Updated April-28-2012

Fetishistic Disorder

In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in an Uncontrolled Environment)

Rationale

The rationale for changing the proposed diagnostic criteria for this Paraphilic Disorder from those used in DSM-IV-TR may be considered under three headings: (1) those that affect the diagnostic criteria for all Paraphilic Disorders, (2) those that specifically affect the diagnostic criteria for Pedophilic Disorder, and (3) those that concern changes from the last posted version of the proposed criteria (November 18, 2011) to the present version.

Changes Affecting the Diagnostic Criteria for All Paraphilic Disorders

One of the first questions addressed by the Paraphilias Subworkgroup was whether all paraphilias are ipso facto mental disorders. We took the position that they are not. We therefore proposed that the DSM-5 make a distinction between paraphilias and Paraphilic Disorders, as described below.

A Paraphilic Disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others in the past. A paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not automatically justify or require clinical intervention.

It was possible to implement the distinction between paraphilias and Paraphilic Disorders without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. In the diagnostic criteria set for each of the listed Paraphilic Disorders, Criterion A specifies the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the genitals to strangers), and Criterion B specifies the negative consequences of the paraphilia (distress, impairment, or harm—or risk of harm—to others).

The change proposed for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be diagnosed as having a Paraphilic Disorder. The word diagnosis would not be used in regard to individuals who meet Criterion A but not Criterion B, that is, individuals who have a paraphilia but not a Paraphilic Disorder. If an individual meets only Criterion A for a particular paraphilia—a circumstance that might arise when a benign paraphilia is discovered during the clinical investigation of some other condition—then the act of noting or reporting that the individual acknowledges the paraphilia should be referred to as ascertainment rather than diagnosis. Usage of the term ascertainment does not mean that an additional or a special step has been added to clinical assessment. It is simply a convenient way of avoiding the inappropriate word diagnosis when the individual has a paraphilia but not a Paraphilic Disorder.

The distinction between paraphilias and Paraphilic Disorders is one of the changes from DSM-IV-TR that applies to all atypical erotic interests. 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. An additional advantage of this approach is eliminating certain logical absurdities in the DSM-IV-TR. In that version, for example, a man could not be identified as having transvestism—however much he cross-dressed and however sexually exciting that was to him—unless he was unhappy about this activity or impaired by it (Blanchard, 2010). This change in viewpoint is reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias.

The second overarching change from DSM-IV-TR is the addition of the course specifiers, “In a Controlled Environment” and “In Remission,” to the diagnostic criteria sets for all the Paraphilic Disorders. These specifiers were added in response to clinicians’ complaints that the DSM-IV-TR and earlier versions provided no mechanism for indicating important changes in the individual’s status. There is no expert consensus about whether a longstanding paraphilia can disappear spontaneously or be removed by therapy. There is less argument that consequent psychological distress, psychosocial impairment, or the propensity to do harm to others can be ameliorated by therapy or reduced to acceptable levels. Therefore, the “In Remission” course specifier was written so as to indicate remission from a Paraphilic Disorder. It is silent with regard to changes in the presence of the paraphilic interest per se. The intended meaning of remission is clarified in each of the diagnostic criteria sets with a parenthetical expression: “In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in an Uncontrolled Environment).” The other course specifier, “In a Controlled Environment,” was included because the propensity of an individual to act on paraphilic urges may be more difficult to assess objectively when the individual has no opportunity to act on such urges.

Updated October-18-2010

Fetishistic Disorder

Severity Rating for the Past Two Weeks

99 (Missing data): Rating cannot be assigned because of the patient's mental condition or the circumstances of the assessment 

0 (None): No evidence of paraphilic sexual fantasies, urges, or behaviors

1 (Mild): Paraphilic sexual fantasies, urges, or behaviors are weaker than normophilic sexual interests and behaviors

2 (Moderate): Paraphilic sexual fantasies, urges, or behaviors are approximately equal to normophilic sexual interests and behaviors

3 (Severe): Paraphilic sexual fantasies, urges, or behaviors are stronger than normophilic sexual interests and behaviors

4 (Very Severe): Paraphilic sexual fantasies, urges, or behaviors completely replace all normophilic sexual interests and behaviors

Patient Self-Rated Measure

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).