What diagnosis best fits a 40‑year‑old married male who is abusive toward his wife, prefers sexual encounters at parties, cross‑dresses with makeup and has undergone plastic surgery to appear female?

Clinical Assessment: Multiple Differential Diagnoses Requiring Comprehensive Psychiatric Evaluation

This clinical presentation requires urgent psychiatric evaluation to differentiate between several possible diagnoses, with the abusive behavior toward the spouse representing an immediate safety concern that must be addressed first, regardless of the underlying psychiatric condition. 1

Primary Diagnostic Considerations

Gender Dysphoria

The cross-dressing, makeup use, and plastic surgery to appear female suggest possible gender dysphoria, defined as psychological distress associated with incongruence between gender identity and sex assigned at birth. 1, 2 However, several critical factors complicate this diagnosis:

• Gender dysphoria is distinct from the formal DSM-5 diagnosis of Gender Dysphoria, and not all individuals who cross-dress or pursue gender-affirming procedures meet diagnostic criteria. 2
• The presence of dissatisfaction with heterosexual marriage and preference for "sex parties" raises questions about whether gender expression is ego-syntonic (comfortable, part of identity) versus ego-dystonic (unwanted, anxiety-provoking). 3
• True gender dysphoria typically involves a persistent, long-standing sense of gender incongruence, not behaviors that emerge primarily in the context of sexual dissatisfaction or relationship dysfunction. 1, 2

Obsessive-Compulsive Disorder with Gender-Related Obsessions

An alternative diagnosis to consider is OCD with intrusive thoughts about gender identity, particularly if:

• The cross-dressing and gender-related behaviors are accompanied by intense fear or anxiety rather than comfort. 1
• There is evidence of "testing" behaviors to prove or disprove gender identity. 1
• The patient engages in reassurance-seeking about gender-related concerns. 1, 3
• The American Psychiatric Association recommends that when OCD and gender concerns co-occur, treating the OCD prior to making any decisions regarding gender identity is crucial. 1

Transvestic Disorder

Transvestic fetishism (now termed Transvestic Disorder) involves eroticized cross-dressing in heterosexual males and should be considered given the sexual dissatisfaction and preference for sex parties. 4, 5 Key distinguishing features include:

• Cross-dressing is primarily sexually arousing rather than an expression of core gender identity. 4
• Research shows transvestites seeking psychiatric consultation display more negative body image, more feminine gender role perception, and significantly more psychological distress on standardized measures. 5
• Those with concurrent psychiatric disorders (which may include the abusive behaviors) are more frequently gender dysphoric. 5

Critical Safety and Behavioral Concerns

Intimate Partner Violence

The physical and mental abuse toward the wife represents the most urgent clinical priority, as this behavior pattern is associated with:

• Increased risk of severe injury or mortality to the victim. 1
• Higher rates of harassment, discrimination, and violence that transgender and gender-diverse individuals both experience and perpetrate when untreated psychiatric conditions are present. 1

Sexual Behavior Patterns

The dissatisfaction with monogamous marriage and preference for "sex parties" requires assessment for:

• Paraphilic disorders beyond transvestism. 4
• Compulsive sexual behaviors that may represent attempts to manage underlying distress. 1
• Risk behaviors that may compromise health outcomes. 1

Recommended Diagnostic Approach

Conduct a structured psychiatric evaluation using validated instruments:

• Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to assess for OCD symptoms, ensuring both obsessions AND compulsions are evaluated (a common pitfall is assessing only obsessions). 1
• Assess whether gender-related thoughts are ego-dystonic (intrusive, unwanted) versus ego-syntonic (comfortable, identity-congruent). 3
• Evaluate for reassurance-seeking patterns, checking behaviors, and mental reviewing about gender concerns. 3
• Screen for depression, anxiety, and suicidal ideation, as these commonly co-occur with both gender dysphoria and OCD. 1

Obtain detailed developmental history:

• Age of onset of cross-dressing behaviors and whether they preceded or followed relationship dissatisfaction. 5
• History of gender identity concerns throughout childhood and adolescence versus recent onset. 1, 6
• Sexual orientation history and any homosexual experiences, as these correlate with different clinical presentations in transvestism. 5

Treatment Implications Based on Diagnosis

If Gender Dysphoria is Confirmed

• Gender-affirming care improves mental health, reduces suicide rates, and lowers overall healthcare costs when appropriately indicated. 1
• The World Professional Association for Transgender Health standards emphasize treatments that achieve "lasting personal comfort with gendered selves to maximize overall health and psychological well-being." 1
• However, comprehensive mental health treatment must address the abusive behaviors concurrently. 1

If OCD with Gender Obsessions is Diagnosed

• Initiate or optimize SSRI therapy (sertraline 200mg daily or equivalent) for at least 8 weeks. 3
• Implement Exposure and Response Prevention (ERP) therapy specifically targeting gender-related obsessions, with 10-20 sessions recommended. 3
• Avoid providing reassurance about gender identity, as this functions as a compulsion perpetuating the obsessive cycle. 3
• Case evidence demonstrates Y-BOCS scores can drop from 24 (moderate severity) to 3-4 (minimal symptoms) with targeted treatment. 1, 3

If Transvestic Disorder is Primary

• Address the eroticized cross-dressing through psychotherapy targeting underlying distress and body image concerns. 5
• Treat concurrent psychiatric disorders that may be driving the abusive behaviors. 5

Critical Pitfalls to Avoid

• Do not pursue irreversible gender-affirming procedures until psychiatric comorbidities, particularly OCD, are adequately treated. 1
• Do not dismiss the abusive behaviors as secondary to gender distress—these require immediate intervention regardless of underlying diagnosis. 1
• Do not confuse depressive rumination with OCD obsessions—OCD thoughts are ego-dystonic and anxiety-driven with compulsive neutralizing behaviors. 3
• Do not provide reassurance about gender identity if OCD is present, as this perpetuates the obsessive-compulsive cycle. 3