Paraphilias are defined as sexual disorders characterized by recurrent, intense sexual urges, fantasies or behaviors that involve unusual objects, activities, or situations (1). 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 (1). This disorder almost always occurs in males and usually begins by adolescence (2,3). 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 (2). However, there are several reports of sexual fetishism in adolescents with autism spectrum disorders (4-6) or attention deficit hyperactivity disorder (7). 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. 

CASE 1

Clinical Presentation 

A 13-year-old boy presented with his mother due to concern of sexual interest in woman’s shoes and feet. 

History of Present Illness 

Because the adolescent refused to cooperate, history was taken from the mother. The mother reported that she first recognized his sexual interest in woman’s shoes six months ago. He started to disappear repeatedly at home and the mother found him in stairs while he was handling a young woman’s shoes living in their apartment. Later on, the mother saw him while he was rubbing and smelling the shoes in a fascinated manner that he could not even recognize the mother. He refused talking about this condition at that time. The mother reported that he continued to try to leave home for several reasons, such as going to market to buy home requirements or to empty garbage that he has usually refused to do so far. The mother kept track of him and reported that he was staying within the building, taking the shoes down to the ground floor rather than going outside. The mother finally decided to warn their neighbor not to leave her shoes outdoor. In subsequent days the mother reported that he had become irritable and restless at home. After a week he had a visit to the neighbor’s home while helping her to carry shopping staff. After an apparently normal visit, the neighbor recognized that her shoes were missing. She finally found the shoes in the toilet. The mother tried to talk with him, but he became agitated and refused talking. After several weeks, the mother recognized that her own shoes were missing or being handled in the cloakroom. The mother kept track of him and recognized that he was awaking at night and was dealing with the shoes while he was rubbing and smelling the shoes. The mother did not recognize the sexual nature of his behaviors and thought that he had a compulsive interest in shoes. He was also prompting his mother to go outside or to deal with his 4-years-old sister possibly to have opportunity to pursue his interest in shoes. The mother later recognized that he started to change his underwear frequently as he claimed that they got dirty or wet. The mother reported that he also started to spend much time, such as more than thirty minutes, in the toilet. She finally decided to see what he was doing in the toilet as he was inside for a long time and making some unusual sound. She entered the toilet and caught him on masturbation while he was keeping and rubbing her shoe in his hand. The mother recognized the sexual nature of his interest in shoes for the first time. Subsequently the mother recognized some video records in his mobile phone. They were records of young women’s feet with or without shoes including records of naked feet of the mother. There were dozens of these records with earliest record dating back four months ago. 

Developmental & Family History

His developmental milestones were within normal limits. The mother and the child denied any sexual abuse or exposure history. His sexual developmental and sex-oriented behaviors were reportedly within normal limits so far. The mother reported that he used to love his 4-years-old sister’s naked feet since her infancy. He was helping his sister to take her socks off and then rubbing and smelling her feet. He expressed his admire several times saying, ‘Mom look at them, what lovely things they are’. The mother reported that there are family-protection codes in television and internet at home and it is reported that he was not allowed and it was not possible to be exposed any sexually inappropriate content in these media. His academic achievement was below normal. His truancy has been concerning for the last year. He was not a popular boy among his peers. He mentioned his desire several times to have a girlfriend. But the mother reported that he was not able to make a girlfriend so far. He has spent most of his time on television, computer games or play-station. The parents had reportedly a normal sexual life and appropriate privacy. There is no past or current history of sexual paraphilias in the family, including fetishism. There is no significant history of any psychiatric or neurological disorders in the family. 

Clinical Assessment & Follow Up

Because the child denied his sexual interest and behaviors, and did not accept to talk about on this issue, psychiatric examination was conducted after a negotiation not to ask any question about his sexual interest/behaviors. His structured psychiatric examination using Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version-Turkish Version (K-SADS-PL-T) (8) revealed attention-deficit hyperactivity disorder (ADHD) combined type, oppositional-defiant disorder (ODD), social phobia and chronic motor tics. He did not have any past or current symptoms suggestive of a (hypo) manic episode. His psychometric evaluation using Wechsler Intelligent Scale for Children-Revised (WISC-R) revealed normal intellectual capacity. During the history, he was reported to use methylphenidate 20-30 mg/day for the treatment of his ADHD symptoms. However he discontinued his medication for the last year due to non-compliance. 

His laboratory work up revealed no significant abnormality with normal testosterone levels. His previous brain imaging and electroencephalogram (EEG) performed two years ago were within normal limits. 

His cooperation and motivation for treatment was poor. Because he refused to use any medication, we negotiated for a psychotherapeutic approach at the first place. After two visits, he was lost to follow up. After four months the mother reported, on a phone call, that his sexual interest/behavior continued and he refused to come to visit. Two months after this call, they appeared in the clinic. He came to the clinic with his consent. They reported that he was taken into custody one week ago due to stealing a woman’s shoes from a neighbor apartment. Shoes were found in the baggage of their car. He was taken into custody and then released after the attempt of his parents. He admitted his sexual interest/behavior in this visit and was cooperated to mention in details. His first masturbation was 14-months ago, at the age of 12 year-old. He reported that he used to masturbate three or four times in a week. He mostly needed his fetish object-female shoes- and he defined his masturbation as less satisfactory without fetish object. He reported that he was rubbing, smelling and touching shoe to his genitalia while he was imagining erotic contents during masturbation. He defined his fetishistic interest as ‘not so much abnormal and not harmful to anybody’. However he reported that he was very frightened with this custody experience and he decided to get rid of this problematic behavior. The mother also reported ongoing ADHD symptoms. He was started OROS methylphenidate 27 mg/day and sertraline 25-50 mg/day treatment for ADHD and social phobia symptoms and fetishistic behavior. We planned to encourage him to masturbate without fetish object and help him to experience that he can masturbate without shoe with satisfaction. We planned to substitute his fetish object, in the first place, with some other thing such as erotic pictures/imaginations. In line with this consideration, he was suggested to record his masturbations with or without shoes and to rate satisfaction for every masturbation on a zero to ten scale (zero: no satisfaction and ten: the most satisfactory). However he was lost to follow up again. The mother reported on a phone call six weeks later that his fetishistic interest seems to be continued, but no unusual event happened. He did not use his medications regularly. 

CASE 2

Clinical Presentation

A 12-year-old boy was referred by his parents due to sexual interest to female undergarments for the last several months. 

History of Present Illness 

The first thing to be recognized was the unexplained disappearance of undergarments of his aunt. Undergarments were getting disappeared at home, laundry or where they hang out the laundry. Family members kept track of undergarments and discovered that they were stolen by him. He was taking away undergarments to brushwood near to home. They confronted him, but he denied at that time. Undergarments were still getting to disappear. He was finally caught red-handed. He admitted stealing undergarments and promised not to repeat. However he continued to steal. Parents reported that they found a dozen of undergarments, particularly underpants around the brushwood most of them were red and some of them did not belong to his aunt. He later admitted to steal his cousin’s undergarments also. 

Developmental & Family History 

His developmental history was within normal limits. His prenatal, postnatal and medical history was unremarkable. He did not have any hypersexuality or inappropriate sexual behaviors so far. The parents and child did not report any sexual abuse or exposure. His academic achievement has been poor so far. He had only one close friend. There was no past or current history of sexual perversion in the family including fetishism. The mother had past history of a major depressive episode and current history of generalized anxiety disorder. The father had possible adult ADHD and was considered to have borderline mental capacity. 

Clinical Assessment & Follow Up

His structured psychiatric interview using K-SADS-PL-T revealed ADHD combined type and social anxiety disorder. His psychometric evaluation using WISC-R revealed borderline mental capacity. Because he did not have past neurological history or current signs/symptoms suggestive of a neurological disorder, and due to his typical clinical picture suggesting sexual fetishism, no further imaging studies were conducted. 

During psychiatric interviews, he genuinely admitted having this interest and stealing all these undergarments. He reported that he was taking undergarments to brushwood and visiting them as much as possible. He was handling, rubbing and smelling the undergarments while masturbating most of the time. He reported that he has had this interest for the last six months, but he started to steal four months ago. He was able to admit his interest and behavior as unacceptable and shameful. He reported that he actually was not happy with this interest and behavior and tried to control himself, but was not able to control himself most of the time. He was sometimes able to control himself and he did not steal at that times. He reported that he liked to look at the pictures of young beautiful women with undergarments on newspaper or television for the last two years. He was used to masturbate five to ten times in a week, most of them occurred in brushwood. 

He was cooperative and motivated for the treatment. Therefore we made a therapeutic negotiation on not steal anymore as a first intervention. He was also suggested some social-physical activities. We started methylphenidate 20 mg/day and sertraline 25-50 mg/day treatment for his ADHD and social anxiety symptoms and fetishistic behavior. On the next visit, three weeks later, he reported that he did not steel undergarments and did not go to the brushwood anymore. Parents confirmed his report. His ADHD symptoms showed moderate improvement on Conner ADHD and clinical global impression-improvement (CGI-I) scales, and methylphenidate was increased to 30 mg/day. On the next visit, two months later, no fetishistic behavior reported and his ADHD and social anxiety symptoms showed further improvement. He reported that his thoughts of undergarments have decreased more than fifty percent and he did not attempt to steal. His masturbation frequency was also decreased as two or three times in a week. He generally tolerated medications well without any significant side effects only with some initial nausea. 

Here we presented two adolescent boys who developed sexual fetishism during preadolescence. In terms of DSM-IV diagnostic criteria, both subjects met criteria for sexual fetishism, including criteria for duration of at least six months (1). Sexually explorative behaviors, paraphiliac fantasies or sexual confusion of adolescence may be considered in differential diagnosis in such cases. However, given the typical clinical picture of sexual fetishism, related functional impairment and acting out the fantasies in these cases are all in favor of sexual fetishism. Despite the relatively-well documented characteristics in adult subjects, there are limited number of reports on paraphilias, such as sexual fetishism, in adolescent subjects. A review of literature revealed that there are several case reports of multiple paraphilias (9), or paraphilia not otherwise specified (10) in male adolescents and sexual fetishism in adolescent subjects with autism spectrum disorders (4-6) or ADHD (7). Female undergarments and shoes are among the most frequently preferred fetish objects among individual with sexual fetishism, and in terms of object preference, both cases had an usual preference. An interesting observation could be the fact that both subjects had comorbid ADHD and SAD. While the impact of ADHD and SAD on developing sexual paraphilias in adolescents should warrant further research, it can be speculated that ADHD and SAD may have contributed on developing sexual fetishism in these subjects to some extent. Previous studies have reported 60 to 90% of psychiatric comorbidity in juvenile sexual offenders. The most prevalent co-morbid psychiatric disorders are conduct disorder and ADHD, mood disorders, anxiety disorders, and substance abuse (3,11-14). Shaw et al. (11) reported that the younger the child when he committed his first sexual offense, the higher the number of coexisting psychiatric diagnoses. Kafka and Prentky (15) and Kafka and Hennen (16) have studied DSM-III-R and DSM-IV Axis I diagnoses of lifetime comorbid psychiatric disorders in males with paraphilias and non-paraphilic forms of sexual impulsivity. In both groups, they found high rates of mood disorders; anxiety disorders, especially social phobia; and substance use disorders. The prevalence of any ADHD in the sex offender paraphiliacs was 43.3%, and nearly 25% of offenders were diagnosed with ADHD-combined subtype (16). Thus, ADHD was the single most common nonsexual Axis I diagnosis that statistically significantly distinguished males with paraphilias from a non-paraphilic hypersexual comparison group (15,16). Meanwhile it has been reported that paraphilias are commonly associated with sexual hyperactivity, often with compulsive and/or impulsive features (17). In the light of available literature, regarding our cases, it can be suggested that ADHD may have contributed in developing sexual fetishism as sexual impulsivity, and social phobia may have contributed as it restricts socially appropriate emotional/sexual relationship. It may be important to note the interest and admiration of Case 1 in his 4 years-old sister’s naked foot. In family’s cultural milieu, as in the country in general, it is not considered abnormal to love a child with close physical contact (i.e. touching, kissing, hug). But the mother defined his behavior as not acceptable and bizarre. She needed to warn him several times not to love his sister this way. This point may raise a question whether his early interest in his sister’s naked foot may be an early manifestation of his fetishistic behavior. Paraphilias may result in a variety of psychological disturbances, such as guilt, depression, shame, isolation, and impaired capacity for normal social and sexual relationships (3). However emotional and cognitive reaction of the subjects to their paraphilias differed significantly. Case 1 considered his behavior ‘not so much abnormal’ and reported no significant shame or guilt, except for a fear after being convicted, and did not desire to get rid of his behavior until he was convicted. However, Case 2 considered his behavior ‘unacceptable and shameful’ and reported some guilt and desire to get rid of his behavior. We believed that comorbid oppositional-defiant disorder and related personality characteristics of Case 1 contributed in his attitude toward his behavior and non-compliance to treatment. 

A multimodal treatment including pharmacological and psychotherapeutic approaches is recommended in the management of paraphilias (3). Regarding psychopharmacological treatment of sexual paraphilias, there are a number of papers reporting some level of efficacy or inefficacy of several psychotropic medications including antidepressants, antipsychotics or anticonvulsants (3). However these reports are usually limited by case reports, series or they are uncontrolled studies. There seems to be no randomized controlled trials documenting efficacy of psychotrophic medications [for a further reference, refer to the most recent review article by Thibaut et al. (3)]. In particular, selective-serotonine-reuptake inhibitors (SSRIs) have been shown to have some level of efficacy in the treatment of sexual paraphilias in young (9,10) and adult subjects (3,18,19). SSRIs have been considered most promising psychopharmacological agent in the treatment of paraphilias and it has been recommended to add SSRIs to treatment in case of paraphilias in juveniles (3,12). In addition, Kafka and Hennen (19) reported that methylphenidate combined with SSRIs was effective to ameliorate paraphilias and paraphilia-related disorders in adult subjects. In the light of available literature, despite being limited, we expected that a combination of methylphenidate and sertraline would be effective in the management of sexual fetishism as well as ADHD and SAD in these young subjects. However we had outcome data only for one subject (Case 2), as one of them (Case 1) was non-cooperative in the treatment and clinical follow up. A combination of methylphenidate and sertraline alongside with a psychosocial intervention was very effective in controlling fetishistic behavior in Case 2. There has been no recidivism during the next ten months of follow up. However it is difficult, at this point, to ascertain which part of the therapeutic intervention, psychopharmacological versus psychotherapeutic, was more effective in controlling paraphilia in this case. 

In conclusion, youth with sexual fetishism are not common in clinical practice. Given the nature of the behavior, it could be difficult to cooperate/communicate with these subjects on their fetishistic behavior. Because treatment of comorbid disorders may also lead improvement in sexual paraphilias, youth with sexual fetishism should have a thorough diagnostic assessment for any comorbid psychiatric disorders. Clinical assessment should include developmental and medical history, sexual development, history of abuse, family history, academic and social functioning, and criminal history if relevant. Combined psychosocial and psychopharmacological interventions would be more effective than either intervention alone. SSRIs are safe and could be effective in the management of young subjects with sexual fetishism. Despite several limitations, such as paucity and reliability of information on psychosexual development, absence of a structured CBT intervention, this case report may contribute understanding and management of sexual fetishism in adolescents. 

More systematic research are needed on the clinical characteristics and treatment of sexual fetishism and impact of comorbid psychiatric disorders, such as ADHD and SAD, in the development of sexual fetishism in adolescents.

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