Fetishism and kleptomania: a case report in forensic psychiatry/Fetisizm ve kleptomani: bir adli psikiyatri olgu bildirimi.
Abstract: Fetishism is defined as the recurrent and intense use of nonliving objects for sexual arousal and gratification. Kleptomania is defined as a recurrent failure to resist impulses to steal objects not needed for personal use or their monetary value. Both fetishism and kleptomania cases are generally sent mandatory to psychiatric clinics by courts. In this paper, a 32-year old male patient, followed-up with a diagnosis of fetishism and kleptomania, and referred for psychiatric evaluation as a result of multiple stealing of the "fetish", with multiple jail experience and some social losses is reported, and fetishism and kleptomania are discussed with regard to the biological and dynamic approaches and forensic psychiatry.

Keywords: Fetishism, paraphilia, kleptomania, forensic psychiatry

Fetisizm, cinsel uyarilma ve haz icin cansiz nesnelerin yogun ve yineleyici bir sekilde kullanilmasidir. Kleptomani ise kisisel kullanim ya da parasal degeri icin gereksinme duyulmayan nesneleri calmaya yonelik durtulere karsi koyamama olarak tanimlanmaktadir. Her iki bozuklukta da olgular genellikle mahkemelerce psikiyatrik degerlendirmeye zorunlu olarak gonderilmektedirler. Bu yazida, fetisizm ve kleptomani tanilariyla izlenen, fetis nesnesini yineleyici bir sekilde caldigi icin cok sayida cezaevi yasami olan, hastanemize gonderilerek ceza sorumlulugu konusunda degerlendirilen, 32 yasindaki bir erkek hasta sunularak fetisizm ve kleptomaninin klinik ozellikleri belirtilmis, nedenleri, siniflandirilmasi, bu konuya biyolojik ve dinamik yaklasimlar ile adli psikiyatri acisindan ele alinarak tartisilmistir.

Anahtar kelimeler. Fetisizm, parafili, kleptomani, adli psikiyatri
Article Type: Case study
Subject: Kleptomania (Risk factors)
Kleptomania (Diagnosis)
Kleptomania (Care and treatment)
Kleptomania (Patient outcomes)
Kleptomania (Case studies)
Fetishism (Sexual behavior) (Psychological aspects)
Fetishism (Sexual behavior) (Control)
Fetishism (Sexual behavior) (Research)
Authors: Oncu, Fatih
Turkcan, Solmaz
Canbek, Ozge
Yesilbursa, Dogan
Uygur, Niyazi
Pub Date: 09/01/2009
Publication: Name: Archives of Neuropsychiatry Publisher: Galenos Yayincilik Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Galenos Yayincilik ISSN: 1300-0667
Issue: Date: Sept, 2009
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Turkey Geographic Code: 7TURK Turkey
Accession Number: 209408750
Full Text: Introduction

Fetishism means loving inanimate objects to the extend of adoring them. In psychiatry, however, it is dealt with as an issue of sexuality. In clinical studies on fetishism it has become common practice to discuss and present reports of a single case or multiple cases. During a period of hundred years, these case reports have made possible various clinical pictures (e.g. coprophilia--marked interest in excretion, hyphenophilia--use of footwear, leather or rubber as a stimulus for sexual arousal, mysophilia--abnormal attraction to filth, urophilia--marked interest in urine) to be listed under the heading "fetishism" (1,2).

According to DSM IV, fetishism falls into the category of paraphilias and is recognized as the revelation of one's sexual urges or behavior, or intensely sexually arousing fantasies by using such nonhuman objects as women's underwear. These patterns must be recurrent and must have existed for a period of at least six months. The individual either acts on his sexual urges or is considerably distressed by them, or his urges cause problems in his relations with others. Female clothing used in transvestic fetishism (cross-dressing) or devices designed for the purpose of tactile genital stimulation (e.g., vibrator) are not regarded as fetish objects in this pattern (3).

According to ICD 10, fetishism is classified as a disorder of sexual preference, and the stimulus that sexually arouses or gratifies the individual must be a nonliving object. Often, the fetish objects are clothes and footwear, which, in a way, are additions to human body. Other common objects are leather and rubber, which are known to have a special texture. Although a person may have a lot of fetishistic fantasies, this is not considered as a disorder unless it leads this individual to behave in a coercive and unreasonable manner, thereby damaging his/her sexual relation with the partner and causing distress. Originally, it was asserted that fetishism only prevails among men; however, today women are also thought to have fetishistic behaviors (3-5).

The main focus in fetishism is the use of nonliving objects (fetishes). Although the number of these objects (e.g., rubber, feather) is gradually increasing, they mainly consist of such garments as women's underpants, bras, stockings, shoes and boots (3,5) The individual with fetishism often masturbates while holding, smelling or rubbing the fetish object against his body. The sexual activity may be directed towards the fetish object itself (masturbation with or into a shoe), or the individual may ask the partner to put on this object or cover part of her/his body with it (3,6,7).

Kleptomania is defined as a recurrent failure to resist impulses to steal objects not needed for personal use or their monetary value. DSM IV classifies it as "Impulse-Control Disorders Not Elsewhere Classified", and in ICD-10, it falls into the group of "Habit and Impulse Disorders". The person experiences an increasing sense of tension immediately before committing the act and intense gratification or relief while committing it. However, s/he cannot resist the temptation to steal again. Although the person tries a little to conceal the act, it cannot be said that s/he has taken all the necessary precautions to do so. The stealing is done without assistance from or collaboration with others. The stolen objects may be discarded, given away, kept or even returned surreptitiously. It is typical that these objects are stolen despite the fact that the person can afford to pay for them. They are, therefore, of not much value to that person who usually gives or throws them away. The act of stealing is ego-dystonic. The person regards the act of stealing

as nonsensical, shameful and erroneous (3,4,8,9) If in such an act the person aims to possess the stolen object, the diagnosis is not kleptomania. The basic aim in kleptomania is not the stolen object itself but the act of stealing (10).

Despite the lack of knowledge regarding its incidence, kleptomania is defined as a rare disorder. Since most of the cases that have been identified so far are the shoplifters tried in courts, the present data is far from reflecting the exact rate of its incidence in society. It has been asserted that the incidence rate among shoplifters ranges between 3.8%-24%, and that it might be 0.6% in the whole society (10). It has been assumed that the below causes might be responsible for the low rate of the condition: The act of stealing is frequently considered as a result of an antisocial behavior; it is not adequately questioned during psychiatric interview; and the DSM IV criteria make it difficult for the psychiatrist to diagnose cases with kleptomania, thereby to find out the exact rate of its incidence (11).

Paraphiliac or nonparaphiliac sexual behaviors can constitute a crime (6,12). Fetishism is not considered as a criminal behavior unless it is accompanied by stealing fetish objects 12,61 Some writers defined kleptophilia when the sexual focus involves illicitly entering and stealing from the dwelling of a stranger or potential partner and they evaluated it as a paraphiliac behavior although currently it is not often used (13). However, the act of stealing makes it obligatory for such a case to apply to a psychiatry clinic during legal proceedings.

This paper is, therefore, aimed at dealing with fetishism and kleptomania as observed in a forensic psychiatric case repeatedly stealing the fetish.

Case

V.K. is a male of 32, and had been married for four years with no children. He had been separated from his wife for seven months at the time of psychiatric evaluation. He lives with his father and siblings, farms certain crops, and chops wood for living.

He was first sent by order of court to the forensic unit of the hospital for assessment of his criminal responsibility because of "daytime theft in a building and aggressive drunkenness", which he had committed for two months.

When analyzing the court file, it was found out that V.K. had get into a house through an open window while drunk, and had stolen three scarves and a skirt. He was denounced by a witness to the police and arrested while trying to escape from the scene. According to his testimony, he had gone downtown on business, had some alcohol in a pub and got into that house on his way back. While rummaging through the wardrobe, he found the scarves and skirt, and taking them, he left the house. He wanted to surreptitiously take those items to his village and get satisfaction from them. As he was declared a past offender, he had a medical report certifying this condition.

During the interviews made with the case and his relatives, it was further found out that at the age of 13-14 he had started to steal women's garments (particularly scarves and skirts) at night. He used to take them to a secret place and masturbated with them while imagining having sex with the women he admired. After ejaculation, he threw the clothes away or burnt them. It was fifteen years ago when he first served a short jail sentence of about 45 days for stealing women's garments. Due to his young age, he was discharged without serving the full sentence. The same year he was arrested and jailed for 15 more days for the same reason, which was repeated 2-3 times in the next year, when he was jailed for one month for each act, and four more times in the next ten years. As a result of the crimes he had been committing, he was socially degraded in his village; no one in his village wanted to marry him and he married a girl living in a far away town. After then, he started to commit crime of theft for the monetary value of the goods. At first he committed the act when he was not drunk. However, for 10 years, he had been doing the same thing only when he was drunk. He had never taken any jewelry from the houses where he had stolen women's garments from. After he had satisfied himself, he felt distressed and regretful.

Eight years ago, when he committed a crime similar to those mentioned above, a medical report with a diagnosis of "Psychosexual Disorder-Fetishism" was issued by a state hospital. The report certified his diminished capacity to exercise his free will as a result of the mental status at the time of the conduct and his sentence was reduced (old Turkish Criminal Act, article 47).

He had no history of any physical illness, other than a head trauma approximately twenty years ago, causing him to remain unconscious for 15 minutes. He did not receive any treatment for the above condition. He had been drinking for about 12 years (3-4 pints of beer or 35 cc vodka in a week) and smoked a packet of cigarettes a day. Besides that he did not have any other harmful habits. He completed his military service without any problems. He was the second of five sons, and his family history did not show any hereditary disease or psychiatric disorder.

Psychiatric evaluation revealed that he was conscious, cooperative, and oriented. He looked his chronological age, and he seemed to be taking good care of himself. His psychomotor activity was within normal limits. His mood was euthymic. His associations were proper, and his cognitive functions were within normal limits. He could make simple mathematical calculations. No defects of perception or hallucination were detected. He was particularly distressed and feeling shameful while talking about stealing and masturbation. He cried during interviews and stated that he felt guilty and regretful. In view of his cooperative manner towards the medical team and his relations with the other patients, he was considered to be an agreeable person.

His physical and neurological examination did not reveal any pathology. He had a verbal IQ score of 77. No data in favor of organicity were obtained from the Bender-Gestalt visual-motor coordination test.

Considering that V.K., unable to control his impulses, repeatedly stole women's garments (particularly while intoxicated) and had orgasm with these objects despite all social difficulties and punishments, and that he felt distressed, ashamed and regretful about his acts of stealing, he was diagnosed with the mental disease of "Fetishism and Kleptomania (involving only the fetish object)". It was therefore concluded that he had diminished capacity to exercise freedom of conscience and free will as a result of the mental status at the time of the conduct and his sentence was reduced according to old Turkish Criminal Act, article 47.

V.K. was sent by order of court and admitted to forensic unit in order to determine his criminal responsibility for "theft in a building at night", which he had committed three months ago, the same year. He had once again get into a house through an open window, and had stolen a nightgown, skirt, two scarves and some women's underwear.

He stated that his wife had leaved him at her family's request approximately six months after the last crime. Then he had increased the intake of alcohol, lost his control in such an instance and stole those articles of women's clothing and had orgasm. He explained that he was ashamed and regretful.

A similar expert report as mentioned above was issued, stating that the case had a tendency to repeat the act of stealing, and that he should undergo psychotherapy.

Discussion

During judicial process, it is common practice to refer cases with either fetishism or kleptomania to psychiatric services for evaluation. As is often the case, patients with the above described two disorders are not referred for psychiatric evaluation voluntarily but by order of court, which makes it difficult to determine the incidence of these two disorders in society (2,6,141. Chalkey and Powell (1983) have reported that 13 referrals of 48 fetishistic cases came from the courts, probationary service or police, and that only 14 were self-referrals, disregarding referrals for other reasons. McElroy et al. (1991) has stated that of the 20 cases with kleptomania, 15 were apprehended for stealing at least once (1-12 times)(14).

Chalkey and Powell (1983) have found out that the choice of 58.3% of the 48 cases as a fetish object was articles of clothing (excluding leather and footwear). 27% were in the habit of stealing the fetish objects. The authors further stated that one of the 48 patients stole because he was attracted to stealing clothes, another to procuring used and stained clothes, a third to obtaining something belonging to someone he had desired and followed her home (2).

Paraphilias, which could potentially be classified as impulse-control disorders, fall into another group according to the criteria of DSM IV. Some authors have asserted that impulse-control disorders not elsewhere classified, show phenomenological similarities with alcohol and drug abuse, paraphilias, and bulimias (141.

Paraphilias, characterized by such co-morbid diseases as OCD, posttraumatic stress disorder, mood disorders and impulse-control disorder, are considered a subgroup of other nosologic categories 161.

Whether a paraphilia patient's behavior is compulsive or impulsive is one of the parameters that determine the severity of the disorder. Such behavior is characterized by the loss of autonomy. So much money, time, concentration and energy are consumed to fulfill the need for sexual behavior that the patient describes himself as out of control. Some paraphilia patients, however, lose control not only because they are constantly preoccupied with sexual thoughts but because they suddenly perceive an opportunity to behave in a manner they have long fantasized about 161 It is in support of this opinion that our case committed the act of stealing particularly while he was intoxicated and distressed by some misfortune.

From a psychodynamic point of view, there is a close relation between fetishism and kleptomania, as stated by Ginsberg. Some authors who share this comment contend that kleptomania and other impulse-control disorders may have something in common with fetishistic behaviors, and that fetishism may be the basis of kleptomania (10,111. Of these authors, Coleman has further stated that many young patients with kleptomania have stolen women's underwear, and stressed that the ecstasy and urge as felt while stealing a fetish object contribute to sexual arousal and orgasm; a condition which is also observed in individuals with other fetishistic behaviors (10). Fenichel (1974) has drawn attention to the fact that stealing may have a sexual sense, and that doing a forbidden thing secretly may be a means of masturbation. The same author further stated that for some cases, the sexual meaning is in the foreground, that such cases are close to paraphilias, and that the stolen object is the fetish itself 1151 If the objects are the focus, then fetishism may be the appropriate diagnosis. If the act, but not the taken object is the focus, then a diagnosis of kleptophilia is appropriate (13).

It has been reported that fetishism is characterized by a marked disorder in the relations between a mother and her child during the period of separation and individualization, which corresponds to the problems arising in the phallic stage of the psychodynamic process, as observed in some kleptomaniac cases (10) Likewise, the relation of fetishism with traumatic events during childhood is similar to that of kleptomania with problems during psychosexual development (5,10,11). It has been reported that the effective stimulus is different in each case with fetishism and it would be misleading to claim that patients are the same in other respects (2) McElroy et al (1991) have reported that of the 20 cases, nine had a lifetime and two had a current diagnosis of alcohol abuse or dependence (14).

Forensic psychiatry focuses on the concept of paraphiliac impulse as a persistent, compulsive and an irresistible power preventing an individual from feeling morally guilty during the act by adversely affecting one's will to control him/herself. This makes it quite impossible for the individual to logically think about the consequences of the act. Only after the act is completed s/he does fully realize that it is legally and morally forbidden. Despite feeling regretful, ashamed and distressed, s/he cannot help but repeat the crime (12).

It has been reported that in order for the criminal responsibility of such cases to be determined, the below criteria should be met: paraphiliac act has existed in the process of fantasizing and masturbation since early childhood, and it results from lack of impulse control due to psychic coercion or charge in the course of one's normal life (i.e. without any adaptation difficulties) (16).

It is in accordance with the literature that our case has repeatedly been stealing nonliving objects and masturbating with them since his childhood, which has affected his social functions. The most significant characteristics of this case are that the case steals objects not needed for personal use or their monetary value; the act of stealing is recurrent and compulsive, but not preplanned; it occurs while the case is intoxicated or suffering from stress or inner conflicts; it is followed by the feelings of regret, shame and distress after the act is completed and is repeated despite all social difficulties that it creates. The above findings are in conformity with the literature regarding kleptomania. Although it may seem that the intention here is to possess the fetish object, it is obvious that the case is further gratified by committing the act of stealing. Despite the fact that he does not need the objects for their monetary value, and that people close to him do already have such objects, he has been trying to obtain the fetish object for several years by stealing, which suggests kleptomania. Because of the fact that the term kleptophilia doesn't exist both in DSM IV and ICD 10, we preferred the term kleptomania.

Of note, the case has never presented for psychiatric therapy. He is in fact in need of such, considering that his disorder is recurrent. This would certainly affect judicial process and pose a serious threat to the community. This is why a medical report was issued and submitted to the court, suggesting that the case might be treated, and this health care could be provided by the court, although article 47 of the old Turkish Criminal Act does not stipulate that such treatment is mandatory. "Mandatory clinical treatment" of paraphiliac cases has also been suggested by other authors (161 In 2005, the old Turkish Criminal Act was changed and the new Turkish Criminal Act went into effect. According to article 32/2nd of new Turkish Criminal Act (171, mandatory clinical treatmentwas started when necessary for patients with diminished criminal responsibility and this application has been an important improvement for this type of forensic cases.

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Fatih ONCU, Solmaz TURKCAN *, Ozge CANBEK, Dogan YESILBURSA **, Niyazi UYGUR

Bakirkoy Ruh Sagligi ve Sinir Hastaliklari Egitim ve Arastirma Hastanesi, Adli Psikiyatri Birimi,

* Psikotik Bozukluklar Egitim ve Arastirma Merkezi ve 6. Psikiyatri Birimi, Istanbul, Turkiye

Address for Correspondence/Yazisma Adresi: Dr. Fatih Oncu, Bakirkoy Ruh Sagligi ve Sinir Hastaliklari Egitim ve Arastirma Hastanesi, Adli Psikiyatri Birimi, Istanbul, Turkiye E-mail: fatihoncu@yahoo.com Received/Gelis tarihi: 16.04.2009 Accepted/Kabul tarihi: 17.06.2009
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