My earlier post about whether it is possible to eradicate fetishes appears to have struck a nerve, as I have heard from folks all over the world with their comments, questions, and requests for further information. I want to thank everyone for writing in– everyone’s communications have been very thoughtful and respectful, and it is really heartening to be able to reach so many in constructive dialogue.

As I read over the article however, I realize that, while pointing out what I believe to be inappropriate and unethical treatment, I do not go into any detail about what I do believe to be appropriate treatment protocols when someone is seeking help with a fetish. So, to address that gap, I’m going to go into some treatment protocols here in this particular post. It’s a lengthy and very broad topic, so I think this may very well turn into a series of postings, but I’ll see how it goes. For this article though, I’m just going to focus on initial steps (edit: as you’ll see, I found that laying down some groundwork of important initial considerations took up a lot of writing, so in this post, I am focusing on the groundwork, and I’ll talk about specific interventions in subsequent posts).

First, in the interest of disclosure, let me put it out there that I hold a sex-positive perspective. For more on what this means, you can take a look at my article about sex positivity here. Basically, I start out with the assumption that sexual behavior is neither inherently negative nor pathological unless shown to be otherwise. In other words, the meaning of the sexual behavior depends on its context. Two people can be engaged in the same exact behavior, and for the first person it is pleasurable and empowering, while for the other person it can be experienced as abusive and traumatic. It’s all about context.

As I’ve written about before, because there is so much that is unknown in psychology (and especially sexology), much of psychotherapeutic practice is grounded in myth, personal biases, and culture-bound assumptions. For example, 40 years ago homosexuality was listed in the DSM as a mental illness, and then it became ego-dystonic homosexuality, which meant that you were mentally ill if you were gay and had a problem with it (if you were gay and did not have a problem with it, you were fine). At that time, if you were gay and went to a therapist, you would likely be told that you had a mental illness, probably derived from some troubles with your father, and then you would be made to believe that your “gayness” would be cured by merely talking about your difficulties with this learned, all-knowing wiseman. Looking back on it, we can see how ridiculous this sounds. With group consciousness, political activism, and scientific discovery, we now do not view sexual orientation as an illness that needs curing, but for decades, well-meaning and highly educated folks thought they were engaged in a scientific enterprise of “curing” gays. This kind of curing, btw, known as reparative or conversion therapy, is still practiced in various places even today, although it has been denounced by virtually every mental health organization in the country.

My point is, it’s easy to look back and see all the ways that silly and unnecessary medical procedures and interventions were misguidedly entrenched as gold standards of treatment based on personal biases and culture-bound assumptions. It’s harder though to step outside of our sphere of reality to see how these same things are still happening today, and will probably always happen. As individuals, we are all culture-bound, but the role of science is to help us distinguish faith (culture) from reality. That said, I think it is imperative for any mental health clinician to make clear to any prospective client/patient what his/her biases and assumptions are– in other words, to provide the opportunity for informed consent.

Even today, an individual can go to two different therapists complaining of a problematic fetish, and get two radically different treatments. One therapist may help the individual to accept and integrate the fetish, while the other will see it as pathology and attempt to “eradicate” it. (My earlier post was less about how to work with fetishes, and more about putting a spotlight on the assumption that fetishes need to be “eradicated.”) In this way, an individual’s entire course of life can be altered depending on which therapist he/she chooses, but most insidiously, this life choice will be made without informed consent because the patient/client often has no way of determining what the therapist’s personal biases are.  Often, an individual may be so confused and/or distressed, that they don’t even know what they want, and so they rely on the authority of the therapist. However, without full disclosure on the part of the therapist, the individual has no idea which authority they are trusting.

Well, I find myself going now into a diverse group of topics that are not directly about fetishes… but I don’t think that we can really accurately talk about working with fetishes, unless we also put on the table such important issues such as therapist’s disclosure of treatment methods, informed consent and power/authority differentials between therapist and client. I think I’ll write more about each of these, because they are so integral to psychotherapy, but for now, I just wanted to put out there that all of these are important considerations before even embarking on working with clients who struggle with fetishes.

BTW, I’m not just talking about fetishes here. Most positions on sexuality and relationships are culture-bound and prone to bias. Here’s some examples: monogamy, traditional pair-bonding arrangements, type of sex, quantity of sex (too much or too little), modern notions of “intimacy”, definitions of intimacy…. all culture-bound. All of it, despite how uncomfortable it may be to think about or how much certain ideas may feel like fixed reality.

That said, when a client comes in, I first want to find out what the fetish means for him. (It’s usually men, btw, so let’s just stay with male pronouns). If his spouse/partner brings him in, I want to know what this fetish means for both of them, together and individually. In other words, I take a systemic approach to understanding the significance of the fetish. If the guy is ambivalent about his fetish, while the partner is disgusted, now we have a systemic issue. In this case, the first line of treatment is not, I repeat: NOT, NOT, NOT to embark on a project of eradicating the fetish.

I’ll stop there because it looks like this is turning into a expansive tract. I’ll make this into a series, and in the next article, I will talk more about the specific initial steps in working with folks who are distressed by their fetishes.