Thursday, August 20, 2009

Fetishism and Paraphilia

This is a complex subject with no easy answers. The DSMIV has been criticized soundly for it's inclusion of sex related diagnosis. However, it's normal for patients to present seeking help with sexual and intimate relationship issues if the clinician is non judgemental and opens the subject or at least is open to discussing matters medical. Most psychiatrists and doctors in general would be unlikely to hear about paraphilia or sexual fetishisms simply because 1) people don't talk about them 2) people certainly don't talk about them to mommy or daddy figures 3) and people don't see them as a problem 4) psychiatrists and doctors don't ask. The most casual survey of a adult sex store though shows a vast array of objects and 'toy's'. Yet, sex toys and objects made to represent sexual parts are not considered in some definitions paraphilias though anthropologists at very least have considered these objects often of ancient history as 'fetishs'. The literature on fetishism is broad and includes those who might desire a 'type' of woman, say one with long legs or big breast, or a type of men, say one with slim butt or large penis. In the area of objects there is this confusion whereas the demarcations become clearer when the line moves out to the less common areas including self cutting in women and coprophilia or feces associated sexual behaviour in men and women.
There is an idea that what is normative is heterosexual coupling for reproduction or genital sexual intercourse and movement away from this missionary position of sexuality is in some way 'abherrent'. Indeed there's always this black feather on the white feathered chicken "difference' which gets a disease categorization from the conservative herd. Foreplay however has long been associated with much fetishistic behaviour from corsettes to lip sticks.
Developmentally 'imprinting' as seen by psychologists, can have a profound effect on sexual arousal and appreciation. English boys whipped in schools describe anecdotally involuntary sexual arousal and orgasm with subsequent preference for 'spanking' play. Neurological studies suggest some actual 'cross wiring' whereby a non normative sexual act can cause arousal and then be learned with the patterning following. Sexual Addiction research shows clearly that behaviours can be learned and unlearned by group therapy and individual practice.
There has been a strong suggestion however that if one 'prefers' some sexual activity, especially one which involves inanimate objects, over an actual sexual encounter with a real living human then that would indeed represent a paraphilia and the object would be a sexual fetish. This is distinct from what may be called the 'transitional object'. A young woman may take a fancy to a cucumber in her exploration of her developing sexuality in the same way as adolescent males not infrequently show up in emergency departments with unusual encounters which trap them, the vacuum cleaner nozzle being one such. Every radiologist working in emergency has seen any number of inanimate objects in vaginas or anal cavities from plastic fruit to screw drivers. They show up on the xray when a patient shyly complains of abdominal pain. "I"ve seen lots of lost vibrators but not one when the batteries were still working" said one crusty radiologist in the emergency late one night.
The idea of 'transitional object' is simply that in the process of learning there is not uncommonly exploration and once the 'normative' experiences are established alternatives die away. And in a world where sex was readily available for all this might be the case. However that's not the ideal world and 'objects' collected in Victorian times by doctors were often put on impressive displays.
It's increasingly felt that what "consensual" adults do in their bedrooms and what individuals do in their bedrooms is their own business. Hard as that idea is for people to grasp some people despite the state and religion enjoy the idea of 'privacy'.
However, there's a tremendous amount of shame confusion, and sometimes harm associated with paraphilia and fetishistic behaviour. Recently the material used in some 'dildos' and 'vagina simulator's' was recognised as having a slight medical risk with alternative materials being developed. Similiar questions have been raised about condoms and lubrications. Asked specifically about the sex toy material in clinic one day , I frankly had no idea, and despite a quick perusal of the limitted literature didn't know if the 'risk' was serious or not despite the fact that the industry is moving to the newer materials. Frankly I didn't know who in public health or medicine might know or answer the question without being suspicious of me, a psychiatrist and sexual medicine specialist. "Sure you're asking for your patients, doctor" wink. wink. And I figure if that's the perverse response I'm concerned about getting to questions of a medical and scientific natures it's much much worse for patients.
There is no doubt in my mind that the paraphilias and fetishism remain in medicine and psychiatry however I"m concerned that the diagnosis be associated with some form of acknowledgement that an individual who sees a clinician is 'concerned' about the issue and not that we, as psychiatrists and physicians, have to enter the murky political world of what is 'right' or 'wrong'. I am thankful that I've been available to be asked by patients about fetishist activities or paraphilias and been able to answer questions specific to 'physical health'.

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