Diaper Fetishism Due to A Case

Turkish Journal of Psychiatry 2005; 16(2):133-138

Diaper Fetishism Due to a Case

Dr. Nihan OĞUZ- Research Associate, 7th Psychiatry Department.

Dr. Niyazi UYGUR-Assoc. Forensic Psychiatry Department, Bakırköy Mazhar Osman Training and Research Hospital for Mental and Neurological Disorders, Istanbul.

SUMMARY: A Case of Diaper Fetishism

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.

Key Words: Fetishism, diaper, paraphilia, forensic psychiatry

INTRODUCTION
Fetishism is a state of sexual desire for inanimate objects or specific parts of the body. (Juninger 1997). This condition was coded among the ICD-10 disorders of sexual selection in the category DSM-IV paraphilia. According to the ICD-10, the disorder is that the fetish object becomes important for sexual stimulation and response (Mason 1997). Fetishism is a disorder that mainly occurs in men. People with fetishism don't seek treatment until their perverted desires affect their daily life. The rate of fetishism in psychiatric disorders is 0.8% (Chalkley and Powell 1983). Fetish items are mostly underwear, synthetic clothing, feet, shoes, socks and similar items of clothing.  One fetish object was discovered in 35.4% of the fetishists, and three or more fetish objects were discovered in 45.8%. Fetish objects and behaviors were examined in the sex forum; Here the fetish articles are listed as underwear (tights, diapers, bras, silk stockings, silk petticoats), articles such as rubber pacifiers, body parts, leather clothing, catheters, silk handkerchiefs, baby beds. Behaviors were reported as carrying, looking, caressing, stacking, stretching, inserting into the rectum, rubbing, sucking, stealing, lying, sitting and sleeping (Juninger 1997). Fetishists use inanimate objects to get sexually aroused. Freud suggested that fetishism was caused by castration anxiety. Objects selected as fetish represent the female penis. In this way, castration is both denied and confirmed. It is believed that the origin of fetishism is traumatic experiences that occurred in the first months of life. For this reason, it has been suggested that the integrity of the self is disrupted and that integrity is achieved through sexuality (Gabbard 2000).

This article presents a case report of diaper fetishism, which is rare and has been studied in the context of forensic psychiatry.

Case

Mr B. has been referred to our hospital by the attorney general. 22 years old, single, born in Iskenderun, elementary school graduate, unemployed, lives with his family Mr B., who was hospitalized and examined in the forensic psychiatry for attempting to steal diapers, was examined by the landlord on the balcony of the Caught house, which he went into to steal the diaper, because he was tired and fell asleep with the diaper in hand, he was examined by the competent court after it was determined that he had stolen the diaper because of his mental health problems.

Anamnesis

 He was born in 1981 as the seventh of eleven siblings, his birth was normal, he was breastfed until he was one year old. His earlier personal history showed that his motor development was normal, his older sister took care of him after he was one year old, his mother looked after his siblings one year younger and he only played with male children until he was six years. He fell off the roof at the age of six while playing with his friends. Mr B., who was hospitalized by his family, had no injury or loss of consciousness after the fall. After this incident, however, the binding behavior to the neighbors' used diapers (fabric or nylon and any color) began. Mr B. tied himself to his skin for two to three hours in his parents' bedroom and then kept them under the bed so that no one could throw them away, a behavior he gave up after two or three months. He started elementary school at the age of seven, often had problems with girls in school and was often beaten by his father for mistreating his siblings.When he saw a "tourist lady in a red dress" at the age of twelve, he spontaneously experienced an erection and ejaculation of the penis. This event triggered again the diaper binding behavior used by the neighbors. He stated that he had two orgasms without masturbating by putting on a diaper and imagining a "tourist lady in a red dress" and that he did this behavior, which he continued every day, but stopped it of his own will after 3- 4 months. At the age of seventeen, he repeated this behavior and continued for 4-5 months, and was again able to prevent it of his own accord. He was able to stop this behavior during his military service, but started stealing and bandaging diapers again after his military service, but he was arrested for theft and was imprisoned for a month. He stated that he had not benefited from 4 mg pimozide / day from the private doctor he had consulted because of this behavior. Mr B. stated that since he could not escape this interest, he had tried to kill himself twice. He was also diagnosed with an anxiety disorder due to fainting during his military service, and his EEG had "beta dysrhythmia" (compatible with an anxiety disorder).The age of the circumcision could not be obtained from him or from his family. He reported that he had no memories of the circumcision and no experience of intercourse.

No pathological finding was found on his physical and neurological examination.

On his psychiatric evaluation, it was found that he was of medium height, dark skin, self-sufficient, fully orientated, and natural psychomotor activity. He was able to fully assess the reason for the hospitalization and examination, and had verbal communication and eye contact. His speech was purposeful, he expressed his affect was euthymic and his mood as "I'm fine". His cognitive functions were adequate, his associations were smooth, and he did not describe hallucinations and delusions. Test judgment and abstraction were sufficient. He had insight. He admitted that his sexual urges caused dissonance in society. No signs of substance withdrawal or poisoning were found. It was compatible within the service. EEGs (including sleep deprivation) and head magnetic resonance imaging were found to be normal.

In the psychometric examination, the verbal IQ: 89 in the Weschler Adult Intelligence Test (WAIS) was determined to be “dull normal”. A tendency to reject cards according to the Rorschach Protocol. He made no effort to be productive, has a strict mindset, does not go into generalizations and details. It was found that his participation in social thinking was sufficient, but his adaptability was not good, he was childish. His ability to judge reality was retained and his fear was significant.

Minnesota Multiphasic Personality Inventory (MMPI): It was found that the patient was unable to capture the test instructions and therefore could not be fully assessed.

Structured Clinical Interview Clinical Version for DSM-IV Axis I Disorders (SCID-I): He was found to be mildly depressed and SCID-II was found to be obsessive-compulsive, passive-aggressive, paranoid, schizoid, Has narcissistic, borderline, schizotypic personality traits. The Hamilton Depression Scale was 8 (compatible with mild depression) and the Hamilton Anxiety Scale was 0.

Although he reported that he did not consume alcohol or substances during the clinical follow-up, tetra-hydrocannabinol (THC-50) was found positive on urinalysis. At the next weekly urine test, THC-50 was negative, while ethyl alcohol was positive on the blood test.

An epileptic situation was not considered in the neurological consultation because of Mr B.'s fainting in stressful environments. It was assumed that all EEGs were normal, the fainting occurred due to a conversion disorder, and the diaper attachment behavior was diaper fetishism (paraphilia).

In the forensic psychiatric evaluation of Mr B. it was found that he could benefit from Article 47 of the Turkish Penal Code at most because he has no impairment of consciousness, his fetishism is aimed at satisfaction and his ability to control his efforts to control his behavior was inadequate.

DISCUSSION

Deviant fantasies can be seen in adult sexual behavior, but they are not perceived as problems because they are not experienced as compulsions (Gabbard 2000). Paraphilia is viewed as a perversion because it relies on an obsessively strange stimulus to initiate, maintain, and orgasm erotic arousal. 30 different types of paraphilias have been defined (Money 1984). Fetishism is divided into the classification of sexual diversity in the paraphiliac group, which does not require a partner to become sexually aroused. Women's underwear, women's shoes, and non-sexual parts of the female body are commonly used for sexual stimulation. In fetishism, satisfaction from a normal relationship is achieved through the fetish object (Brandon 1980, Gabbard 2000). It is mostly found in men. Sexual preferences in women are more limited than in men. Since this also applies to fetishism, female fetishists are rare (Mason 1997).

The diaper fetishism (auto epiophilia) of fetish paraphilias develops at a young age (Money 1984).

In the study by Chalkey and Powell in 1983 it was found that 43.8% of the cases were wearing fetish clothing, 22.9% liked to see the fetish outfit on someone else, 12.5% put the rubber object in the rectum, 21% stroking it, sucking on it, or burning it (Juninger 1997, Money 1984, Brandon 1980).

It is noteworthy that Mr B. tied these diapers in contact with his body for 2-3 hours in his mother's and father's bedroom. Stealing a fetish object is a common behavior. 25% of the fetishists steal the fetish object. In general, underwear and shoes are stolen, in rare cases observed and the fetishist attacks the person wearing the fetish object in order to either observe the fetish body parts or to get in contact with them. The compulsive urge to become a fetish object is characteristic of the disorder. In this respect it is similar to obsessive-compulsive disorder (Mason 1997).

Legal problems with fetishism are mainly due to theft (Juninger 1997, Mason 1997).

Mr B. also received the diapers from the theft. It is noteworthy that he stole the neighbours 'diapers even though he also had his siblings' diapers in the house.

The urge to only have the fetish object is very evident in fetishists. Some of these people are known as collectors (Fenichel 1945). The fact that Mr B. collects diapers in a similar way and does not allow anyone to throw them away seems to be compatible with the collecting function of fetishists.

The fetish may be of little importance for its own worth, but becomes very important with the overvaluation of the fetishist. Odor is often a decisive factor in this assessment (Fenichel 1945). The use of diapers preferred by Mr B. shows the importance of odor and the overrated used diapers which are normally of negligible value.

It can be seen that Mr. B. 's information and test results are contradictory, his tendency to reject Rorschach cards, his claim that he could not grasp the test instruction in the MMPI application, and he presents himself with a slight depression. Indeed, it is noteworthy that those who have such a legal problem generally have a defensive attitude and a credibility problem.

Early childhood experiences with genital stimulation and baby items can lead to the formation of fetish objects such as diapers and pacifiers. It is believed that fetishism is a learned behavior as a result of classical conditioning. Studies draw attention to the fact that the fetish object is perceived in childhood (around the age of 4) and becomes sexually stimulating in adolescence (Mason 1997, Wilson 1981). It was observed that the diaper binding behavior in Mr. B. began at the age of 6 and became sexually stimulatory at the age of 12.

Freud found that the choice of the fetish object is related to traumatic experiences in childhood (Fenichel 1945). In other words, in deviation, it is found that childhood trauma is transformed into success for adults. Patients are believed to have fantasies in order to avenge humiliating childhood traumas. This revenge can take the form of humiliation of the spouse and avoidance of the relationship in the event of deviant behavior (Gabbard 2000). According to Freud, the fetish object represents the penis, protects the man from the fear of castration and is the refusal of the woman without a penis. The fetishist rejects the female genitals, but knows that in reality the woman does not have a penis. Hence an ego split develops. It is stated that separation from the mother and the fear that arises in the prefal phase are important in the formation of fetish objects. It is suggested that fetishists turn to inanimate objects to overcome their low self-esteem and feelings of inadequacy. It is stated that fetish behavior occurs at an early age due to the trauma caused by poor parental attitudes. In the formation of fetish objects, 1) the individual punishes the person (object) who caused him harm in childhood, 2) separates the object from the person, 3) combines the inanimate object with the stolen person, 4) pulls the fetish of the Person who once loved and needed it and traumatized it (Mason 1997).

Fear of castration leads to the discovery of a woman without a penis. The fetish object is formed by the displacement mechanism. Defense mechanisms of division, separation of the object from the person and overvaluation play a role here. In other words, children's sexuality is preferred to adult sexuality. This can be due to a pause in development or a regression. However, certain parts of children's sexuality have been suppressed. The child's sexual element hypertrophy is used to reinforce this oppression. The fetish object can be a selfless object from childhood. However, with the overrating of the fetishist, it becomes of great importance. An object that represents the female penis only arouses sexual arousal as long as it is not connected to the female body. The original object is suppressed and only part of it, the fetish, remains conscious in the event of excessive violence (Mason 1997, Wilson 1981, Fenichel 1945).

The care of Mr. B. was carried out by his older sister after the 1st year of life due to the mother's pregnancy. This situation suggests that the mother's pregnancy increased the normal separation anxiety that can arise during the separation individualization phase. It suggests that the (bad) mother who abandoned him was punished and replaced with a diaper. The diaper replaces the once loved, needed mother. Many fetishists have not completely separated and individualized themselves from their mother's internal representation. Therefore, as an independent person, they feel the danger of being destroyed by internal and external objects. The overwhelming mother figure they internalize can manifest as deviant sexual behaviour. On the other hand, they can gain control over the mother, which they internalize through deviant sexual behavior (Gabbard 2000).

Fetishism: a) the fetish is a part of the female body, b) is a part of women's clothing, c) the fetish is a special material, d) it has been classified as animal fetishism (Mason 1997).

It has been suggested that fetish objects are containers or hollow objects that represent the uterus and vagina. Some authors have also divided fetish objects into two separate groups, for example the material of the object (rubber, leather) and its shape (shoes, belt). Fetish objects were examined according to brightness, structure, shape and smell and classified according to perceptual preferences. According to this, it was indicated that there is a connection between these characteristics and the mother or an important person. The object represents the identification with the desired person and marks a critical development phase. For example, it is suggested that shoes resemble the female pubic area (Mason 1997).

The fact that Mr B. prefers even just one diaper suggests that it is important to use that diaper so that the diaper can act as the bond between him and his mother. It suggests that the diaper itself could represent the vagina as well. Again, when the diaper is viewed as a transitional object, it is believed that the faulty internalization process in the absence of empathic self-objects can lead to deviant sexual activities. Sexuality can enable us to control painful experiences that traumatically damage the self (Gabbard 2000).

Personality disorders, psychiatric illnesses, and delinquency often coexist with paraphilias (Wilson 1981). It is believed that patients in neurotic organizations use paraphilic activities to achieve sexual superiority and patients with psychotic boundaries to prevent self-dissolution (Gabbard 2000).

In Mr B.’s case, the borderline personality organization observed in fetishists and the schizotypal characteristics draw attention to themselves. From here it can be assumed that Mr B. used the diaper to prevent self-dispersion. It can be assumed that the diaper is a transitional object and through this object the traumatic experience is processed when the mother's care has decreased.

It is stated that the majority of deviant men come from sexually restrictive families and that these men do not watch pornography in their childhood (Wilson 1981). Mr B.'s family is of a similar nature. Successive births in an overcrowded and neglected environment may have resulted in Mr B. receiving inappropriate and inappropriately warning for his age. On the other hand, the family environment in which sexuality is defined as shame and sin may have given Mr .B conflicting messages about sexuality. All of these conflicting messages could have made Mr. B. feel guilty.

In differential diagnosis, the psychiatric history and examination include psychotic disorders as there are no delusions, hallucinations, disorganized language, or disorganized behavior; Mood disorders were excluded because there was no depressed, exuberant, blistering, or angry mood. His psychiatric history found that he was diagnosed with an anxiety disorder due to fainting during his military service and that he had "beta dysrhythmia" (compatible with an anxiety disorder) on his EEG, but there were no signs of anxiety, avoidance or anxiety increased arousal during his stay on duty and anxiety disorders were excluded since all EEGs were normal. Dissociative disorders were excluded because the perception of integrated consciousness, memory, identity and the environment was not impaired. Although case reports of the association between fetishism and temporal lobe epilepsy have attracted attention in the literature, it has been observed that all EEGs taken by Mr. B. are normal; However, the onset of diaper-binding behavior after falling from the roof at the age of 6 suggests a suspicious pathology of the temporal lobe. However, it was found that Mr B. was rushed to the hospital after falling off the roof, there were no injuries or loss of consciousness, and there was no problem with his aftercare. This situation keeps us away from temporal lobe pathology. Although Mr B. reported that he had not used alcohol or substances in his clinical follow-up, tetrahydrocannabinol (THC-50) was found positive on his urine test and ethyl alcohol was positive on his blood test. No signs of poisoning or withdrawal were observed in Mr. B. during his stay on duty. His family was told that there was no inappropriate alcohol consumption that caused clinically significant deterioration or distress within 12 months. While the laboratory results are positive, this alone is not enough to diagnose alcohol abuse and addiction. Therefore alcohol and substance related disorders were excluded.

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