I recently read the book, “The Paraphilias: Changing Suits in the Evolution of Sexual Interest Paradigms” by J. Paul Fedoroff. I found it not only tremendously fascinating but quite helpful. You don’t all need to go out and purchase the book because the book is more technical than what many of you would prefer, and you can glean the main points here from my review. In this post I would like to tell you what I learned from the book particularly in relation to our struggles with crossdressing, and I will share several long quotations. This book is written from a completely secular perspective and is incredibly well researched and based on real life clinical experience.

In this post, I will:

  1. Give my personal reactions to the book.
  2. Examine some of the main ideas concerning treatment of paraphilias in general.
  3. Examine the book’s ideas about transvestic fetishism in particular and its treatments.
  4. Share other random quotations that I found interesting about other topics.


1. My overall impression after reading this book is that paraphilias, (including transvestic fetishism or autogynephilia or crossdressing, whatever precise term you want to use), are surprisingly very treatable. There is a high rate of treatment success both in terms of people being able to resist their urges, but also in terms of people experiencing real change in their desires and proclivities. In fact, even with something that seems as set in stone as pedophilia, the author argues that it is quite changeable. Those with pedophilic desires can change not only their behavior, but they also change in their attractions. The book is extremely hopeful and positive about people who receive treatment for paraphilias of any kind.

It prompted me to reflect on our culture. It seems popular opinion is that sexual appetites and desires are very fixed and unchangeable. People view unwanted sexual urges with a kind of fatalism, that people can’t change and that people are ultimately helpless to resist their sexual urges. This often results in sex offenders being marked for life as dangerous perverts. In contrast, this book humanizes people like us (even people with far more disturbing paraphilias). The author explains how people with paraphilic urges can still live normal lives and why other people don’t need to live in constant fear of them.

And this cultural fatalism about sexuality and paraphilias results in fatalism on the part of those who experience the unwanted sexual desires. If there is no hope of change, why try to change? In fact, why try to resist the urges at all? They have no hope. This is exactly what you see on crossdressing websites and forums even though it is not based on any data or research. The common wisdom is, “you can’t change, you won’t be able to live without crossdressing, so take it from me, don’t even try to give it up.” But the clinicians at the author’s counseling center claim the opposite. Change is not only possible, they even have high success rates.

But my most overwhelming thought as I read the book was that we need to have more compassion on people who have paraphilias. There are so many people, through no choice of their own, who have grown up with completely odd or dangerous sexual desires. I think back to my high school days when my crossdressing addiction was most intense and out of control. It seemed to be all I thought about, to the point that it was hard to concentrate in class at times. I lied, hid, and did all I could to find time alone at home. I was completely obsessed. I turned down friends who wanted to hang out. I took incredibly foolish risks that could have made me get caught. Then I think about what my life would have been like if I didn’t have transvestic fetishism, but rather a sexual desire for statues, or desire to hurt animals for sexual pleasure. What foolish things might I have done? What risks would I have taken?

I’m not saying that people should not be held responsible for their actions. They certainly should. And sometimes people will need to be put in prison to protect others. It’s possible for anyone to exercise self-control and not give in to their sexual urges. But man, think about the people who experience such things. It cannot be easy. In comparison, it seems like having the paraphilia of transvestic fetishism is quite easy to deal with.

I encourage all of you to peruse this list of some of the paraphilias that are out there. Remember that these people did not choose to have these desires. They need our understanding and compassion. And they need help so that they don’t give in to these urges and create harmful addictions. And they need help so that they don’t harm other people.



2. The book had some great points about treatment of paraphilias in general. I think I can share some quotes without a lot of extra explanation. I will just add a few comments here and there as it relates to our goal to overcome crossdressing.

The point here is that it is important for clinicians not to lose sight of the goals of treatment, which should be (in order) (1) immediate cessation of illegal or problematic behaviors, (2) stabilization of lifestyle, (3) enhancement of nonproblematic sexual interests and behaviors, and (4) stabilization of the new healthy lifestyle to the point that the problematic sexual behaviors are no longer of interest. The patient should not feel they have “given up”anything of value but instead feel they have gained a new sexual identity in which their sexual interests are both lawful (consensual) and pleasurable to the point that returning to their previous problematic behaviors would be an aversive experience.”

The following paragraph I found very interesting. Most guys that come to this website share similar stories about how they think their crossdressing or other paraphilias got started. It’s as if popular culture has made us all think that psychoanalysis is important for any problem and that we are all capable of doing it. I think there is some value, but not a lot, in speculating about the origins of our crossdressing desires, but ultimately none of us know for sure how those desires got started when we were young. I think it’s far more helpful to analyze what is going on in our minds when we experience the desires, and what techniques will enable us to exercise self-control when those desires come.

Some psychotherapies have little evidentiary support. For example, there is little or no evidence that psychoanalytic therapies are effective or practical in the treatment of paraphilic disorders. This fact is often a disappointment to people with paraphilic disorders who present for help with the expectation that this will involve an in-depth and lengthy review of their childhood to uncover the traumatic event(s) that led to the development of their paraphilic interests. It is important to respect the person’s life-story perspective and explanation for how they got the way they are now. However, to follow this route to solve the presenting problem is a mistake because it can delay change, and there is no way to know when the correct explanatory “event” has been discovered. For example, a person with transvestic fetishism may recall a Halloween when his older sister dressed him as a girl. However, there is no evidence that mischievous older sisters cause transvestic fetishism. Also, spending time uncovering childhood events may convey the false impression that the process of recovery will take a long time and, more importantly, permit the person with the paraphilic disorder to rationalize continuing to engage in problematic sexual acts. In the SBC, patients are reminded that all sexual behaviors are voluntary and that all members of society are expected to limit their sexual behaviors to the requirements of the law and social expectations.”

The following quote is similar to what I always counsel crossdressers. Ultimately, learning how to enjoy intimacy with your wife will be much more pleasurable and fulfilling than crossdressing which is a fake image of the real thing. Crossdressing is an unsatisfying shortcut. I also appreciate the cold turkey approach. There is nothing rational about trying to stop crossdressing in stages.

In the SBC, the idea of avoiding acting on a theoretically irresistible (paraphilic) addiction is replaced with the idea that sexual behaviors are always under voluntary control and that paraphilic behaviors are less pleasurable than nonparaphilic goals. A common analogy is a comparison of “unhealthy fast food,” which may be attractive, with healthy and/ or gourmet food, which may require more effort to prepare but ultimately is much more enjoyable. A second analogy is to compare playing tennis with an unwilling child to playing tennis with a willing, age-matched, opponent. It is easy for patients to understand that sexual relations with a consenting partner will be better than with a nonconsenting partner in the same way that playing tennis with someone who is unwilling or unable to hit the ball back is less enjoyable. They also easily agree that forcing anyone to engage in any activity is wrong. Also, people with paraphilic interests are invited and expected to stop all problematic paraphilic acts immediately. They are helped to understand that having paraphilic interests is different from having an addition to a drug. Importantly, they are reassured there is no need to “taper” paraphilic behaviors because there are no adverse physiologic effects from stopping paraphilic acts “cold turkey.” Stopping the problematic sexual behaviors is not only eminently possible but also healthy and the first step to getting better. This intervention is important not only to stop harm to innocent victims but also to establish that SBC therapists are there to help, which means insisting on no more victims, ever.”

I found this next paragraph quite interesting. If the urge to have sex decreases the longer it is not acted upon, might it also be true for crossdressing? That certainly seems to be what I and many others have experienced.

Motivated Behaviors Patients who claim they cannot resist their sexual urges are educated about motivated behaviors ( Toates, 2009 ). These are acts that are motivated by physiologic mechanisms. Some, such as breathing, are indeed impossible to resist. The urge to sleep can be resisted for a day or two but then becomes irresistible. Others, such as eating, are possible to resist acting on for days or even weeks. Sex is comparatively weakly motivated. Unlike breathing or eating, it is possible to live without sex, and in fact, the urge to have sex decreases the longer it is not acted upon.”

The author emphasizes group therapy the most, but also individual therapy. And the following paragraph looks at couple’s therapy as well:

Sex is inherently an interactive activity. Therefore, therapy designed to change a person’s sexual interests and activities needs to take the person’s romantic and sexual partner(s) into account. To engage the patient’s partner, it is important to avoid appearing to blame the partner. Blame is never a useful therapeutic device. In the SBC, partners are invited to join the person seeking treatment in the role of being an authority about the person: “Thanks for joining us today Ms. X, you probably know more about your husband than anyone else.” Spouses rarely disagree with this assessment and are comfortable in this role. They generally welcome being consulted, especially when there has been a breakdown in trust between the spouse and the person seeking treatment.”

This next paragraph is probably controversial, but I found it interesting in light of what many Christians teach about sin. There is a debate in the North American Church about whether a person should say, “I am gay, but not giving in to my desires” or “I experience same-sex attraction, but I’m not giving in to my desires.” Some people claim that the first statement is identifying far too much with our sinful nature and that we shouldn’t ever base our identity on sin. Others argue that it is healthy to acknowledge that we are broken and giving that label gives acknowledgment that there is an ongoing struggle. It would seem that the author’s view is similar to the Christians who claim we shouldn’t identify with our sin as we label ourselves.

Some new members mimic the pattern of many AA groups and introduce themselves as follows: “Hi, I am [first name], and I am a pedophile.” They are discouraged from doing so by other group members, who explain that self-labeling can be self-fulfilling. Instead, they are invited to introduce themselves by their first name as a first step in establishing a new identity as a person who no longer has pedophilia (or other unwanted paraphilia ). These steps help to personalize the experience for people who often feel both martialized and stigmatized.”

Other quotations:

They are also reminded that sexual behaviors are entirely voluntary. They are reminded that contrary to what they may have been told, there is absolutely no evidence that paraphilic interests cannot be changed.”

Treatment began by reminding the man that he was in control of his own finances. When he said he could not possibly stop buying shoes, he was advised to cut up the credit card with which he used to secretly charge his purchases. Next, therapy focused on helping him dissociate the sexual arousal of his fetish from the anxiety-reducing aspects of his fetish. This proved to be a very effective strategy, likely due to the fact that much of his shoe hoarding resembled an anxiety-related obsessive–compulsive disorder (OCD). He was encouraged to keep track of when he felt the urge to buy shoes, and he soon noticed this happened when he was under stress at work or in relations with his wife. Due to his anxiety and OCD-like symptoms, he was offered and accepted a treatment trial with a selective serotonin reuptake inhibitor (SSRI), which greatly improved his symptoms. Readers will note that none of these interventions directly targeted his sexual fetish. As his anxiety and OCD symptoms remitted, his concerns about his fetish decreased. He was asked if he wanted to include his wife in the treatment, which caused him to literally gasp. His entire relationship with his wife had centered around what he thought was his successful ability to hide his fetish from her. However, when asked if he would have come for treatment if he had not been married, he laughed and said “of course not.” He now realized it was his relationship with his wife, and not his finances or his fetish, that had motivated him to seek help.

In the context of substantial improvement in the couple’s relationship, both marital and sexual, the shoes “lost their power.” This loss of dependence in the fetish when it became an interest known to his wife is typical. John Money stated, “Paraphilias are like mushrooms, they grow well in the dark” (personal communication, 1996– 2001). Fortunately, the reverse is also true.”

One review of published cases (Fedoroff, 1994) of various paraphilias with SSRIs found that all but two papers reported successful results. The two negative papers were notable for the fact that they reported on treatments with SSRIs using doses usually used to treat OCD. Unfortunately, at those doses, inhibited orgasm is a frequent occurrence. Fedoroff noted that people with fetishes (and other paraphilias) tend to revert back to their paraphilic fantasies in order to achieve orgasm. It has been the SBC’s experience that SSRIs are more effective in treating fetishes, and other paraphilias, when they are used at doses that are low enough to not cause inhibited orgasm.”

The aim of therapy therefore starts with the insistence that the person assume responsibility for any current or future sexual behaviors. Again, they should be reminded that sexual behaviors are voluntary and therefore under their control. If they report their sex drive is too high, and they are unwilling or unable to manage their sex drive by conventional means such as masturbation to orgasm, high sex drive can be reliably treated with anti-androgens and gonadotropin-releasing hormone medications.”

The statement that every paraphilia has an opposite may seem surprising. However, patients often report that their unconventional sexual interest(s) in many ways is caused by a sense of anxiety leading to opposing interests. Examining this more closely, it is clear that sexual feelings are normal and vital not only to individual health but also to the survival of the species. Despite this, many people have feelings of guilt about sex. One way to deal with this problem is to develop sexual feelings that are the opposite of conventional sexual interests. A person who feels guilty about engaging in sex with a person they love may divert their interests toward a person or thing or situation in which sex and love do not coexist.”



3. Now let us turn to the areas in the book that specifically addressed transvestic fetishism.

Fedoroff (1988) published a case report of a man whose sexual interest in lingerie was enough to cause his wife to complain he was not sexually interested in her. His fetishistic interest in lingerie disappeared when he was treated with the serotonergic modulator buspirone, to the point that his wife noticed he no longer “tuned out” when they had sex.

In the Sexual Behaviours Clinic (SBC), selective serotonergic reuptake inhibitors (SSRIs) have been found to be very successful in the consensual treatment of men who feel dependent on cross-dressing to the point that it is interfering with their sexual relations. It is important to prescribe SSRIs at low doses in order to avoid inducing delayed orgasm.”

Some men with transvestic fetishism experience a complete resolution of their urges to cross-dress when treated with low-dose SSRIs.”

If you are interested in how crossdressers age and change as the following paragraph describes, I recommend reading – The Transvestic Career Path, and Crossdressing without Sexual Component?

In some cases, the sexual arousal from cross-dressing is replaced by a sense of reduced anxiety when wearing women’s clothes. Sessions in which cross-dressing is accompanied by masturbation are gradually replaced by increasingly lengthy sessions in which the man cross-dresses while assuming his view (often stereotypic) of a female gender role. The Sexual Behaviors Clinic at Johns Hopkins Hospital referred to men who presented in this way as “aging transvestites” because the change in interests and behaviors was associated with a reduction in sex drive and a process by the man of coming to terms with his comfort in assuming a female gender role and, in some cases, female gender identity.”



4. In this last section, I will share a few random quotations that are not about crossdressing, but I found them interesting to reflect on.

The author made a distinction between same-sex attraction and paraphilias. He did so by saying that same-sex attraction is about romantic interest, not sexual interest. And he sees nothing wrong with homosexuality. But I want to think deeper about this. Is he just categorizing homosexuality this way because it seems harmless, whereas paraphilias seem to usually be harmful to others as well as to the person with the paraphilia? What I’d like to research further is why the author and his clinic think that a man with pedophilia can change in his attractions to the point where he no longer sexually desires children at all, but why they think that same-sex attraction cannot change? Why make homosexuality and paraphilia out to be such different things? Consider what Ray Blanchard, a sexologist, had to say about this, “pedophilias are the sexual orientations that we don’t like.” Is it possible that paraphilias are just like homosexuality or heterosexuality in that they are all just descriptions and labels for different sexual desires/orientations, and paraphilias is just a more derogatory term? If they all really belong in the same category, then why would paraphilias be changeable but same-sex attraction would not be? I think homosexuality must be treatable and changeable at least to some extent, while I would also not guarantee any gay person that they would experience change, nor would I pressure them to get married to someone of the opposite sex. If being gay is anything like what I experience with crossdessing, I would expect gay people to have a journey similar to mine, which is that I have experienced a lot of change and reduced desires to crossdress, but not a complete elimination of crossdressing desires. There are hundreds if not thousands of testimonies of people who have experienced change in their same-sex attractions. They may be in the minority, but unless they are all liars, there seems to be real evidence of change.

Read the quotes yourself and see what you think:

Successful treatment begins with education about the fact that homosexuality is healthy and that recovery from pedophilia does not and should not require a change in orientation. This step is important because it helps the person focus on what actually needs to change. It also helps to disabuse the person from the idea that pedophilic interests cannot be modified. It may also explain why programs that do not explicitly distinguish between orientation and interest report failures in any attempts to modify sexual interest.”

The fact is, orientation is not necessarily immutable. For women in particular, there is evidence that people may change the gender of the people with whom they have romantic interests (L. Diamond, 2016 , 2018 ). Modern mental health practices take the view that it is wrong to “treat” a person who wants to change their orientation because they are ashamed of being gay or lesbian. Increasing numbers of US states have legislated against so-called reparative therapy, which is sometimes erroneously referred to as “conversion therapy.” This has been viewed as a positive development by advocates of the right to have any orientation. This may be a mistake. The SBC’s view is that legislators have (almost) no business in therapists’ offices. It is a slippery slope from laws forbidding therapy aimed at changing orientation to laws interfering with legitimate therapeutic interests, such as the wish of a bisexual woman to enhance her sexual interest in her husband.”

To be clear, the SBC in no way advocates so-called reparative therapy, which is based on instilling and increasing sexual shame. However, the SBC is not against assisting consenting patients to enhance their orientations, gender identities, sex drives, or sexual interests anyway they wish as long as it enhances consensual (i.e., lawful) sex. As stated previously, the difficulty of changing varies (in descending order of greater difficulty) as follows: genotype, gender identity, orientation, interest, and drive. In each case, the SBC approach is to enhance interest in the desired direction rather than by attempting to shame or otherwise disrespect the patient’s current state.”

Of course, retrospective studies rarely prove anything. Of more interest is how upsetting the study seems to have been, especially to commentators not directly involved in the treatment of people with pedophilia. One might expect that any evidence that pedophilia can be treated successfully would be welcomed, but for some this has not been the case. One argument is that there is insufficient proof to definitively state that sexual interests can change. This is an argument that is difficult to support given that interests of all kinds change more or less constantly. In fact, there is little or no evidence that sexual interests cannot change and that they are somehow permanently fixed. These arguments (and more) were recently discussed in invited reviews ( Cantor & Fedoroff, 2018 ; Fedoroff, 2018 ). In contrast, there is evidence that telling people with pedophilia that pedophilia is untreatable decreases the efficacy of treatment ( Tozdan & Briken, 2017 ; Tozdan et al., 2018 ).”

But the problem is worse for defenders of the Money paradigm because not only are there many people with pedophilia who say their pedophilic interests have changed (black swans) but also their reports are supported by their change in behaviors, which is supported by their change in offense patterns (they stop reoffending), and their adult sexual partners. Claims that anyone who says his sexual interests have changed must be lying, are difficult to believe in the case of people who have sought treatment on their own. Why would they say they are better if they are not? Furthermore, if for some reason they are not actually better, why do they not act like people who still have pedophilic interests?”

Virtuous pedophiles”self-identify as pedophiles who have chosen to give up sex. In contrast, the men and women who receive treatment in the SBC admit to a wish for sexual activity. They describe a change in sexual interests from children to adults and bring their adult girlfriends and boyfriends to the SBC’s Friends and Family group. They report a change in sexual interest from children to adult(s) that is confirmed by their adult sexual partner(s). Many in the Virtuous Pedophile group question the honesty of people who say their sexual interests have changed. But their “proof”rests on their own subjective beliefs that pedophilia is unchangeable. They have committed to this belief to the point that they self-identify as “virtuous”because of it. Given the frequent reports by people with pedophilia that their interests did change (either acquiring a sexual interest in children or experiencing a change to sexual interest in adults), and given the absence of any verifiable mechanism that could explain why sexual interests are the only unchangeable interests that we know of, is it not time to question the claim by some people with pedophilia that they cannot change their sexual interests.”


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