feeling of guilt, and stigma with illness followed by 10 psychotherapy sessions focused on “orgasmic reconditioning training” along with Fluoxetine 20 mg once a day. Initially, he was unable to achieve orgasm without fetish objects of crossdressing, fantasies or watching visuals of transformed male and female. Therefore, a gradual approached tried where fetish object was initially replaced by transvestism related visual content, then by imageries of transvestism for arousal and at last orgasm achieved by normal masturbation. Initially, more time was required for ejaculation and orgasm was less satisfactory, then gradually his ejaculation time and orgasm improved. Gradually, he started finding increased control on his sexual fantasies, impulse and behaviors and also reported improvement in his mood. Currently, he is well and following up regularly with further progress in career without low mood or self-esteem.

A history of fetishistic transvestism can be seen as an earlier phase by transsexuals and probably represents a stage in the development of transsexualism in such cases. But index case had onset in late childhood and continued to those sexual practices even in adulthood without any desire to live and accepted as a member of the opposite sex and without any discomfort with his anatomic sex. Transvestitism in index case might have been caused by psychological disorder linked with genetic disorder–ectodermal dysplasia or a result of psychological development at earlier age influenced by lesser body and facial hair, as manifestation of ectodermal dysplasia and rejection by others and self-doubts on his masculinity.

SSRI is found effective in reducing fetishist behavior.[4] Successful use of desensitization techniques and orgasmic reconditioning training is reported effective for the treatment of transvestism.[5] Index case has shown a very good response with multipronged approach of fluoxetine, supportive psychotherapy, and orgasmic reconditioning training. This case signifies the importance of thorough evaluation, positive therapeutic alliance, multipronged patient-tailored team approach in patients with fetishistic transvestism.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Deshmukh S, Prashanth S. Ectodermal dysplasia: A genetic review. Int J Clin Pediatr Dent 2012;5:197-202.  Back to cited text no. 1
    
2.
Maxim RA, Zinner SH, Matsuo H, Prosser TM, Fete M, Leet TL, et al. Psychoeducational characteristics of children with hypohidrotic ectodermal dysplasia. ScientificWorldJournal 2012;2012:532371.  Back to cited text no. 2
    
3.
Långström N, Zucker KJ. Transvestic fetishism in the general population: Prevalence and correlates. J Sex Marital Ther 2005;31:87-95.  Back to cited text no. 3
    
4.
Velayudhan R, Khaleel A, Sankar N, Kumar M, Kazhungil F, Raghuram TM, et al. Fetishistic transvestism in a patient with mental retardation and psychosis. Indian J Psychol Med 2014;36:198-200.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Laws RD, O'Donohue WT. Sexual Deviance: Theory, Assessment, and Treatment. 2nd ed. New York: Guilford Publications; 2008.  Back to cited text no. 5
    

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Correspondence Address:
Jitendra Rohilla
Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_71_18

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