Cultural factors

Sometimes, whole cultures can develop the fetish to such an extent that it is no longer perceived as a fetish, but merely as a normal sexual desire; for example the commonplace "fetishes" for lingerie, or women lacking body hair.

Sometimes what a culture covers up eroticizes the boundaries of what remains exposed. For example, a woman's ankle was considered erotic [7] in late-Victorian England; in many European countries, women are free to be topless, while in the United States, this is both a taboo and illegal in most states.

In this regard, there can be said to be a degree of fetishistic arousal in the average person who responds to particular bodily features as sign of attractiveness. However, fetishistic arousal is generally considered to be a problem only when it interferes with normal sexual or social functioning. Sometimes the term "fetishism" is used only for those cases where non-fetishist sexual arousal is impossible.

Women and fetishism

Most of the material on fetishism is in reference to heterosexual men, with most of the objects fetishized being high-femme items such as lingerie, hosiery, and heels. Until recently there was little mention of women ever having fetishes.

However, the visual map of fetishes linked below flags several clusters as having a number of women admirers, such as corsetry and some of the medical-related fetishes. The preferences of women fetishists are not necessarily a mirror image of those of male fetishists; just because many men are attracted to women in high heels does not necessarily mean there are many women attracted to men in construction boots.

The book Female Perversions, which also discussed corsetry and self-cutting, in part discusses "female transvestism". It gave examples both of women who became excited by dressing in a "butch" way, i.e. the mirror image of male transvestite fetishism, and of women who became aroused by dressing in a very "femme" way, or parallel to male transvestite fetishism.

Some of the fetishes where a generally male attribute is being fetishized are:

• Foreskin fetish
  
• Muscle fetishism / sthenolagnia
  
• Sock fetishism
  
• Suit and tie fetishism
  

Medical aspects

Most of the sexual orientations popularly called fetishism are regarded normal variations of human sexuality on behalf of psychologists and medics. Even those orientations that are potential forms of fetishism are usually considered unobjectionable as long as all involved persons feel comfortable. Only if the diagnostic criteria presented in detail below are met, the medical diagnosis of fetishism is justified. The leading thought is that a fetishist is not ill because of his or her addiction but because he or she suffers from it.

Diagnosis

According to the ICD-10-GM, version 2005, fetishism is the use of inanimate objects as a stimulus to achieve sexual arousal and satisfaction. The corresponding ICD code for fetishism is F65.0. The diagnostic criteria for fetishism are as follows:

• Unusual sexual fantasies, drives or behavior occur over a time span of at least six months. Sometimes unusual sexual fantasies occur and vanish by themselves; in this case any medical treatment is not necessary.
  
• The affected person, her object or another person experience impairment or distress in multiple functional areas. Functional area refers to different aspects of life such as private social contacts, job, etc. It is sufficient for the diagnosis if one of the participants is being hurt or mistreated in any other way.
  

It must be noted that a correct diagnosis in terms of the ICD manual stipulates hierarchical proceeding. That is, first the criteria for F65 must be fulfilled, then those for F65.0. As criteria are not repeated in substages this can be mistakable to laymen or medics that have not been educated in the use of this manual. Furthermore, it must be noted that according to the ICD, an addiction to specific parts or features of the human body and even "inanimate" parts of corpses, under no circumstances are fetishism, even though some of them may be forms of paraphilia.

According to the DSM-IV, fetishism is the use of inanimate objects or parts of the human body as a stimulus to achieve sexual arousal and satisfaction. The corresponding DSM-code for fetishism is 302.81, the diagnostic criteria are the same as those of the ICD. That means that ICD and DSM diverge in their interpretation of fetishism with respect to body parts. This can lead to misunderstandings when evaluating publications that come from different countries and use different diagnostic manuals. In the DSM manual, all diagnostic criteria are given in the corresponding section of the text book, i. e. here no hierarchical processing is needed.

Both definitions are the result of longsome discussions and multiple revisions. Still today, arguments go on whether a specific diagnosis fetishism is needed at all or if paraphilia as such is sufficient. Some demand that the diagnosis be abolished completely to no longer stigmatize fetishists, e. g. project ReviseF65. Others demand that it be specified even more to prevent scientists from confusing it with the popular use of the term fetishism. And then again, ever and anon researchers argue that it should be expanded to cover other sexual orientations, such as an addiction to words or fire.

Treatment

There are two possible treatments for fetishism: cognitive therapy and psychoanalysis. Both may be supported by an additional medicaments treatment.

Cognitive therapy

Cognitive therapy seeks to change the patient's behavior without analyzing how and why it shows up. It is based on the idea that fetishism is the result of conditioning or imprinting. The therapy is not able to change the patient's sexual preference itself but can only suppress the resulting unwanted behavior.

One possible therapy is aversive conditioning: the patient is being confronted with his fetish and as soon as sexual arousal starts, exposed to a displeasing stimulus. It is reported that in earlier times painful stimuli such as electric shocks have been used as aversive stimulus. Today a common aversive stimulus are photographs that show unpleasing scenes such as penned in genitals. In a variant called assisted aversive conditioning, an assistant releases abominable odors as aversive stimulus.

Another possible therapy is a technique called thought stop: the therapist asks the patient to think of his fetish and suddenly cries out "stop!". The patient will be irritated, his line of thought broken. After analyzing the effects of the sudden break together, the therapist will teach the patient to use this technique by himself to interrupt thoughts about his fetish and thus prevent undesired behavior.

Psychoanalysis

Psychoanalysis tries to spot the traumatic unconscious experience that caused the fetishism in first instance. Bringing this unconscious knowledge to conscience and thus enabling the patient to work up his trauma rationally and emotionally shall relieve the him from his problems. As opposed to cognitive therapy, psychoanalysis tackles the cause itself.

There are versatile attempts at this analyzing process, including talk therapy, dream analysis and play therapy. Which method will be chosen depends upon the problem itself, the patient's attitude and reactions to certain methods and the therapist's education and preference.

Strictly speaking, in psychoanalysis a fetish is the last thing a small boy sees before discovering that women do not have a penis. The erotic excitement of a boy's first observation of a girl or woman undressing becomes traumatic when he discovers that castration is a real threat after all. What had become increasing arousal is suddenly turned to horror. The child then fixates on the moment of heightened arousal just before the trauma. This is usually an undergarment or feet, but it could be anything.

In the strictest definition, secondary sexual displays—such as breasts and buttocks—cannot be considered fetishes.

Medication

Pharmaceutical treatment consists of various forms of drugs that inhibit the production of sex steroids, above all male testosterone and female estrogen. By cutting the level of sex steroids, sexual desire is diminished. Thus, in theory, a patient might gain the ability to control his fetish and reasonably process his own thoughts without being distracted by sexual arousal. Also, the application may give the patient relief in everyday's life, enabling him to ignore his fetish and get back to daily routine. Other research has assumed that fetishes may be like obsessive-compulsive disorders, and has looked into the use of psychiatric drugs (serotonin uptake inhibitors and dopamine blockers) for controlling paraphilias that interfere with a person's ability to function.

Although ongoing research has shown positive results in single case studies with some drugs, e. g. with topiramate[8], there is not yet any medicament that tackles fetishism itself. Because of that, physical treatment is only suitable to support one of the psychological methods.

Surgery

In few cases, brain surgery has turned out to be a remedy for fetishism[9]. It must be noted, however, that these surgical engagements were always due to other diagnosis like epilepsy and the relief of fetishism was a mere side effect. Though some consider brain construction a possible cause for fetishism, surgery is never considered a possible treatment.