Updated May-17-2010

Fetishistic Disorder

[1] The Paraphilias Subworkgroup is proposing two broad changes that affect all or several of the paraphilia diagnoses, in addition to various amendments to specific diagnoses. The first broad change follows from our consensus that paraphilias are not ipso facto psychiatric disorders. We are proposing that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder.

This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it. This change in viewpoint would be reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, Sexual Sadism would become Sexual Sadism Disorder; Sexual Masochism would become Sexual Masochism Disorder, and so on.

In general, the distinction between paraphilias and paraphilic disorders is reflected in the format of the diagnostic criteria for specific paraphilias. Paraphilias are ascertained according to the “A” criteria, and paraphilic disorders are diagnosed according to the “A” and “B” criteria. The distinction between paraphilias and paraphilic disorders is discussed in the context of specific diagnoses by Blanchard (2009b, 2009c).

The second broad change applies to paraphilias that involve nonconsenting persons (e.g., Voyeuristic Disorder, Exhibitionistic Disorder, and Sexual Sadism Disorder). We propose that the B criteria suggest a minimum number of separate victims for diagnosing the paraphilia in uncooperative patients. This was done to reflect the fact that a substantial proportion—perhaps a majority—of patients referred for assessment of paraphilias is referred after committing a criminal sexual offense. Such patients are not reliable historians, and they are typically not candid about their sexual urges and fantasies. The criteria have therefore been modified to lessen the dependence of diagnosis on patients’ self-reports regarding urges and fantasies. This change also addresses the past criticism that the word “recurrent” in the DSM-IV-TR A criteria says nothing beyond “more than once” and is too vague to be clinically useful. The reason for diagnosing specific paraphilic disorders from multiple, similar offenses in uncooperative patients is to achieve a level of diagnostic certitude closer to the certitude in diagnosing these disorders from self-reports in cooperative patients. It is not derived from legal theory or practice.                  

The suggested minimum number of separate victims varies for different paraphilias. This represents an attempt to obtain similar rates of false positive and false negative diagnoses for all the paraphilias. The logic runs as follows: Paraphilias differ in the extent to which they resemble behaviors in the typical adult’s sexual repertoire. For example, sexual arousal from seeing unsuspecting people in the nude seems more probable, in a typical adult, than sexual arousal from hurting or maiming struggling, terrified strangers. It follows that the more closely a potentially paraphilic behavior resembles a potentially normophilic behavior, the more evidence should be required to conclude that the behavior is paraphilically motivated. We have therefore suggested, for example, three different victims for Voyeuristic Disorder but only two different victims for Sexual Sadism Disorder. We felt that fewer than three victims for Voyeuristic Disorder would result in too many false positives and more than two victims for Sexual Sadism Disorder would result in too many false negatives.

[4] Prior to the advent of DSM-III-R (1987), Fetishism was historically operationally characterized as persistent preferential sexual arousal in association with nonliving objects, an over-inclusive focus on (typically non-sexual) body parts (e.g., feet, hands) and body secretions (Kafka, 2009b).

In the DSM III-R, Partialism, an “exclusive focus on part of the body,” was cleaved from Fetishism and added to the Paraphilia Not Otherwise Specified category. The specific rationale for this distinction was not apparent.

The current literature reviewed suggests that Partialism and Fetishism are related, can be co-associated (e.g., most commonly fetishistic sexual arousal to feet and footwear), and are non-exclusive domains of sexual behavior (Chalkley & Powell, 1983; Scorolli, Ghirlanda, Enquist, Zattoni, & Jannini, 2007; Weinberg, Williams, & Calhan, 1994, 1995). Fetishism and Partialism can both be associated with Criterion B levels of distress and/or role impairment.

Kafka (2009b) recommends that since the advent and elaboration of the clinical significance criterion (Criterion B) for designating a psychiatric “disorder” in DSM-IV (1994), a diagnostic distinction between Partialism and Fetishism is no longer clinically meaningful or necessary. It is recommended that the diagnostic Criterion A for Fetishism be modified to reflect the historically-based reintegration of Partialism with Fetishism and that a fetishistic focus on non-sexual body parts associated with Criterion B impairments be a Specifier of Fetishistic Disorder.

References

Blanchard, R. (2009b). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior. Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9536-0

Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3

Chalkley, A. J., & Powell, G. (1983). The clinical description of forty eight cases of sexual fetishism. British Journal of Psychiatry, 142, 292-295.

Kafka, M. P. (2009b). The DSM diagnostic criteria for Fetishism. Archives of Sexual Behavior. Oct 1 [Epub ahead of print]. DOI: 10.1007/s10508-009-9558-7

Scorolli, C., Ghirlanda, S., Enquist, M., Zattoni, S., & Jannini, E. A. (2007). Relative prevalence of different fetishes.International Journal of Impotence Research, 19, 2-437.

Weinberg, M. S., Williams, C. J., & Calhan, C. (1994). Homosexual foot fetishism. Archives of Sexual Behavior, 23, 611-626.

Weinberg, M. S., Williams, C. J., & Calhan, C. (1995). "If the shoe fits...": Exploring homosexual foot fetishism. Journal of Sex Research, 32, 17-27.

FETISHISTIC DISORDER

1. During the past two weeks, how often did you feel a sexual urge involving a fetish (specific items of clothing, like shoes or underwear; certain materials, like rubber or leather; or particular parts of the body, like feet, that are not sexually exciting to most people)? 

1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day

2. During the past two weeks, how often did you feel sexually aroused while imagining (or remembering) yourself touching, looking at, smelling, wearing, or stroking your body with your favorite fetish? 

1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day

3. During the past two weeks, how sexually exciting was the idea of touching, looking at, smelling, wearing, or stroking your body with your favorite fetish? 

1. Not at all exciting
2. Slightly exciting
3. Moderately exciting
4. Strongly exciting
5. Extremely exciting

4. During the past two weeks, how times did you masturbate or have sexual intercourse while touching, looking at, smelling, wearing, or stroking your body with your favorite fetish? 

1. 0
2. 1
3. 2
4. 3
5. 4 or more

5. Over the course of your life, excluding the past two weeks, how times did you masturbate or have sexual intercourse while touching, looking at, smelling, wearing, or stroking your body with your favorite fetish? 

1. 0
2. 1
3. 2
4. 3–50
5. More than 50

Fetishism

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the use of nonliving objects (e.g., female undergarments).

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The fetish objects are not limited to articles of female clothing used in cross-dressing (as in Transvestic Fetishism) or devices designed for the purpose of tactile genital stimulation (e.g., a vibrator).