Fetishism in Forensic Psychiatric Evaluation

• 50 • Taiwanese Journal of Psychiatry (Taipei) Vol. 25 No. 1 2011 Case Report

Shao-Chiu Juan, M.D., Chiung-Hsu Chen, M.D., M.S., Hung-Yu Chan, M.D., Ph.D., Happy Kuy-Lok Tan, M.D., M.P.H., M.H.S., Hsiao-Ju Sun, M.D., M.P.H.

Objective: In this article, we present a forensic patient whose fetishistic behaviors apply to reduced criminal responsibility. Case Report: A 47-year-old married man developed fetishism for female undergarments during his adolescent age. Stress and negative emotional states frequently provoked more paraphilic behaviors. He was accused of theft due to stealing more than one thousand pieces of female undergarments. Conclusion: Insanity defense may be successful if the fetishist has another comorbid mental illness or difﬁ culties in impulse control over paraphilic urges. Experts such as psychiatrists are important in successful treatment. Major treatment modalities in Taiwan include cognitive-behavioral approaches and sex education. In USA, pharmacotherapy such as antidepressants or antiandrogens is proved effective.

Key words: fetishism, paraphilia, forensic evaluation, forensic psychiatry (Taiwanese Journal of Psychiatry [Taipei] 2011; 25: 50-3)

ly came to be regarded in medical science as indi- Introduction cators of possible mental illness. In psychiatry, fetishism is deﬁ ned by DSM- The term “fetish” is derived from Portugese IV-TR as one of the paraphilias characterized by “feitico,” which means any material object made “recurrent, intense sexually arousing fantasies, to have magical power or to symbolize a larger sexual urges or behaviors involving the use of object such as a spirit. Concepts of erotic fetish- nonliving objects,” which cause clinically signiﬁ - ism are stemmed from the French psychologist cant distress or impairment in social or other im- Alfred Binet in 1887, gaining wide currency by portant areas of functioning. No reliable epidemi- the Italian criminologist Cesare Lombroso. ology of sexual deviance is available because the Richard von Kraft-Ebing, an Austro-German psy- clinical or forensic population may only be a small chiatrist, made liberal use of legal terms as “per- portion of sexually unusual persons [1]. Persons version” or “deviance” in his book Psychopathia with paraphilias do not seek voluntary treatment Sexualis. Fetishism and other paraphilias gradual- with the exception of those who are in legal or

Taoyuan Mental Hospital, Department of Health, Taiwan Received: June 25, 2010; revised: August 2, 2010; accepted: August 2, 2010 Address correspondence to: Dr. Chiung-Hsu Chen, Taoyuan Mental Hospital, Department of Health, No.71, Longshou Street, Taoyuan City, Taoyuan County 330, Taiwan Juan SC, Chen CH, Chan HY, et al. • 51 •

marital troubles. Fetishism is not considered as a and got married. During the early years of mar- criminal behavior unless it is accompanied by riage, he did not have fetishistic behaviors. Despite theft or assault. wishing for happy marriage, he failed to get rid of The aim of this paper was to deal with fetish- the fear of being betrayed by his domineering ism through a case demonstration as observed in a wife. At age of 30 years, he slashed his wrist while forensic psychiatric patient who repeatedly stole his wife wanted to break up with him. He would female undergarments. The act of stealing made it rather suppress his anger instead of sacrifi cing his obligatory for the patient to receive a forensic marriage. After numerous quarrels with his wife, evaluation during legal proceedings. his fetishistic activities started to fl are up again. He started to give excuses for leaving home in the Case Report early morning and raid female undergarments from cloth lines far from his home. He hid them Mr. X was a 47-year-old engineer. He was above the ceiling of his study room where his wife deprived during his childhood. His father used to used to leave him alone without disturbing when have frequent physical assaults toward his mother. he worked. He fondled or smelled these stolen ar- When he was an elementary school child, he had ticles while masturbating. His moral values re- witnessed his mother having sexual intercourse mained intact but were overwhelmed by fetishistic with different men. His mother frequently left urges. But his guilty feelings were defeated by se- home and ignored his need for maternal love. He cret pleasures. could recall limited pleasant memories of his Mr. X was caught when he attempted to steal childhood. Excessive worries about domestic vio- the underwear of a policeman’s wife. Cooperatively, lence and unfaithfulness distressed him greatly. he made a self-report about his fetishistic behav- In his adolescent life, Mr. X developed a fe- iors of hoarding more than one thousand pieces of tish to female underwear. At age of 13 years, he stolen underwear. Most of the victims felt embar- started his fetishistic activities with stealing un- rassed after knowing Mr. X’s acts and were reluc- dergarments. He used to take the stolen articles to tant to testify or to take legal action against him. a secret place and hid them instead of putting them His wife felt humiliated and angry after knowing on. He masturbated himself with them while im- his sexual deviance. She threatened to divorce aging having sex with the attractive girl whom he him if he refused to receive psychotherapy admired. His fantasies were heterosexual and fe- voluntarily. tishistic in nature. This unusual sexual interest had Mr. X did not have any history of physical or once been detected by his mother, who later re- other mental illness. The fi ndings of the physical garded him as a boy of problematic character. and neurological examinations were negative. In Mr. X began dating when he was in the mili- psychiatric evaluation, he was conscious, cooper- tary service. He did not have any sexual contact ative, euthymic, and oriented. He denied any delu- with his past four girlfriends. If his girlfriend was sions or hallucinations. His cognitive functions not shy when he embraced her for the fi rst time, he such as memory, judgment or calculations, were would devalue her as a cheap woman and ended within normal limits. The result of his IQ test was the relationship with her. When he was 26 years average intelligence. Personality test showed nar- old, he met his present wife. Soon they fell in love cissism, distrust of others, and superfi cial inter- • 52 • Forensic Evaluation of Fetishism

personal relationship. During the interview, he between Mr. X’s acts at the time of the offense stated that he was ashamed of his misconduct and with the symptoms of his mental illness. The stan- agreed with psychiatric treatment for fetishism. dard of “not guilty by reasons of insanity” (NGRI) He was sentenced to less than one year in jail. is commonly guided by M'Naghten rules, Durham Later, reduced criminal responsibility was an- rule, irresistible impulse rule or American Law nounced with possible suspension of punishment. Institute test. Mr. X did not lack substantial capac- He also received psychiatric treatment with anti- ity to appreciate the criminality/wrongfulness of depressant medication as the selective serotonin his conduct. His stealing behaviors were triggered reuptake inhibitors at a mental hospital. by strong paraphilic urges. The challenge is to evaluate his ability to conform his conduct to the Discussion requirements of law. To determine the criminal responsibility, the following two criteria should be Forensic psychiatrists are often called to be met: (A) paraphilic act has existed in the process expert witnesses in legal proceedings. An evalua- of fantasizing and masturbation before adulthood, tion report should include the subject’s mental and (B) it results from lack of impulse control condition, the level of criminal responsibility, over paraphilic urges. We also reviewed 35 legal risks of recidivism, and treatment advice. cases of fetishism convicted by district courts in As an expert witness, a forensic psychiatrist Taiwan from 1999 to 2008. Twenty patients were needs to provide the court with detailed account as judged as having reduced criminal responsibility to how the diagnosis is made, possible causes and due to poor impulse control while seven of them underlying psychopathology are important. had comorbid mental illness. Regardless of the in- In psychoanalysis, a fetish is regarded as a sanity defense, most sentences were relatively substitute for the genitalia, to protect against the mild, ranging from 20 days to 18 months of im- fear of castration. It also acts as a defense against prisonment. Insanity defense may be successful if impotence and becomes a more reliable stimulus the fetishist has another comorbid mental illness to sexual arousal. Perversion is generally thought or difﬁ culties in impulse control over paraphilic as the result of repression of infantile sexuality urges. [2]. Ward et al. in 2005 summarized bio-psycho- By court order, Mr. X was asked to receive social theories of causation in a review of sexual psychiatric treatment. Like most criminals who deviance. Possible causes include genetic predis- might use strategies to avoid further punishment, positions; psychological dispositions, e.g., deviant he alleged that complete remission of paraphilic sexual preferences, interpersonal problems; social acts was presently achieved after receiving foren- learning/environment; adverse developmental ex- sic community treatment. But the validity of his periences, e.g., rejection, abuse, attachment difﬁ - treatment outcome should still be open to ques- culties; and contextual factors, such as severe tion. His recidivistic possibility remained high. stress [3]. These theories may help understand Regular assessment of paraphilia-related disor- how Mr. X developed fetishism and he repeatedly ders such as compulsive masturbation or sex dis- got relapsed into it under stress. inhibition may help identify increased sexual im- Considering criminal responsibility, a foren- pulsivity [4]. sic psychiatrist needs to describe the correlation Juan SC, Chen CH, Chan HY, et al. • 53 •

Recidivism is actually based on treatment bates about whether pharmacotherapy serves as outcome studies. Heim in 1977 reported that sur- chemical castration against human rights. But us- gical castration can reduce recidivism rate from ing sexual drive-reducing agents had brought over 60% to less than 5%. Pharmacological treat- American psychiatrists into a vital position of ment was based on the assumption that suppres- paraphilic patients’ successful treatment. Even sion of sexual fantasies and urges would decrease when a specifi c treatment for fetishism is ongoing, deviant paraphilic behavior, which was well-sup- we sometimes need additional alternatives to treat ported in surgical castration and antiandrogen those patients. The use of SSRIs may be justifi able studies. From 1970 to 1990, antiandrogen treat- and more preferable when antiandrogens are pre- ment such as cyproterone acetate (CPA), me- served for dangerous sex offenders. Experts such droxyprogesterone acecate (MPA), and analogues as psychiatrists are important in successful of luteinizing hormone releasing hormone (LHRH) treatment. formed the basis of pharmacological treatment in America. The selective serotonin reuptake inhibi- References tors (SSRIs) create a new era in the treatment because they provide the general psychiatrist a fa- 1. Brown JR: Paraphilias. Sadomasochism, fetishism, miliar and safe pharmacological tool [5]. Further transvestism and transsexuality. Br J Psychiatry research is also required for other pharmacologi- 1983; 143: 227-31. cal agents such as clomipramine [6], desipramine, 2. Kohon G: Fetishism revisited. Int J Psychoanal 1987; neuroleptics, fl utamide, lithium, topiramate [7], 68: 213-28. 3. Ward T, Beech A: An integrated theory of sexual of- buspirone [8], and tryptorelin. Estrogen’s side ef- fending. Aggress Violent Behav 2006: 11: 44-63. fects are the contraindications to their use today. 4. Kafka MP: The paraphilia-related disorders: com- Fetishism and other paraphilia are commonly mon, neglected, misunderstood. In: Lieblum SR, eds. observed among sex offenders. Since forensic Principles and Practice of Sex Therapy. New York: psychiatrists are now involved in the treatment of Guilford Press, 2000: 471-503. prisoners and in the care of the mentally ill but 5. Zonana H, Abel G, Bradford J, et al.: Dangerous Sex potentially dangerous (such as those who have Offenders. 1st ed. Washington DC: American been found NGRI), what should be the best treat- Psychiatric Association, 1999: 103-27. ment for a criminal fetishist like Mr. X? The 6. Clayton AH: Fetishism and clomipramine. Am J Supreme Court of the United States in Kansas v. Psychiatry 1993; 150: 673-4. Hendricks in 1997 upheld the civil commitment 7. Shiah IS, Chao CY, Mao WC, Chuang YJ: Treatment of sexually deviant persons for psychiatric treat- of paraphilic sexual disorder: the use of topiramate in ment. Treatment for paraphilia is focused on cog- fetishism. Int Clin Psychopharmacol 2006; 21: nitive-behavior approaches and pharmacotherapy. 241-3. 8. Fedoroff JP: Buspirone hydrochloride in the treat- In Taiwan, the major treatment modalities are cog- ment of transvestic fetishism. J Clin Psychiatry 1988: nitive-behavior treatment, law and sex education 49: 408-9. for sexual offenders. Specifi c treatment for fetishism has not been established. There are still de-