Is a fetish a mental disorder? What the DSM keeps and the ICD dropped

The word fetish lives in two places at once. In a survey it names a preference, and the preference is common: in Joyal and Carpentier's 2017 survey of 1,040 adults weighted to match the population of Quebec, interest in fetishism passed the 15.9% line that marks a fantasy as statistically unusual, in men and in women, with no significant difference between the sexes. In a diagnostic manual the same word names a disorder, and for most of the twentieth century the interest and the disorder were one thing.

They came apart in stages. Fetishism entered medicine in 1887, gained a second clinical requirement in 1994, left the national classifications of Sweden, Norway and Finland between 2009 and 2011, and left the World Health Organization's classification in 2022. The American manual still names a disorder, and the door into it is narrow. The wider question of whether any kink counts as a disorder has its own article; this one follows the fetish.

What the American manual diagnoses

The DSM-5-TR, the American Psychiatric Association's manual in its 2022 text revision, names fetishistic disorder among its eight specific paraphilic disorders. The fetishism entry records its three criteria.

• Criterion A: for at least six months, recurrent and intense sexual arousal from nonliving objects or from a highly specific focus on one or more non-genital body parts, shown in fantasies, urges or behaviour.
• Criterion B: the fantasies, urges or behaviour cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
• Criterion C: the objects are not limited to clothing used in cross-dressing, which belongs to transvestic disorder, or to devices designed for genital stimulation, such as a vibrator.

Criterion A describes the interest. Criterion B is the disorder, and a person untroubled by the interest does not meet it. The manual separates the two in its own vocabulary: a paraphilia is the atypical interest, a paraphilic disorder is a paraphilia that causes distress or impairment or harms someone else, and the first is a necessary condition for the second but not a sufficient one.

The diagnosis carries specifiers that record the focus (body parts, nonliving objects, or other) and two states: in a controlled environment, and in full remission. The body-part specifier is the trace of an argument about partialism, a focus on a part of the body, which the manual treated as a separate category for twenty-six years before folding it back in.

What the WHO classification removed

The ICD-11, adopted by the World Health Assembly in 2019 and in force since January 2022, has no fetish diagnosis. Its predecessor, the ICD-10, coded fetishism as F65.0 and fetishistic transvestism as F65.1. Both are gone, and so is sadomasochism, F65.5.

The working group that recommended the change set out its reasoning in a 2017 paper by Krueger and colleagues in Archives of Sexual Behavior. The three categories, it wrote, described consensual or solitary sexual activity that does not involve inherent harm to self or others. The ICD is a public-health reporting tool, which member states use to define their obligations to provide free or subsidised healthcare, and the group asked which arousal patterns mattered from the perspective of a public-health agency. Keeping the three categories, the paper argued, stigmatised the people who had it, which it called inconsistent with the human rights principles the United Nations and the WHO endorse.

What remains are the disorders that involve other people who have not consented (exhibitionistic, voyeuristic, pedophilic, coercive sexual sadism and frotteuristic disorder, plus a category for other paraphilic disorders involving non-consenting individuals) and one residual category, other paraphilic disorder involving solitary behaviour or consenting individuals. A fetish could land there in only two ways: the person is markedly distressed by the nature of the arousal pattern, or the behaviour carries a significant risk of injury or death.

	DSM-5-TR (2022)	ICD-11 (2022)
Named fetish diagnosis	Fetishistic disorder	None
Body-part focus	A specifier of fetishistic disorder	Not named
Route to a diagnosis	Six months plus distress or impairment	Marked distress or risk of injury or death
Distress caused only by others' disapproval	Left to the clinician	Excluded explicitly

How the diagnosis narrowed

The erotic sense of fetishism is a coinage of 1887. The psychologist Alfred Binet, drawing on cases Charcot and Magnan had published in 1882, borrowed a word from the study of religion, where fétichisme named the worship of objects, and used it for arousal attached to shoe nails, nightcaps and white aprons. Krafft-Ebing's Psychopathia Sexualis had catalogued such cases a year earlier as a pathology of association. Freud, in 1905, placed fetishism on a continuum with ordinary erotic life, and Havelock Ellis treated it as an exaggeration of normal selectivity. The manuals of the next century took the first reading, and the revisions since 1994 have moved them toward the second.

Before 1980 the American manual filed the interests under sexual deviation; the DSM-III of 1980 introduced the word paraphilia and restricted fetishism to nonliving objects, excluding body parts. The DSM-III-R of 1987, as Martin Kafka's 2010 review recounts, cleaved partialism from fetishism and placed it in the paraphilia-not-otherwise-specified category. The DSM-IV of 1994 then added the clinical significance criterion, criterion B, to the paraphilias, and with it the idea that an interest alone is not a disorder.

Kafka argued that once criterion B existed, the line between an object and a body part was no longer clinically meaningful, and recommended folding partialism back into fetishism as a specifier. The DSM-5 did so in 2013, and made the distinction between a paraphilia and a paraphilic disorder explicit. The DSM-5-TR of 2022 kept both.

The Nordic countries went first

Four countries removed the categories from their own versions of the ICD-10 before the WHO did, and Krueger's paper lists them. Denmark removed sadomasochism in 1995. Sweden in 2009, Norway in 2010 and Finland in 2011 removed fetishism, fetishistic transvestism, sadomasochism and the category for multiple disorders of sexual preference. The Norwegian group that campaigned for the removals, ReviseF65, took its name from the ICD-10 code block. ReviseF65 describes the ICD-11 as the WHO following the Nordic countries, and on fetishism the dates bear it out: the last national removal came seven years before the WHO released the new classification in 2018.

What counts as distress

Distress is the only route into the American diagnosis for a person whose fetish involves no one else. The ICD-11 guidance defines it by excluding a cause: the distress must not be only a consequence of rejection, or feared rejection, by other people. A person who is unhappy because a partner or a community disapproves of the interest is not, by that fact, disordered. The working group's guidance directs clinicians to a counselling code for that case instead.

The DSM-5-TR leaves that judgement to the clinician who applies criterion B. In the catalog's reading of the clinical literature, what tips a fetish into the disorder is usually rigidity: the object becomes required for arousal in a way that distresses the person or disrupts a relationship, work or daily life. The content of the interest is not a criterion. A preference for leather and a preference for an object few people have heard of meet the same test, and neither becomes a disorder without distress or impairment.

The catalog's fetishism entry describes treatment in the same terms. Where someone seeks help, clinical care aims at the distress and the relationship strain around the interest, and at helping the person integrate it. Eliminating a harmless preference is not the goal.

What the catalog records

Three of the catalog's eleven families hold what most people mean by a fetish: Body Parts & Partialism with 42 entries, Clothing & Garments with 32, and Objects & Materials with 30. Every one of the 104 carries a clinical_status field written from the two manuals. None states that the interest is a disorder in itself. Each says the interest is a normal variation, or a disorder only with distress, impairment or a non-consenting person.

The most common of them are common by any measure. Foot fetish sits fifth on the whole index of 486 entries, at an estimated 14% of adults. Lingerie follows at 12%, shoes at 7%, leather at 6% and latex at 4%. Across the three families, four entries are estimated at 8 to 20% of adults, 32 at 2 to 8%, and 30 below 0.5%. The methodology explains how each estimate is made and from which survey.

One of the 104 is flagged as harmful. Crush fetish has a lawful form involving objects and a second form that is animal cruelty, and the flag belongs to the second.

The disorder has its own pages. The fetishism entry sits in the Clinical Paraphilias family, at an estimated 8% and rank 41, and covers both the broad interest and the narrow diagnosis that shares its name. Cross-dressing and transvestic disorder are split the same way: the manual names a disorder, the interest is common and benign, and one page cannot hold both meanings without blurring them. Object sexuality, in which an object is experienced as a partner, is filed apart from fetishism and described in the literature as an orientation toward objects.