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We would like to expand on the response to the letter "Boy keeps women's clothingWhat could it mean?" (Behavior: Ask the experts, July 2002) by pointing out some additional diagnostic and treatment considerations. Curiosity and experimentation would be a plausible explanation for the boy's behavior if the cross-dressing had been short lived. Since female garments were found repeatedly in the 12-year-old boy's possession, a more likely explanation, for which the patient gave a clue ("wearing the clothes excited [me]"), is a sexual fetish. This pattern of sexual excitement elicited by cross-dressing, known as "fetishistic cross-dressing," often starts in childhood or adolescence. It frequently involves undergarments and can present in heterosexual and homosexual males.
In any differential diagnosis of persistent boyhood cross-dressing, two other possible causes need to be considered: 1) cross-dressing as a part of fantasy-play seen in the childhood of some gay men. This type of play-acting often includes make-up, wigs, and mimicking of a female celebrity or glamorous fictional character. And 2) cross-dressing as part of an opposite-sex identity (gender identity disorder, transgender). Recurring statements of being, or wishing to be, of the opposite sex accompany this type of cross-dressing.
The last two possibilities are referred to as "gender-nonconforming" boys. This child may end up belonging to the category of gender nonconforming boy, which usually does not affect the person's overall functioning but may be difficult for parents to bear and handle (Menvielle EJ et al: J Am Acad Child Adolesc Psychiatry 2002;41:1010).
Rather than questioning the child about the reason for cross-dressing, you may choose a less confrontational approach, which is more likely to elicit clinically useful information. For example, after acknowledging the parents' concern, you can have a conversation, or series of conversations, with the patientthe gist of which would be: "An interest in female clothing does not mean there is something wrong with you or that you are a bad person. You are not the only one with this interest; there are other boys and men who like girl clothes for different reasons. Let me tell you some of the reasons. Some boys get sexually excited and get an erection playing with girl clothes. These boys may be sexually attracted to girls. Other boys like to play dress-up and pretend to be a girl or a woman. These boys might be gay, and they may or may not know it yet. "Gay" means that when they are older they will fall in love with another guy. Another possibility is when boys experiment with cross-dressing for a while to see how it feels. Which kind do you think is more like you?" We left gender identity issues out of this example, but it could also be included if the history suggests this possibility.
If the pediatrician refers the patient to a mental health professional, that professional should be selected carefully. Some providers lack the competence or feel uncomfortableconsciously or unconsciouslywith these issues. The rarity of clinical presentations of childhood cross-dressing, combined with inadequate training and personal biases, contributes to this problem. A potential resource for identifying knowledgeable clinicians is the local Parents, Families and Friends of Lesbians and Gays (PFLAG). PFLAG has chapters throughout the United States and they usually know professionals experienced in working with sexual minority youth.
Readers' Forum. Contemporary Pediatrics October 2002;19:22.