cent and adult males (rarely in females) fo r whom cross-dressing behavior generates sex-
ual excitement and causes distress and/or  impairment without drawing their primary
gender into question. It is occasionally ac companied by gender dysphoria. An individual
with transvestic disorder who also has clinica lly significant gender dysphoria can be given
both diagnoses. In many cases of late-onset  gender dysphoria in gynephilic natal males,
transvestic behavior with sexu al excitement is a precursor.
Body dysmorphic disorder. An individual with body dy smorphic disorder focuses on
the alteration or removal of a sp ecific body part because it is perceived as abnormally formed,
not because it represents a repudiated assign ed gender. When an individual’s presenta-
tion meets criteria for both gender dysphori a and body dysmorphic disorder, both diag-
noses can be given. Individuals wishing to  have a healthy limb amputated (termed by
some body integrity identity disorder) because it makes them feel more “complete” usually
do not wish to change gender, but rather desi re to live as an amput ee or a disabled person.
Schizophrenia and other psychotic disorders. In schizophrenia, there may rarely be
delusions of belonging to some  other gender. In the absence of psychotic symptoms, in-
sistence by an individual with gender dysphori a that he or she is of some other gender is
not considered a delusion. Schizophrenia (or other psychotic disorders) and gender dys-
phoria may co-occur.
Other clinical presentations. Some individuals with an emasculinization desire who
develop an alternative, nonmale/nonfemale ge nder identity do have  a presentation that