Exhibitionism

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Exhibitionism

Definition

Exhibitionism is a mental disorder characterized by a compulsion to display one’s genitals to an unsuspecting stranger. The Diagnostic and Statistical Manual of Mental Disorders , also known as the DSM-IV-TR, classifies exhibitionism under the heading of the “paraphilias,” a subcategory of sexual and gender identity disorders. The paraphilias are a group of mental disorders marked by obsession with unusual sexual practices or with sexual activity involving nonconsenting or inappropriate partners (e.g., children or animals). The term paraphilia is derived from two Greek words meaning “outside of” and “friendship-love.”

In the United States and Canada, the slang term “flasher” is often used for exhibitionists.

Description

Exhibitionism is described in the DSM-IV-TR as the exposure of one’s genitals to a stranger, usually with no intention of further sexual activity with the other person. For this reason, the term exhibitionism is sometimes grouped together with “voyeurism,” (“peeping,” or watching an unsuspecting person or people, usually strangers, undressing or engaging in sexual activity) as a “hands-off” paraphilia. This contrasts with the “hands-on disorders” which involve physical contact with other persons.

In some cases, the exhibitionist masturbates while exposing himself (or while fantasizing that he is exposing himself) to the other person. Some exhibitionists are aware of a conscious desire to shock or upset their target; while others fantasize that the target will become sexually aroused by their display.

Causes and symptoms

Causes

Several theories have been proposed regarding the origins of exhibitionism, although none are considered conclusive. They include:

biological theories. These generally hold that testosterone, the hormone that influences the sexual drive in both men and women, increases the susceptibility of males to develop deviant sexual behaviors. Some medications used to treat exhibitionists are given to lower the patients’ testosterone levels.
learning theories. Several studies have shown that emotional abuse in childhood and family dysfunction are both significant risk factors in the development of exhibitionism. A Swedish survey (Sweden is globally recognized for its excellent health data survey system) found that exhibitionism is associated with psychological problems, although whether the problems precipitate the behavior or vice versa was not identified. This same study found no association between exhibitionistic behavior and a history of sexual abuse.
psychoanalytical theories. These are based on an unsubstantiated assumption that male gender identity requires the male child’s separation from his mother psychologically so that he does not identify with her as a member of the same sex, the way a girl does. It is thought that exhibitionists regard their mothers as rejecting them on the basis of their different genitals. Therefore, they grow up with the desire to force women to accept them by making women look at their genitals.

head trauma. There are a small number of documented cases of men becoming exhibitionists following traumatic brain injury (TBI) without previous histories of alcohol abuse or sexual offenses.
a childhood history of attention deficit/hyperactivity disorder (ADHD). The reason for the connection is not yet known, but researchers at Harvard have discovered that patients with multiple paraphilias have a much greater likelihood of having had ADHD as children than men with only one paraphilia.

Some psychiatrists disagree about whether exhibitionism should be considered a disorder of impulse control or whether it falls within the spectrum of obsessive-compulsive disorders (OCDs). Recent studies suggest that there is an obsessive-compulsive element to these behaviors, and some papers now describe these behaviors in a category of compulsive-impulsive sexual behaviors. Single case studies have suggested some effectiveness of drugs used to treat bipolar disorder in treating exhibitionistic behaviors, implying a potential link also to bipolar disorders. People who exhibit pedophilia , which is also characterized as a paraphilia, have abnormalities in brain imaging studies that are similar to those observed in imaging studies of people with obsessive-compulsive disorder . Disruption of dopamine and serotonin (both nerve signaling molecules) pathways is implicated in many of these disorders.

Symptoms

One expert in the field of treating paraphilias has suggested classifying the symptoms of exhibitionism according to level of severity, based on criteria from the DSM-III-R (1987):

Mild. The person has recurrent fantasies of exposing himself, but has rarely or never acted on them.
Moderate. The person has occasionally exposed himself (three targets or fewer) and has difficulty controlling urges to do so.
Severe. The person has exposed himself to more than three people and has serious problems with control.
A fourth level of severity, catastrophic, would not be found in exhibitionists without other paraphilias. This level denotes the presence of sadistic fantasies which, if acted upon, would result in severe injury or death to the victim.

Because exhibitionism is a hands-off paraphilia, it rarely rises above the level of moderate severity in the absence of other paraphilias.

Demographics

The incidence of exhibitionism in the general population is difficult to estimate because persons with this disorder do not usually seek counseling by their own free will. Exhibitionism is one of the three most common sexual offenses in police records (the other two are voyeurism and pedophilia). It is rarely diagnosed in general mental health clinics, but most professionals believe that it is probably underdiagnosed and underreported.

In terms of the technical definition of exhibitionism, almost all reported cases involve males. A number of mental health professionals, however, have noted that gender bias may be built into the standard definition. Some women engage in a form of exhibitionism by undressing in front of windows as if they are encouraging someone to watch them. In addition, wearing the low-cut gowns favored by some models and actresses have been described as socially sanctioned exhibitionism. One textbook description of exhibitionism says “women exhibit everything but the genitals; men, nothing but.”

Although the stereotype of an exhibitionist is a “dirty old man in a raincoat,” most males arrested for exhibitionism are in their late teens or early twenties. The disorder appears to have its onset before age 18. Like most paraphilias, exhibitionism is rarely found in men over 50 years of age.

In the United States most exhibitionists are Caucasian males. About half of exhibitionists are married.

Diagnosis

Diagnosis of exhibitionism is complicated by several factors. For example, most persons with the disorder come to therapy because of court orders. Some are motivated by fear of discovery by employers or family members, and a minority of exhibitionists enter therapy because their wife or girlfriend is distressed by the disorder. Emotional attitudes toward the disorder vary; some men maintain that the only problem they have with exhibitionism is society’s disapproval of it; others, however, feel intensely guilty and anxious.

A second complication of diagnosing exhibitionism is the high rate of comorbidity among the paraphilias as a group and between the paraphilias as a group and other mental disorders. In other words, a patient in treatment for exhibitionism is highly likely to engage in other forms of deviant sexual behavior and to have depression (an anxiety or substance-abuse disorder). In addition, many patients with paraphilias do not cooperate with physicians, who may have considerable difficulty making an accurate diagnosis of other disorders that may also exist.

A diagnosis of exhibitionism follows a somewhat different pattern from the standard procedures for diagnosing most mental disorders. A thorough workup in a clinic for specialized treatment of sexual disorders includes the following components:

a psychiatric evaluation and mental status examination to diagnose concurrent psychiatric and medical conditions, and to rule out schizophrenia, post-traumatic stress disorder (PTSD), mental retardation, and depression.
a neurologic examination to rule out head trauma, seizures, or other abnormalities of brain structure and function, followed by a computed tomography (CT) scan or magnetic resonance imaging (MRI), if needed.
blood and urine tests for substance abuse and sexually transmitted diseases, including an HIV screen.
assessment of sexual behaviors. This includes creation of a sex hormone profile and responses to questionnaires. The questionnaires are intended to measure cognitive distortions regarding rape and other forms of coercion, pedophilia, aggression, and impulsivity.

Treatments

Exhibitionism is usually treated with a combination of psychotherapy , medications, and adjunctive treatments.

Psychotherapy

Several different types of psychotherapy have been found helpful in treating exhibitionism:

cognitive-behavioral therapy (CBT). This approach is generally regarded as the most effective form of psychotherapy for exhibitionism. Patients are encouraged to recognize the irrational justifications that they offer for their behavior, and to alter other distorted thinking patterns.
orgasmic reconditioning. In this technique, the patient is conditioned to replace fantasies of exposing himself with fantasies of more acceptable sexual behavior while masturbating.
group therapy. This form of therapy is used to get patients past the denial frequently associated with paraphilias, and as a form of relapse prevention.
twelve-step groups for sexual addicts. Exhibitionists who feel guilty and anxious about their behavior are often helped by the social support and emphasis on healthy spirituality found in these groups, as well as by the cognitive restructuring that is built into the twelve steps.
couples therapy or family therapy. This approach is particularly helpful for patients who are married and whose marriages and family ties have been strained by their disorder.

Medications

There are several different classes of drugs used to treat the patient with exhibitionism and the other paraphilias. However, one difficulty in evaluating the comparative efficacy of different medications should be noted: ethical limitation. Double-blind placebo-controlled studies of medication treatment of sexually deviant men raises the ethical question of the possibility of relapse in the subjects who receive the placebo. Withholding a potentially effective drug in circumstances that might lead to physical or psychological injury to a third party is difficult to justify.

Medications are often the only form of treatment for patients with exhibitionism that can suppress deviant behaviors. The categories of drugs used to treat exhibitionism are as follows:

selective serotonin reuptake inhibitors (SSRIs). The SSRIs show promise in treating the paraphilias, as well as depression and other mood disorders. It has been found that decreased levels of serotonin in the brain result in an increased sex drive. The SSRIs are appropriate for patients with mild- or moderate-level paraphilias; these patients include the majority of exhibitionists.
hormones, their mimics, and their antagonists. The three classes of medications most often used to treat paraphilias are hormones, particularly the synthetic medroxyprogesterone acetate, or MPA; luteinizing hormone-releasing hormone (LHRH) agonists (mimics), which include such drugs as triptorelin (Trelstar), leuprolide acetate, and goserelin acetate; and antiandrogens, which block the uptake and metabolism of testosterone as well as reducing blood levels of this hormone. In particular, these drugs with antiandrogenic effects (interfering with the action of the body’s androgenic hormones) have shown some effectiveness.

Surgery

Surgical castration, which involves removal of the testes, is effective in significantly reducing levels of testosterone in blood plasma. This form of treatment for paraphilias, however, is generally reserved for more serious offenders than exhibitionists (violent rapists and pedophiles with a history of repeated offenses, for example).

KEY TERMS

Aversion therapy —An approach to treatment in which an unpleasant or painful stimulus is linked to an undesirable behavior in order to condition the patient to dislike or avoid the behavior.

Castration —Desexing a person or animal by surgical removal of the testes (in males) or ovaries (in females). Castration is sometimes offered as a treatment option to violent rapists and pedophiles who are repeat offenders.

Comorbidity —Association or presence of two or more mental disorders in the same patient. A disorder that is said to have a high degree of comorbidity is likely to occur in patients diagnosed with other disorders that may share or reinforce some of its symptoms.

Compliance —In medicine or psychiatry, cooperation with a treatment plan or schedule of medications.

Denial —A psychological defense mechanism that reduces anxiety by excluding recognition of an addiction or similar problem from the conscious mind.

Double-blind placebo-controlled study —A study in which patients are divided into two groups—those who will recive a medication, and those who will receive a placebo (a pill that looks like the medication but has no active ingredients). Neither the patients nor their physicians know which pill any specific patient is receiving.

Paraphilias —A group of mental disorders that is characterized by recurrent intense sexual urges and sexually arousing fantasies generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one’s partner (not merely simulated), or (3) children or other nonconsenting persons.

Placebo —An inactive substance or preparation used as a control in experiments with human subjects to test the effectiveness of a medication.

Recidivism —A tendency to return to a previously treated activity, or repeated relapse into criminal or deviant behavior.

Serotonin —A chemical produced by the brain that functions as a neurotransmitter. Low serotonin levels are associated with the paraphilias as well as with mood disorders. Medications known as selective serotonin reuptake inhibitors (SSRIs) can be used to treat exhibitionism and other paraphilias.

Voyeurism —A paraphilia that involves watching unsuspecting people, usually strangers, undress or engage in sexual activity.

Other treatment methods

Another treatment method that is often offered to people with exhibition disorder is social skills training. It is thought that some men develop paraphilias partially because they do not know how to form healthy relationships, whether sexual or nonsexual, with other people. Although social skills training is not considered a substitute for medications or psychotherapy, it appears to be a useful adjunctive treatment for exhibitionism disorder.

Legal considerations

People with exhibitionism disorder are at risk for lifetime employment problems if they acquire a police record. An attorney who specializes in employment law has pointed out that the Americans with Disabilities Act (ADA), enacted by Congress in 1990 to protect workers against discrimination on grounds of mental impairment or physical disability, does not protect persons with paraphilias. People with exhibitionism disorder were specifically excluded by Congress from the provisions of the ADA, along with voyeurs and persons with other sexual behavior disorders.

Prognosis

The prognosis for people with exhibition disorder depends on a number of factors, including the age of onset, the reasons for the patient’s referral to psychiatric care, degree of his cooperation with the therapist, and comorbidity with other paraphilias or other mental disorders. For some patients, exhibitionism is a temporary disorder related to sexual experimentation during their adolescence. For others, however, it is a lifelong problem with potentially serious legal, interpersonal, financial, educational, and occupational consequences. People with exhibition disorder have the highest recidivism rate of all the paraphilias; between 20% and 50% of men arrested for exhibitionism are rearrested within two years.

Prevention

One important preventive strategy includes the funding of programs for the treatment of paraphilias in adolescents. According to one expert in the field, males in this age group have not been studied and are undertreated, yet it is known that paraphilias are usually established before age 18. Recognition of paraphilias in adolescents and treatment for those at risk would lower the risk of recidivism. A second important preventive approach is early recognition and appropriate treatment of people who have committed child abuse.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Beers, Mark H., MD, and Robert Berkow, MD. “Exhibitionism,” In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Carnes, Patrick. Out of the Shadows: Understanding Sexual Addiction. Minneapolis, MN: CompCare Publications, 1983.

Kasl, Charlotte D. Women, Sex, and Addiction. New York: Harper and Row, Publishers, 1990.

PERIODICALS

Abouesh, A., and A. Clayton. “Compulsive Voyeurism and Exhibitionism: A Clinical Response to Paroxetine.” Archives of Sexual Behavior 28 (February 1999): 23–30.

Bradford, John M. W. “The Treatment of Sexual Deviation Using a Pharmacological Approach.” Journal of Sex Research 37 (August 2000): 485–92.

Brannon, Guy E., MD. “Paraphilias.” eMedicine Journal 3 (January 14, 2002).

Carnes, P., and J. P. Schneider. “Recognition and Management of Addictive Sexual Disorders: Guide for the Primary Care Clinician.” Lippincotts Primary Care Practitioner 4 (May-June 2000): 302–18.

de Silva, W. P. “Sexual Variations.” British Medical Journal 318 (March 6, 1999): 654.

Greenberg, D. M. “Sexual Recidivism in Sex Offenders.” Canadian Journal of Psychiatry 43 (June 1998): 459–65.

Kafka, Martin P., and J. Hennen. “Psychostimulant Augmentation During Treatment with Selective Serotonin Reuptake Inhibitors in Men with Paraphilias and Paraphilia-Related Disorders: A Case Series.” Journal of Clinical Psychiatry 61 (2000): 664–70.

Langstrom, Niklas, and Michael C. Seto. Exhibitionistic and Voyeuristic Behavior in a Swedish National Population Survey. Archives of Sexual Behavior 35 (2006): 427–35.

Lee, J. K., and others. “Developmental Risk Factors for Sexual Offending.” Child Abuse and Neglect 26 (January 2002): 73–92.

Marazziti, Donatella, and Bernardo Dell’Osso. “Topira-mate Plus Citalopram in the Treatment of Compulsive-Impulsive Sexual Behaviors.” Clinical Practice in Epidemiology in Mental Health 2 (2006): 9.

Schiffer, Boris, and others. “Structural Brain Abnormalities in the Frontostriatal System and Cerebellum in Pedophilia.” Journal of Psychiatric Research (2006).

Schober, Justine M., Peter M. Byrne, and Phyllis J. Kuhn. “Leuprolide Acetate is a Familiar Drug That May Modify Sex-Offender Behavior: the Urologist’s Role.” BJU International 97 (2006): 684–86.

Simpson, G., A. Blaszczynski, and A. Hodgkinson. “Sex Offending as a Psychosocial Sequela of Traumatic Brain Injury.” Journal of Head Trauma and Rehabilitation 14 (December 1999): 567–80.

Sonnenberg, Stephen P., JD. “Mental Disabilities in the Workplace.” Workforce 79 (June 2000): 632.