Introduction

Sexual fetishism is defined by recurrent, intense, sexually arousing fantasies, sexual urges or behaviors involving the use of nonliving objects, such as female undergarments or non-sexual body parts. Although it is assumed that fetishism usually begins by adolescence, there is very limited data on the characteristics of sexual fetishism in children or adolescents. This paper aims to describe clinical pictures of two adolescent boys who developed sexual fetishism. They were 13 and 12 years-old of age and both have comorbid attention deficit hyperactivity and social anxiety disorders. We plan to discuss clinical picture, treatment intervention and impact of comorbid attention deficit hyperactivity and social anxiety disorders in the development of sexual fetishism in these subjects. The concept of fetishism in anthropology, marxism and psychology is examided as a particular case of the interplay between theories of cognition and collective representations. Classificatory end-products to which the word 'fetish' has been applied cannot be understood simply as special kinds of objects, or defined in terms of their generic functional attributes. Neither do they reflect a particular mental condition. Rather, they reveal a variable combination of three underlying features of categorisation and representation characteristic of all thought. These are concretisation, animation or anthropomorphisation, conflation of signifier with signified and an ambiguous relationship of control between person and object. All lie on a processual continuum which begins with the identification of categories, relationships and phenomena, and proceeds-via reification and iconification-to their personification. In this sequence what we might loosely describe as 'fetishisation' appears with a shift from the balanced simultaneity of signifier and signified towards 'the thing in itself'.

Paraphilias are defined as sexual disorders characterized by recurrent, intense sexual urges, fantasies or behaviors that involve unusual objects, activities or situations. Fetishism is a paraphilic sexual disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving the use of nonliving objects, such as undergarments, over a period of at least 6 months. The fantasies, sexual urges or behaviors often result in clinically significant distress or impairment in social or occupational functioning. This disorder almost always occurs in males and usually begins by adolescence . There is no reliable data available on the frequency and distribution of fetish objects. Fetishism may include different objects (i.e., shoes, undergarments) or body parts. Although the fetish may have been established in childhood, there are no report describing fetishism in children. However, there are several reports of sexual fetishism in adolescents with autism spectrum disorders or attention deficit hyperactivity disorder. Here we present two adolescent boys with normal developmental history who developed sexual fetishism. We plan to discuss clinical characteristics and treatment interventions in these cases.

Mr. M is a single 28-year-old Malay Muslim man presenting with an uncontrollable urge to masturbate with pillows for the past two years. He had witnessed his good friend's wedding bedroom arrangements during the marriage preparations and managed to stay together with his good friend on his wedding night. On the same night, he had a sexual fantasy whereby he masturbated on the newlywed couple's bedroom pillow [1].

Subsequently, to recreate the same feeling, he discovered sexual pleasure by masturbating on his pillow after watching pornographic videos and erotic magazines. Further history revealed that throughout his adolescence, he had been witnessing his neighbors' and siblings' sexual intercourse, which had further intensified his sexual urge without suitable modalities for gratification [2]. However, after his experience during his best friend's wedding, he had a growing desire to access websites selling lace pillows, which he used as fantasies for masturbation. He initially only did so during his free time. Concurrently, there were features of panic disorder. He developed multiple episodes of panic attacks with episodic chest pain, shortness of breath, diaphoresis and nausea. He did not have sexual dysfunction. When his panic attacks frequency increase, he started to identify hotels with lace pillows or friends' houses with lace pillows. He offered himself to house-sit his friends' houses and he achieved his sexual pleasure via masturbation in others' room privately and shooting his videos [3].

Literature Review

Over two years, his urge to masturbate increased tremendously and he needed to masturbate daily to cope with overwhelming work-related stress. He started to spend his time looking at lace pillows; there were salient features whereby the time spent gradually increased from around an hour to around three hours a day, with him simultaneously starting to build his collection of up to 10 lace pillows at home [4]. The increasing need to masturbate initially happened only during his break time, lunch and dinner time, but subsequently, it started to intrude on his working hours. The extent of the behavior and its omnipotence increased significantly to the point where he even offered to help his colleagues collect things at their homes, taking the opportunity to masturbate on colleagues' pillows. He even recorded his masturbation actions into his mobile phone for him to revisit his behaviors anytime. This intense craving further affected his concentration at work [5].

He felt relieved after each act and he found it helped him cope with his stress at work. Mr. M reported that he had no obsessional thought or compulsion [6]. The frequency of this fetishism had eventually increased up to five times per week, unless his working schedule was tight, following which he managed to stay abstinent for several days. He had a regular sexual partner, namely his girlfriend with whom he had been for five years; however, while performing sexual intercourse with his partner, he preferred to be around with the lace pillows instead. He was never caught red-handed for his fetishism behavior. He subsequently realized his behavior had become uncontrollable and was also concerned about potential legal and social consequences. However, he did not cope by abusing recreational drugs, tobacco or alcohol [7].

A series of cardiac examinations, including cardiac enzymes, echocardiograms and stress tests, revealed no abnormalities [8]. There were also no features of organic illness such as hyper- or hypogonadism or any features suggestive of neurological diseases, such as a space-occupying lesion, with a complete physical examination including a detailed neurological examination being normal. During his visit to see the psychiatrist, he was given short-term psychotherapy and was started on the antidepressant sertraline for his panic disorder [9]. Psychotherapy with the main goals of creating awareness of his illness, orgasm reconditioning and behavioral strategies, e.g., adopting a healthy lifestyle, relaxation therapy and reducing the number of lace pillows at home, was initiated [10]. Currently, following a period where a national lockdown in Malaysia worsened his panic attacks momentarily, his symptoms have reduced significantly and he is presently well after a course of psychotherapy and completing six months of antidepressants [11].

Discussion

Paraphilic disorders refer to recurrent, intense, sexually arousing fantasies, urges or behaviors, which may have pathological targets or preferences [12]. They may be distressing or debilitating both physically and psychologically and can harm affected individuals and any life victim if involved. Moreover, they can contribute to high possibilities of reputational risk, as there is a high possibility of humiliation to oneself or any affected partners. Thus, there is a prerogative to identify such a condition and associated underlying organic or psychological aetiologies to treat reversible risk factors [13].

Fetishism per se, as seen in this case, is not part of the DSM-5 category of paraphiliac disorders. Despite that, fetishism itself has various psychoanalytic explanations as to why it occurs. From a biological point of view, fetishism requires ruling out of various neurological disorders, including but not limited to frontal lobe dysfunction, temporal lobe epilepsies, space-occupying lesions and other lesions that primarily affect the dopaminergic areas of the brain. There is also a necessity to assess disorders along the Hypothalamic-Pituitary- Adrenal (HPA) axis, leading to hyperprolactinemia or hyperandrogenism, which can indirectly cause organic fetishism.

Based on the psychodynamic explanation, fetishes are usually related to unresolved conflict during childhood, rather than merely from a modeling or external influence point of view. In this particular instance, the issue began with a specific trigger. However, the client denied any history of childhood trauma or any associated sexual events. With time, the therapeutic alliance needs to be built as it is possible that part of the reason there is no admission of overt childhood trauma can be due to the client being guarded with very intimate private histories. Simultaneously, there needs to be a thorough search for the possibility that fetishistic behavior is masking other primary psychiatric disorders or a personality disorder, most prominently a cluster B personality disorder. As this case suggests, fetishism can be the mechanism that the psyche uses to conceal an underlying anxiety disorder. Therefore, it is essential that a threehundred- and-sixty-degree assessment be performed, ideally across time rather than crosssectionally and with as many informants as the client permits, to get a fuller picture of events.

Conclusion

Fetishism can be highly distressing to individuals as it is socially not accepted and by definition, is associated with high levels of stigma, concealment and possible transformation into more dangerous forms of behavior if left unchecked. Hence, efforts should be heightened to increase the detection of such behavior, as it rarely, if ever, stands on its own, but rather, will be invariably associated with other primary disorders, be it medical, psychiatric or surgical. This will inform which treatments can be utilized to deal with fetishism, as correction of the underlying cause will lead to fetishistic behavior's amelioration.

Ethics Approval and Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Acknowledgments

None.

Conflict of Interest

None.

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Citation: Fetishism and Panic Disorder-An Uneasy Coexistence. ASEAN Journal of Psychiatry, Vol. 24 (7) September, 2023; 1-4.