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Introduction: Recently the guidelines for the diagnosis of paraphilic disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11), have been published., Aim: This article analyzes legal, regulatory, and policy issues relevant to the potential effects of the changes for the classification of paraphilic disorders in the ICD-11 in Germany., Methods: A forensic and a legal expert in Germany worked with other international experts to conduct this evaluation using an assessment guide provided by the World Health Organization., Main Outcome Measures: Possible effects of the changes for the classification of paraphilic disorders in the ICD-11 on forensic practice, health systems, adjudication of individuals who have committed a sexual offense, and the provision of treatment in Germany., Results: Results highlight the special situation of medical confidentiality in the German health system that facilitates the establishment of preventive networks for the treatment of pedophilic patients. The ICD-11 guidelines will help to clarify the boundary between pedophilic disorder and crimes of child sexual abuse. These will also establish a boundary with other paraphilic diagnostic concepts. We describe the central construct of criminal responsibility in the German legal system in relation to paraphilic disorders, the prominent role of expert witnesses, and the differences in the conceptualization of medical confidentiality within the health care system and within the legal system., Clinical Implications: The ICD-11 proposals for paraphilic disorders provide a clearer differentiation, as compared with ICD-10, between variants of normal sexual behavior and sexual behavior that involves a non-consenting person or entity. Particular patterns of sexual preference that are not of relevance to public health, the health care system, or the legal system, such as masochism and fetishism, will no longer be named psychiatric entities and will, therefore, be regarded as private behaviors and destigmatized., Strengths & Limitations: The assessment shows the specific legal situation in Germany for the treatment of paraphilic patients in a sexual medicine, psychiatric, and legal discourse. However, it was done only by a small number of experts., Conclusion: A conclusion of the analysis was that the more specific and narrower definitions in the ICD-11 diagnostic guidelines, compared with those in ICD-10, particularly for pedophilic disorder and coercive sexual sadism disorder, will result in a reduction in false-positive diagnoses. It is unlikely that significant unintended and negative consequences will occur as a result of implementing the ICD-11 guidelines for paraphilic disorders. Briken P, Boetticher A, Krueger RB, et al. Current Legal Situation for Patients with Paraphilic disorders and Implications of the ICD-11 for Paraphilic Disorders for Germany. J Sex Med 2019;16:1615-1622., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

The historical definitions of sexual Fetishism are reviewed. Prior to the advent of DSM-III-R (American Psychiatric Association, 1987), Fetishism was typically operationally described as persistent preferential sexual arousal in association with non-living objects, an over-inclusive focus on (typically non-sexual) body parts (e.g., feet, hands) and body secretions. In the DSM-III-R, Partialism, an "exclusive focus on part of the body," was cleaved from Fetishism and added to the Paraphilia Not Otherwise Specified category. The current literature reviewed suggests that Partialism and Fetishism are related, can be co-associated, and are non-exclusive domains of sexual behavior. The author suggests that since the advent and elaboration of the clinical significance criterion (Criterion B) for designating a psychiatric disorder in DSM-IV (American Psychiatric Association, 1994), a diagnostic distinction between Partialism and Fetishism is no longer clinically meaningful or necessary. It is recommended that the diagnostic Criterion A for Fetishism be modified to reflect the reintegration of Partialism and that a fetishistic focus on non-sexual body parts be a specifier of Fetishism.

The fetish objects in these case histories were unique enough, and the attraction to the objects strong enough, that the individuals could clearly track their interest from early childhood through adulthood. It is much easier to retrieve remote, explicit memories, such as events (eg, a party where balloons popped) or playing with objects, than to recall the process of sexual development with no distinct markers in the individual's history. Because these distinct experiences predated identified sexuality, became a focus of attention for the individual, and then were incorporated into the individual's sexual interests and masturbatory fantasies, it was possible to accurately track the patterns of sexual arousal. We were also able to clearly identify how these men attempted to blend their deviant interests into sexual relationships with partners and the consequences of their efforts. If we are to understand how sexual interests develop, a number of obstacles need to be overcome. Sexual interest has to be openly discussed. Parents need to appreciate how the early sexual interests of their children can go awry, contaminate their adult relationships, and lead to problematic lives. Researchers need a means of understanding how to communicate with children about their earliest interests, sexual interests, and sexual behaviors in a nonjudgmental manner. Until then, tracking unusual interests that lead to erotic interests is the first step in the overall process of understanding how sexual interest develops and is assimilated, either successfully or unsuccessfully, into an individual's adult sexual life.

Compulsive cybersex has become a significant problem for many men and women who have fallen prey to the accessibility, affordability, and anonymity of online sexual behaviors. Some patients develop problems with compulsive cybersex due to predisposition or accidental conditioning experiences. Other compulsive users of cybersex present with underlying trauma, depression, or addiction. Three case studies highlighted obsession, compulsion, and consequence in the pathogenesis of compulsive cybersex. While men and women differ somewhat in their use of cybersex, both genders exhibit maladaptive coping, conditioned behavior, dissociative reenactment of life trauma, courtship disorder, intimacy dysfunction, and addictive behavior. Comprehensive treatment of compulsive cybersex would include the following components: relapse prevention, intimacy enhancement, lovemap reconstruction, dissociative states therapy, arousal reconditioning, and coping skills training. Thanks to recent treatment advances in several fields, help is available for those caught in the dark side of the net.

This article reviews current developments in psychiatric assessment of sex offenders for criminal courts. These developments are characterized by constantly changing laws and increasing neurobiological findings about paraphilias. Psychiatrists must prepare their reports taking into account the tension between psychopathological, neurobiological, and normative aspects of their judgement. The complexity of such assessments can best be demonstrated by narratives. This narrative concerns a 47-year-old patient who killed eight women after strangling them and masturbating or having intercourse with the unconscious victims. He explained in detail six of these crimes and gave ample information about his history, sexual development, fantasies, and a number of other sexual crimes he had committed. From this information a plausible explanation of his development to sexual fetishism and from there to sadism could be derived. Brain MRI displayed gliotic scars in the frontal lobe and right hippocampus. Consequences of the various findings on psychiatric assessment of legal culpability are discussed in this paper, concluding that a differentiated approach to the assessment is possible only from a psychopathological point of view in which behaviour, clinical features, and motivations are analysed.

The presence of inappropriate sexual behaviors in individuals with autistic disorder is one of the important factors disturbing their social adaptation and distressing their families and environment. Therefore, appropriate management of these behaviors seems necessary. This case report describes a 13-year-old male with diagnosis of autistic disorder and fetishistic behavior. His fetishistic behavior was treated successfully using mirtazapine 15 mg/day. The clinical picture and efficacy of mirtazapine will be discussed.

In this article we discuss psychiatric diagnoses of sexual deviation as they appear in the International Classification of Diseases (ICD-10), the internationally accepted classification and diagnostic system of the World Health Organization (WHO). Namely, we discuss the background of three diagnostic categories: Fetishism (F65.0), Fetishistic Transvestism (F65.1), and Sadomasochism (F65.5). Pertinent background issues regarding the above categories are followed by a critique of the usefulness of diagnosing these phenomena today. Specifically, we argue that Fetishism, Fetishistic Transvestism, and Sadomasochism, also labeled Paraphilia or perversion, should not be considered illnesses. Finally, we present the efforts of an initiative known as ReviseF65, which was established in 1997, to abolish these diagnoses.

Some people cannot obtain satisfaction from ordinary sexual relationships; instead they prefer alternative methods. They are referred to in psychiatric terminology as paraphiliacs. Fetishism is a type of paraphilia in which a person is sexually attracted to objects and some body parts. Most fetishists do not intend to cause harm to other people, but may have problems when others become involved in the problem. Underlying personality disorders extending through childhood are thought to be the source of the etiology. Perverted people do not wish to change their behavior pattern. They never seek treatment from a therapist. Psychological issues obviously play a crucial role in determining the choice of paraphilia and the underlying meaning of the sexual acts. Psychodynamic models (object relations theory, self psychology, drive theory) can shed light on the meaning of a perversion. In this case report, a 22- year-old man with diaper fetishism is presented. When family dynamics are considered, the mother has been described as psychologically distant from her son. The fetish object was recognized during childhood at around the age of four. During puberty, the fetish object became sexually attractive. Our patient exhibited his first perverted behavior when he was six years old. Later, he could control this behavior. At the age of twelve, the perverted behavior became sexually arousing. This paper emphasizes the diaper fetishism case through the patient's past psychiatric and medical history. Diaper fetishism is discussed in the light of forensic, cognitive and psychodynamic theories.

From a longitudinal study that began at birth, a case is described in which a man at the age of 30 recalls the onset of a sexual fetish in his fifth or sixth year of life. The memories activated and dreams reported during the thirty-year follow-up interview, were synthesised with parent-infant film data and historical information contained in the research record concerning the child's development, his parents' behaviour and traumatic experiences. Taken together they provide a detailed description of the psychological ontogenesis of the fetish. The case provides unusual information about the manner in which early childhood events-objectively documented-interdigitate with intrapsychic processes and mental structuralisation. This also illuminates processes by which memories are retained, condensed, distorted and lost. In addition, information from other participants in the project who reported sexually anomalous histories at the age of 30 raises questions of what can be predicted from early life experiences.

This study attempted to differentiate two clinical types of fetishism-fetishism proper and tranvestism-and to determine if tranvestites are truly fetishistic. The transvestites were further divided into gender-conforming and gender-noncomforming groups according to their score on a gender identity scale. These groups were compared using a self-report scale measuring fetishistic interests, and a set of questionnaire items regarding their childhood history, parental characteristics, and their emotional closeness with their parents. In addition, the penile responses of a subset of fetishists and tranvestites were recorded while they were presented with visual depictions of female and male public regions and potentially fetishistic objects (nylon stockings, female and male shoes, panties, male underwear, female and male feet). The fetishists proper and the transvestite subgroups did not differ from each other in terms of self-reported fetishistic interest or childhood and family histories. Moreover, there were no differences between these groups in their penile response to the potentially fetishistic stimulus they were most aroused by, relative to the depictions of the pubic region of their preferred gender. These results suggest that transvestites are in fact fetishistic, and that they are difficult to distinguish from fetishists proper.

A case of homosexual erotomania is described in a patient with AIDS-related complex. Direct involvement of the central nervous system was thought an unlikely cause, as specific stressors appeared to have precipitated a reactive psychosis. A psychodynamic understanding of these factors and their interaction with the patient's masochism, fetishism, and personality disorder provided an alternative explanation for the onset of the paranoid illness and its symptom content. The psychodynamic aspects of acute psychotic disorders without evidence of cognitive impairment in patients with HIV infection is a neglected area of study.

In this study I investigated the relation between normal heterosexual attraction and autogynephilia (a man's propensity to be sexually aroused by the thought or image of himself as a woman). The subjects were 427 adult male outpatients who reported histories of dressing in women's garments, of feeling like women, or both. The data were questionnaire measures of autogynephilia, heterosexual interest, and other psychosexual variables. As predicted, the highest levels of autogynephilia were observed at intermediate rather than high levels of heterosexual interest; that is, the function relating these variables took the form of an inverted U. This finding supports the hypothesis that autogynephilia is a misdirected type of heterosexual impulse, which arises in association with normal heterosexuality but also competes with it.

The DSM-III-R definition of mental disorder is inconsistent with the DSM-III-R definition of paraphilias. The former requires the suffering or increased risk of suffering some harm while the latter allows that deviance, by itself, is sufficient to classify a behavioral syndrome as a paraphilia. This inconsistency is particularly clear when examining the DSM-III-R account of a specific paraphilia, Transvestic Fetishism. The author defends the DSM-III-R definition of mental disorder and argues that the DSM-III-R definition of paraphilias should be changed. He recommends that the diagnostic criteria for specific paraphilias, particularly that for Transvestic Fetishism, be changed to make them consistent with the DSM-III-R definition of mental disorder.

Utilizing the NEO Personality Inventory (NEO-PI) and the Derogatis Sexual Functioning Inventory (DSFI), 24 transvestitic fetishists (TVs) were compared with a similar clinic-evaluated group of 26 other paraphilics (OPs). The data replicated previous results and extended them by showing that TVs did not differ from OPs on most dimensions of the NEO-PI and the DSFI. Both groups were significantly higher on neuroticism and significantly lower on agreeableness than the NEO-PI male normative population. The other paraphilic group tended to score lower on conscientiousness than the TVs and the normative comparison group. For nine of the 10 DSFI variables, there were no significant differences between the TVs and the OPs. The TVs were significantly higher than the OPs on role identity, indicating a more feminine identification. Both the TVs and OPs reported elevated levels of fantasy. The implications of these findings suggest that, in general, TVs and OPs are more similar than they are different, with a common personality profile and a similar pattern of sexual functioning.

This article summarizes the discussions and recommendations of the DSM-IV Subcommittee on Gender Identity Disorders, a subcommittee of the Child Psychiatry Work Group, regarding diagnostic issues. The issues reviewed include placement in the nomenclature, the concept of a spectrum of gender dysphoria rather than discrete levels of symptomatology, criticisms of current diagnostic criteria, subtyping by sexual orientation, and proposed changes in diagnostic criteria for the current DSM-III-R diagnoses of Gender Identity Disorder of Childhood, Transsexualism, and Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type.

The literature concerning the relationships between transsexualism and transvestism and their association with fetishism is reviewed. Sexual activity, including sexual arousal to women's clothes, is frequently reported in histories of transsexuals. Characteristics are reported of 12 male subjects who have shown sexual arousal to women's clothes and who have a sustained cross-gender identity combined with a desire for a change-of-sex operation. Diagnostic categories alternative to transsexualism for subjects who cross-dress are inadequate to classify at least some of the 12 subjects reported. Restricting the definition of transsexualism so as to exclude those who have shown fetishistic features is considered premature.

This paper presents a psychodynamic evaluation of a case of fetishism, whose main features are the homosexual or autoerotic choice of the fetish (hair), social and occupational maladjustment and occurrence of epysodes of psychotic depression. After a survey of the literature, with particular emphasis on psychoanalitic and psychodynamic approach, the authors discuss the diagnostic problems presented by this case and decide for a diagnosis works as a largely unsuccessful attempt to escape psychotic regression. In contrast with the situation which prevails in most cases of fetishism, there is no satisfactory adjustment to social and occupational life; the mecanism of ego-splitting is found to be impaired. The authors stress the importance of Kohut's recent contributions to the study of the early phases of narcissism for a better understanding of the differential diagnosis between psychosis, character disorders and perversions, Kohut's narcissistic personality disorders and "borderline syndrome".

A general review of literature delivers information about relevant publications pertaining to the question of transvestism and transsexualism. By and large German and Angloamerican literature is quoted on this subject. Consideration has been given to the variations of the syndrome in both males and females. The display of these symptoms is mainly in accordance with the psychopathological structure of the clinical picture. Symptomatologic and psychodynamically related sexual deviations (fetishism, effeminated homosexuality) as well as endogenous psychoses have been considered from a differential diagnostic point of view. The differential nosology characterizes the efforts made in dealing with the heterogenity of the syndromes. Moreover it is indicative of the sexually specific styles of manifestation. In the etiological approach somatogenic (chromosomal, hormonal and cerebral) and psychogenetic types are differentiated. Interesting results in child and family therapy have been mentioned on the latter type. The contributions of psychotherapy, behavior therapy and surgical operations aiming at sexual transformation including their legal repercussions have been given full consideration in the therapy chapter.