Unlike other chapters of this book that focus on partnering between two or more people and the health effects of such partner-ings, this chapter focuses on attraction to objects and/or anatomical portions of people and related health effects. In effect, at the extreme, the attraction to the object becomes the relationship with the object. This may occur regardless of the sex or sexual orientation of the individuals involved.
The nature and cause of fetish sexual practice has been the subject of vociferous debate. Webster's Third New International Dictionary Unabridged (1986) defines a fetish as a natural or artificial object (as an animal tooth or a wood carving) believed among a primitive people to have a preternatural power to protect or aid its owner often because of ritual consecration or animation by a spirit; broadly: any material object regarded with superstitious or extravagant trust or reverence.
Fire, for instance, can be the object of such a fetish (Balachandra, 2002).
The nineteenth-century sexologist Krafft-Ebing (1886: 218) used the term fetishism to refer to "The Association of Lust with the Idea of Certain Portions of the Female Person, or with Certain Articles of Female Attire." Krafft-Ebing postulated that pathological erotic fetishism occurred when "the fetich itself (rather than the person associated with it) becomes the exclusive object of sexual desire" so that, rather than sexual intercourse, "strange manipulations of the fetich" became the sexual aim (Krafft-Ebing, 1886; spelling as in original text). Empirical research, however, suggests that intimacy and fetishism are able to coexist, either within a specific relationship, or through the maintenance of a primary relationship while engaging in fetish behavior with outside partners (Weinberg, Williams, and Calhan, 1994).
The intensity of fetishism has been conceived of as existing on a spectrum, as follows (Gamman and Makinen, 1994: 38).
Level 2: This represents the lowest level of fetishism, where a strong preference exists for certain kinds of sex partners, sexual stimuli or sexual activity.
Level 3: At this level, fetishism is moderately intense and individuals require specific stimuli in order to experience sexual arousal and perform sexually.
Level 4: This level represents the highest level of fetishism, where specific stimuli take the place of a sex partner.
Fetishism is also conceived of as a mental disorder. The current reference work for the diagnosis of mental disorders, the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR, 2000) classifies fetishism as a paraphilia and sets forth diagnostic criteria for what is considered to be a disorder: recurrent, intense sexually arousing sexual fantasies, sexual urges, or behaviors involving the use of nonliving objects for a period of at least six months; clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of these fantasies, urges, or behaviors; and the nonliving objects consist of articles beyond the use of female clothing used in cross-dressing or devices designed for the purpose of genital stimulation. Transvestic fetishism is delineated as a separate category of paraphilia to refer to biological males who wear clothing of the opposite sex and, at least on some occasions, experience sexual arousal as a function of that use. These criteria must be read, however, in conjunction with the criteria set forth in the DSM-IV-TR (2000: xxi-xxii) for a mental disorder:
a clinically significant behavior or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.
One must ask, then, if the behavior is not causing the individual distress or disability and does not place the individual at increased risk or suffering death, pain, disability, or an important loss of freedom, how can it be considered to be a mental disorder? How can one assess if the fantasies, urges, or behavior are causing a "clinically significant distress or impairment in social, occupational, or other important areas of functioning" absent a specification of what constitutes normative functioning in these domains? Foucault (1978), for instance, asserted that the "psychiatrization of perverse pleasure" constitutes the modern equivalent of the confessional and a form of knowledge-power. Gosselin and Wilson (1980: 23) concluded from their research:
Unusual sex patterns and predilections can be found in anyone—young or old, rich or poor, male or female. What is more, they can be found in people who otherwise don't feel themselves to be "sick" or "abnormal" in any way. It is thus doubly difficult in this field to equate "unhealthy" with "abnormal" with any degree of confidence. During our researches we came across considerable numbers of people who, while having a predilection for [fetishism, sadomasochism, or transvestism], expressed no wish to be "cured" of that predilection ... It seems then, that no definition of abnormality in terms of "illness" is meaningful in this domain
It must be stated from the outset that, despite the research that has been conducted on fetish sexual behaviors and related sexual practices, we actually know relatively little about the behaviors that are called fetishistic and we know even less about the individuals who are attracted to and/or engage in fetishistic sexual practice, the context of those practices, the relationship between context and the fetishistic behavior, and the relationships between health effects and behavioral context. Much of the research that has been conducted to date has focused on "the acts," without examining either the nature of the relationships between the participants or the context in which they engage in sexual behavior. For instance, are individuals who utilize fetish as part of their sexual repertoire more likely to do so with steady, intimate partners or with relatively more casual partners or both? Does the level of safety that is integrated with the sexual repertoire vary depending upon the nature of the relationship (e.g., casual, long-term, steady, romantic, commercial, etc.), the setting in which the sexual behavior occurs (private residence, fetish party, group sex), the number of individuals participating, and/or the sex or other characteristics of the individuals participating? How do individuals perceive risk in the context of related behaviors, such as submission-dominance behavior and how do they address that risk? The paucity of our knowledge and our inability to respond to such basic questions ultimately limits our ability to assess associated health effects.
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