Fetishism was first described in 1886 by Richard von Krafft-Ebing and in 1887 by French psychologist Alfred Binet (41-43). The essential feature is the necessity for an inanimate object to achieve or maintain sexual arousal, either in fantasy or in actual behavior. The fetish is often preferred or required for arousal, egosyn-tonic, and rarely the cause of personal distress. Individuals may experience sexual dysfunction when engaging sexually without use of the fetishistic object or fantasy.
Fetishism is demarcated from paraphilia not otherwise specified by the exclusion of body parts from the definition of fetishism. Fetishism is definition-ally limited to the use of nonliving objects and often features masturbation while holding, rubbing, or smelling the object, whereas fetish-like preferences related to the human body or other living creatures are generally coded as paraphilia not otherwise specified (5). These categorical distinctions and their rationale are unclear and are also the source of professional debate (44). According to DSM-IV-TR nosology, for example, what is commonly referred to as "foot fetishism" is a form of partialism and is coded, therefore, as paraphilia NOS (302.9). Many clinicians and researchers, however, conceptualize fetishism as not limited to nonliving objects but, rather, including arousal to part objects (body parts) as well. In this conceptualization, foot fetishism and other part object paraphilias are coded as fetishes (302.81) (20,45).
There is very limited data about fetishistic individuals, since they rarely seek treatment. Many studies are in the form of single case reports. A review by Chalkley and Powell examined the clinical characteristics of 48 fetishists (9). The sample was predominantly male; 22% were homosexual; the majority described preferences for multiple fetishistic objects; and soft textured fabrics were more arousing than hard textures such as rubber.
In his study of Internet chat groups, Junginger found feminine underwear, rubber objects, and body parts such as feet, toes, legs, hair, and ears to be among the most common, although it also appears quite common to fetishize the form or texture of an object, such as silk or rubber. Discussion groups related to diapers and enemas were also found to be common (46). An interesting phenomenon is the shifting of fetish trends over time. Mason has pointed out that a century ago objects made of velvet and silk were preferred, whereas today rubber and leather appear to be more common (44).
A brief Internet search dispels any doubt regarding the high prevalence and diversity of fetishistic curiosity in modern culture. A search, during the summer of 2003, of the word "fetish" drew a list of 359 possible sites and 1192 possible pages, offering both the curious and the desperate virtual buffet of fetishistic opportunities.
In transvestic fetishism, cross-dressing in feminine apparel is fetishistically used, or the fantasy of such via autogynephilic—meaning love of self—imagery. The term transvestism was coined by the German sexologist Magnus Hirschfeld (47). DSM-IV-TR criteria require that a heterosexual male experience "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing" (5,48). The fantasies and behaviors must cause distress or impairment in psychosocial or occupational functioning. The diagnosis is subcategorized to specify whether gender dysphoria, or discomfort with one's biologic sexual designation, is or is not present. This dimension varies greatly among the cross-dressing population. Some transvestites develop marked distress about their biologic designation and seek sexual reassignment, whereas others express no such wish. Blanchard used the term transvestic autogynephilia, literally meaning "love of oneself as a woman," to refer to the core feature of sexual excitement in response to cross-gender behaviors or fantasies, which include but are not limited to cross-dressing, in the transvestic fetishist (49).
Cross-dressing itself is not diagnostic of transvestic fetishism. Early investigators found cross-dressers to report a wide range of behaviors. The nuclear transvestite clearly and exclusively fulfills DSM diagnostic criteria. Other cross-dressers engage in some bisexual or homosexual experiences, although their basic orientation is heterosexual (50). Still others are effeminate homosexuals whose cross-dressing is in no way fetishistic.
Many transvestic individuals do not seek psychiatric evaluation or do so only if discovered by a spouse or family member or if they become gender dys-phoric. Thus, knowledge is extremely limited regarding the phenomenological features of fetishistic cross-dressers who do not seek psychiatric assistance. When fetishistic cross-dressers seek evaluation for gender dysphoria or for sexual reassignment surgery, they often minimize their arousal patterns when cross-dressed. Resources such as local transsexual support groups and Internet sites may counsel individuals to minimize disclosures that might jeopardize their hopes for surgical or hormonal reassignment. Thus, patients are increasingly savvy about what is expected during psychiatric assessment. The clinician must be aware of these phenomena and that fetishistic arousal is often denied.
A survey of subscribers to a magazine for transvestites offers a broader picture of men reporting themselves to be cross-dressers (51). The vast majority were heterosexual, although almost one-third had some homosexual experiences. Cross-dressing was reported to begin before the age of 10 in two-thirds and the majority noted that cross-dressing allowed them to express a different and preferred side of their personality. The respondents, 57% of whom were above the age of 40, reported that they experienced sexual excitement and orgasm while cross-dressed only occasionally. In total, 75% had experienced the need to purge cross-dressing by throwing out all of their feminine clothes and attempting to renounce the need to cross-dress; 83% reported that their wives were aware of the cross-dressing but only 28% experienced their wives as accepting of it. A distinct minority felt themselves to be a woman trapped inside a man's body, while three-quarters felt that they were men with a feminine side. The majority felt that they were equally masculine and feminine and almost one-half were interested in utilizing female hormones. Only 17% would have sexual reassignment, if possible, and 45% had at some time consulted a psychologist or psychiatrist. Two-thirds of those who had sought therapy reported it as helpful. When compared with a similar survey 25 years earlier, this figure reflected a dramatic difference in those endorsing help by psychotherapy, perhaps suggesting greater understanding of the disorder by the mental health profession (52). The majority of cross-dressers in both surveys were primarily heterosexual. Some males, colloquially designated as "drag queens," cross-dress to mimic feminine behavior satirically rather than fetishistically. Such individuals do not meet criteria for the diagnosis of transvestic fetishism (53).
Transvestic fetishists report a spectrum of behaviors and cognitions. It is important to note that for some, the need for erotic arousal abates over time. As the erotic cross-dresser ages, his cross-dressing may be used more to reduce anxiety than to produce sexual arousal (54).
The content of transvestic fantasy varies. It may be of the self with female genitals and breasts, partially or entirely nude; dressed in female attire; as a pregnant woman; engaged in nonsexual feminine activities such as house cleaning; or engaged in sexual activity, in the role of a woman, with a partner (55).
The personality profiles of fetishistic cross-dressers who present as patients reveal elevated rates of neuroticism as well as lower rates of agreeableness. This may suggest a vulnerability for affective distress and the propensity for disagree-ableness, which may foster marital discord (56). In a nonclinical cohort of cross-dressers attending a weekend seminar, personality characteristics were found to be no different than normal controls, with the exception of higher reported levels of openness to fantasy (57). These data suggest that the cross-dresser who seeks treatment may be significantly different from the nonpatient transvestite. If so, data from clinical cohorts may not be generalized to all cross-dressers.
Studies indicate that ^50% of applicants for surgical sex reassignment have histories of transvestic fetishism (58). The gender dysphoric transvestite may make a dramatic presentation with acute gender dysphoria and the wish for sexual reassignment. Therefore, thorough understanding of these disorders is critical for clinicians (58,59). It must be considered that gender dysphoria is a transient "state phenomenon" related to loss, trauma, or comorbid state (29). Such cases demand consideration of aggressive antidepressant treatment and restraint from supporting sex reassignment as a first line solution. For some trans-vestites, an initial optimism about reassignment is replaced by depression when issues of loss emerge or if illusions about the financial feasibility of reassignment are shattered. Clinicians are advised to avoid simplistic short-term solutions and to remain cognizant of the possibility of emergent deeper levels of dysphoria and self-destructive thoughts. Not uncommonly, complex underlying themes and comorbid conditions become more apparent as treatment progresses, suggesting the pursuit of a long-term treatment approach combining psychotherapy and medication.
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