Background

Fetishistic Disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis given to an individual who gets sexual gratification from objects or a specific body part which is not usually considered as sexually exciting. This behavior can lead to significant distress or functional impairment. Almost any object or body part can be Fetish. Some common fetishes include shoes, aprons, and women’s underclothing, leather and latex items. The DSM-5 reports that Fetishistic Disorder can typically arise at the onset of puberty, or less typically, before adolescent age [1].

The prevalence of Fetishistic Disorder in the general population is not yet identified. A population-based study done among adults have reported 15.9% prevalence of paraphilic sexual behaviors such as Futurism, Voyeurism, masochism and fetishism among both male and female participants [2].

Risk factors for Fetishistic disorder are not clearly identified yet. According to the DSM-5 Fetishistic Disorder can be comorbid with other paraphilias and hypersexuality. It also can occur in the context of neurological disorders [1].

Fetishistic disorder can adversely affect the individual’s intimate relationships and can result in sexual dysfunction [1]. It is reported that paraphilias in general (including fetishism)can be associated with general impairment in psychosocial functioning such as being victims of physical abuse, substance abuse, lower educational attainments, comorbid mental health problems, disability, unemployment, higher risk of getting sexually transmitted diseases, involvement with law enforcement authorities [3].

Cognitive behavioral therapy is the most promising management approach for paraphilias including fetishism [4]. Selective serotonin reuptake inhibitors reported to be effective in treatment of paraphilias including fetishism [5].

Some studies have shown an association between learning disability and paraphilia. Individuals can have deviant sexual behaviors either secondary to direct paraphilia or limited understanding about sexual practices due to learning disability [6].

Stigma attached to paraphilia is universal. People with paraphilia are significantly underserved and misunderstood group of population [7]. In Sri Lanka there are no studies published on social stigma attached to paraphilia including fetishism. However, as clinicians we can see that high social, religious and cultural values and limited awareness among people have created a massive stigma towards individuals with paraphilia’s. This has created challenges in management of these young people.

This case report describes 15 years old boy with mild learning disability presenting with features of fetishism and challenges in management due to multiple factors including social stigma. Consent from the child’s parents have been obtained for clinical assessment and presenting the clinical information in scientific publications.

Case report

A 15 years old boy was referred to Child and adolescent psychiatry unit by judicial medical officer for assessment. He has been caught by the villagers while stealing female undergarments. He was handed over to police after been assaulted by the villagers. On assessment he reported to be getting sexual gratification by touching female undergarment for more than 6 months. After the incident he was expelled from school due to public pressure. He denied cross dressing and using the objects as sexual vibrators. He denied experiencing sexual gratification by watching people naked, showing genitalia to others or contacting prepubertal children. His mental state was stable apart from the preoccupation about female under garments. According to TONI 3 nonverbal test of intelligence [8] he presented with intelligence quotient (IQ) of 68. This indicated the diagnosis of mild mental retardation according to the International Classification of DisordersCD-10[9].

Management- Both pharmacological and psychological methods were used for management. He was given fluoxetine 10 mg daily. Principles of aversion therapy were used to control the behavior. His limited intellectual capacity also affected his engagement in behavioral management. Child psychiatric team liaised with the school principal and his schooling was recommenced. He was able to sit for the General certificate of education ordinary level (GCE O/L) examination conducted by the ministry of education, sri lanka. During the follow-up period he was assaulted by the villagers again accusing him for stealing female undergarments again. However later it was revealed that the lost female undergarment was thrown away by wind and found on a roof of another house. Despite symptom control he had to experience extensive social stigma and marginalization.

Discussion

He fulfilled the diagnostic criteria of fetishistic disorder according to DSM 5[1]. He also had mild mental retardation [9]. Studies have shown an association between mental retardation and abnormal sexual behaviors. He responded well to fluoxetine and sex aversion therapy. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) which group of medications are reported to be effective for abnormal sexual behaviors [10]. Sex aversion therapy also reported to be effective for abnormal sexual behaviors. His functional level improved with treatment. However, it was clearly shown that the social stigma attached to paraphilias affected the outcome of the condition at different levels. At the beginning he was assaulted by the villagers before presenting to the police. School principal had to expel him from school due to public pressure. While in remission also he was falsely accused by the villagers for same behavior. This shows how difficult to manage paraphilia in Sri Lankan context where societal perception on deviant sexual behaviors are highly influenced by religious and cultural believe system of the communities.

In conclusion this case report shows how the outcome of adolescents with deviant sexual behaviors can be highly affected by societal stigma.