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The World Health Organization is currently developing the 11th revision of the International Classifications of Diseases and Related Health Problems (ICD-11), with approval of the ICD-11 by the World Health Assembly anticipated in 2018. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) was created and charged with reviewing and making recommendations for categories related to sexuality that are contained in the chapter of Mental and Behavioural Disorders in ICD-10 (World Health Organization 1992a ). Among these categories was the ICD-10 grouping F65, Disorders of sexual preference, which describes conditions now widely referred to as Paraphilic Disorders. This article reviews the evidence base, rationale, and recommendations for the proposed revisions in this area for ICD-11 and compares them with DSM-5. The WGSDSH recommended that the grouping, Disorders of sexual preference, be renamed to Paraphilic Disorders and be limited to disorders that involve sexual arousal patterns that focus on non-consenting others or are associated with substantial distress or direct risk of injury or death. Consistent with this framework, the WGSDSH also recommended that the ICD-10 categories of Fetishism, Fetishistic Transvestism, and Sadomasochism be removed from the classification and new categories of Coercive Sexual Sadism Disorder, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals be added. The WGSDSH’s proposals for Paraphilic Disorders in ICD-11 are based on the WHO’s role as a global public health agency and the ICD’s function as a public health reporting tool.

This article examines the case files of patients diagnosed with Transvestitismus [transvestism] in the Psychiatric Clinic of the Helsinki University Central Hospital in the years 1954–68. These individuals did not only want to cross-dress, but also had a strong feeling of being of a different sex from their assigned one. The scientific concept of transsexuality had begun to take form, and this knowledge reached Finland in phases. The case files of the transvestism patients show that they were highly aware of their condition and were very capable of describing it, even if they had no medical name for it. Psychiatrists were willing to engage in dialogue with the patients, and did not treat them as passive objects of study. Although some patients felt that they had been helped, many left the institution as frustrated, angered or desperate as before. They had sought medical help in the hope of having their bodies altered to correspond to their identity, but the Clinic psychiatrists insisted on seeing the problem in psychiatric terms and did not recommend surgical or hormonal treatments in most cases. This attitude would gradually change over the course of the 1970s and 1980s.

Since the beginning of the last century, clinical observers have described the propensity of certain males to be erotically aroused by the thought or image of themselves as women. Because there was no specific term to denote this phenomenon, clinicians' references to it were generally oblique or periphrastic. The closest available word was transvestism. The definition of transvestism accepted by the end of the twentieth century, however, did not just fail to capture the wide range of erotically arousing cross-gender behaviors and fantasies in which women's garments per seplay a small role or none at all; it actually directed attention away from them. The absence of an adequate terminology became acute in the writer's research on the taxonomy of gender identity disorders in biological males. This had suggested that heterosexual, asexual, and bisexual transsexuals are more similar to each other-and to transvestites-than any of them is to the homosexual type, and that the common feature in transvestites and the three types of non-homosexual transsexuals is a history of erotic arousal in association with the thought or image of themselves as women. At the same time, the writer was becoming aware of male patients who are sexually aroused only by the idea of having a woman's body and not at all by the idea of wearing women's clothes. To fill this terminological and conceptual gap, the writer introduced the term autogynephilia(love of oneself as a woman).

Blanchard’s (J Nerv Ment Dis 177:616–623, 1989) theory of autogynephilia suggests that male-to-female transsexuals can be categorized into different types based on their sexuality. Little previous research has compared the sexuality of male-to-female transsexuals to biological females. The present study examined 15 aspects of sexuality among a non-clinical sample of 234 transsexuals and 127 biological females, using either an online or a paper questionnaire. The results showed that, overall, transsexuals tended to place more importance on partner’s physical attractiveness and reported higher scores on Blanchard’s Core Autogynephilia Scale than biological females. In addition, transsexuals classified as autogynephilic scored significantly higher on Attraction to Feminine Males, Core Autogynephilia, Autogynephilic Interpersonal Fantasy, Fetishism, Preference for Younger Partners, Interest in Uncommitted Sex, Importance of Partner Physical Attractiveness, and Attraction to Transgender Fiction than other transsexuals and biological females. In accordance with Blanchard’s theory, autogynephilia measures were positively correlated to Sexual Attraction to Females among transsexuals. In contrast to Blanchard’s theory, however, those transsexuals classified as autogynephilic scored higher on average on Sexual Attraction to Males than those classified as non-autogynephilic, and no transsexuals classified as autogynephilic reported asexuality.