What is a fetishistic disorder?
Fetishistic disorder is an intense sexual attraction to either inanimate objects or to body parts not traditionally viewed as sexual, coupled with clinically significant distress or impairment. The term "fetishism" originates from the Portuguese word feitico, which means "obsessive fascination." Most individuals find particular non-genital bodily features attractive, indicating that some level of fetishism is a normal feature of human sexuality. However, fetishistic arousal may become a problem when it interferes with normal sexual or social functioning, or when sexual arousal is impossible without the fetish object.
The paraphiliac focus in fetishistic disorder involves the eroticisation of non-living objects and/or body parts for sexual gratification. Among the more common non-living fetish objects are women’s underpants, bras, stockings, shoes, boots, or other wearing apparel. An individual with a fetish for a body part (e.g., feet, hair) will eroticise a non-genital body part during a sexual encounter. It is not uncommon for sexualised fetishes to include both inanimate objects and body parts (e.g., dirty socks with feet). Fetishistic disorder can be a multisensory experience, including holding, tasting, rubbing, inserting, or smelling the fetish object while masturbating, or preferring that the sexual partner wear or utilise a fetish object during sexual encounters. For many people with Fetishistic Disorder, it can cause problems in relationships. When the item the individual has the fetish toward is not present or removed from the room, he may not be able to complete the sexual act.
Who is considered to have a fetish?
The person with fetishism frequently masturbates while holding, rubbing, or smelling the fetish object or may ask the sexual partner to wear the object during their sexual encounters. Usually the fetish is required or strongly preferred for sexual excitement, and in its absence there may be erectile dysfunction in males.
Many individuals who self-identify as fetishist practitioners do not necessarily report clinical impairment in association with their fetish-associated behaviours. Such individuals could be considered as having a fetish but not fetishistic disorder. A diagnosis of fetishistic disorder requires clinically significant distress or impairment in functioning resulting from the fetish.
According to the DSM-5, fetishistic disorder is characterised as a condition in which there is a persistent and repetitive use of or dependence on non-living objects (such as undergarments or high-heeled shoes) or a highly specific focus on a body part (most often non-genital, such as feet) to reach sexual arousal. Only through the use of this object, or focus on this body part, can the individual obtain sexual gratification. In earlier versions of the DSM, fetishistic disorder revolving around non-genital body parts was known as partialism; in the latest version, partialism was folded into fetishistic disorder.
Common fetish objects include undergarments, footwear, gloves, rubber articles, and leather clothing. Body parts associated with fetishistic disorder include feet, toes, and hair. It is common for the fetish to include both inanimate objects and body parts (e.g., socks and feet). For some, merely a picture of the fetish object may cause arousal, though many with a fetish prefer (or require) the actual object in order to achieve arousal. The fetishist usually holds, rubs, tastes, or smells the fetish object for sexual gratification or asks their partner to wear the object during sexual encounters.
Inanimate object fetishes can be categorised into two types:
- Form fetishes -- the shape of the object is important, such as high-heeled shoes.
- Media fetishes -- the material of the object, such as silk or leather, is important.
Inanimate object fetishists often collect the object of their favour.
Treating fetishistic disorders
Cognitive behavioural therapy (CBT)
The University of Texas’s Sexual Psychophysiology Laboratory lists psychotherapeutic treatment options common to all paraphilic disorders that include:
- aversion therapy
- orgasm reconditioning
- and covert sensitization.
All of these options belong to a larger framework of related techniques known as cognitive behavioural therapy (CBT).
Medication-based options for the treatment of fetishistic disorder and other paraphilic disorders include anti-anxiety/antidepressant drugs called SSRIs and a number of different hormone therapies that achieve their effects by lowering the potential for sexual arousal, or the potential for sexual performance in response to sexual arousal. Examples of available hormonal treatments include estrogen and testosterone-lowering drugs called anti-androgens.
Fetishistic disorder tends to fluctuate in intensity and frequency of urges or behaviour over the course of an individual’s life. As a result, effective treatment is usually long-term. Though the DSM-5 does not specify particular treatments, successful approaches have included various forms of therapy as well as medication therapy (such as SSRI's or androgen deprivation therapy). Some prescription medications may help to decrease the compulsive thinking associated with fetishistic disorder. This allows a patient to concentrate on counselling with fewer distractions.
Some research suggests that cognitive-behavioural models may be effective in treating people with paraphiliac disorders. CBT can be used where the therapist helps the person discover the underlying cause of the behaviour and then works with the person to teach skills to manage the sexual urges in more adaptive ways. This may include the use of aversion therapy and different types of imagery/desensitisation in which the person imagines themselves in the situation and then experiencing a negative event to reduce future interest in participating in the fetishistic activities. Cognitive restructuring (identifying and changing the thoughts that drive the behaviour) may also be used.
Sometimes the therapist will work with the individual to gradually dull the response toward the object that causes the sexual desire. This helps to lessen or completely rid the individual of his sexual feelings toward the object. Aversive conditioning, for instance, involves using negative stimuli to reduce or eliminate a behaviour. One approach, called covert sensitisation, entails the patient relaxing and visualising scenes of deviant behaviour, followed by a visualisation of a negative event (e.g., being arrested by the police for stealing undergarments). The goal here is for the patient to associate the sexual behaviour with the negative event.
Reconditioning techniques centre on immediate feedback given to the patient so that the behaviour will change right away. For example, a person might be connected to a biofeedback machine that is linked to a light, then taught self-regulation techniques that will keep the light within a specific range of colour. They then practice doing this while being exposed to sexually stimulating material. Masturbation training might focus on separating the pleasure of masturbation and climax from the deviant behaviour.
If the etiology of the disorder is a learned behaviour, CBT using a form of systematic desensitisation- gradual exposure to the fetishistic object, coupled with a neutral response, rather than a sexual response, may work to lower or eliminate sexual arousal associated with an object.
Drug therapy
Regarding psychopharmacological treatment of sexual paraphilias, there are a number of papers reporting some level of efficacy or inefficacy of several psychotropic medications including antidepressants, antipsychotics or anticonvulsants (3). However these reports are usually limited by case reports, series or they are uncontrolled studies.
Topiramate, a newer anticonvulsant, has a modulating effect on voltage-dependent sodium and calcium ion channels, potentiates GABA neurotransmitters and blocks kainite/AMPA glutamate receptors. There are some case reports on the use of topiramate (up to 200 mg per day) in the treatment of fetishism, a paraphilic sexual disorder.
Increasingly, evidence suggests that combining drug therapy with cognitive behavioural therapy can be effective. A class of drugs called antiandrogens can drastically lower testosterone levels temporarily, and have been used in conjunction with other forms of treatment for fetishistic disorder. This medication lowers sex drive in males and thus can reduce the frequency of sexually arousing mental imagery.
The level of sex drive is not consistently related to the behaviour of those with fetishistic disorder, and high levels of circulating testosterone do not predispose a male to paraphilias. That said, hormones such as medroxyprogesterone acetate (Depo-Provera) and cyproterone acetate help decrease the level of circulating testosterone, potentially reducing sex drive and aggression—and, in the case of an individual with fetishistic disorder, potentially resulting in a reduction of the frequency of erections, sexual fantasies, and initiation of sexual behaviours, including masturbation and intercourse. Hormones are typically used in tandem with behavioural and cognitive treatments. Antidepressants such as fluoxetine may also decrease sex drive but have not been shown to effectively target sexual fantasies themselves.
The antiandrogens cyproterone acetate (CPA) and medroxyprogesterone acetate (MPA [Amen, Depo-Provera) are the most commonly prescribed agents for the control of repetitive deviant sexual behaviours and have been prescribed for paraphilia-related disorders as well. Although neither drug has been specifically approved by the Food and Drug Administration for the treatment of paraphilic disorders, both agents are used in Canada and Europe and medroxyprogesterone is available in the United States. Both agents, available as oral or parenteral preparations, have been shown in multiple studies to reduce recidivism rates in male sexual aggressors, the group most commonly prescribed these drugs.
Common side effects of antiandrogens include weight gain, fatigue, hypertension, headaches, hyperglycemia, leg cramps and diminished spermatogenesis. In addition, there may be an increased risk of thromboembolism in men (and women) with risk factors associated with clotting disorders and rare feminization effects such as breast swelling and changes in hair distribution during prolonged treatment.
The effect of antiandrogens on sexual desire and associated fantasies, erections, urges and other sexual behaviours is usually evident by two to four weeks after the initiation of pharmacotherapy. Pharmacological tolerance to their effects has not been described, and either agent can be tapered without a rebound increase in sexual or aggressive behaviours. After a period of symptom stabilization, a lower maintenance dose can sometimes be titrated to minimize side effects, and in some cases, to permit a more selective mitigation of deviant sexuality in comparison with conventional sexual desire. Sexual fantasies and erections usually return approximately two to four weeks after an antiandrogen is gradually tapered, although in some men it may take longer for the effects to be fully reversed.
