149 Exhibitionism (302.4)

DSM-IV-TR criteria

• Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the exposure of one’s genitals to unsuspecting strangers
• The person has acted on said urges, or the urges or fantasies cause marked distress or interpersonal difficulty

Associated features

Exhibitionists in some cases masturbate while exposing themselves (or while fantasizing that he/she is exposing himself/herself) to another person. There is a pattern in which males exhibit themselves and there are three characteristic features of the exhibition: 1) It is performed for unknown women. 2) It takes place where sexual intercourse is impossible (e.g. a crowded shopping center). 3) It seems designed to surprise and shock the woman. The male exhibitionist usually exposes his erect penis, but it is not necessarily essential for the activity. Ejaculation may occur at the moment of exposure or develop later with masturbatory stimulation. 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.

Child vs. adult presentation

Generally, society accepts exhibitionism in children as a natural curiosity, not a disorder, however if the behaviors continue a paraphilia is probable. Disorder appears to develop before the age of 18, and rarely is found in people over the age of 50.

Gender and cultural differences in presentation

Most reported cases of exhibitionism involve males. Some scientists argue that women who undress in front of windows (as to invite a person to watch), or who wear low cut gowns are exhibitionists in a sense. Exhibitionism generally appears in Western society and is believed to be almost absent in such countries as Japan, Burma, and India. Additionally, in the American society it can be a crime when committed by a male, but when women expose themselves, excluding total nudity, they are often seen as victims of male voyeurism.

Epidemiology

Prevalence and incidence are not easily defined because people with this disorder usually do not seek treatment voluntarily. Exhibitionism is one of the three most common sexual offenses, the other two being voyeurism and pedophilia. It is rarely diagnosed in general mental health clinics, but most professionals believe that it is probably underdiagnosed and under-reported.

Etiology

• People with these types of paraphilia tend to have personalities accompanied by social isolation, low self-esteem, and, usually, feelings of sexual inadequacy. They are not generally comfortable with normal heterosexual relationships and they are not willing to risk the rejection of their attempts to create willing sexual relationships, so they resort to abnormal sexual activity. They suggest that sexual abuse as children or other traumatic childhood situations may be the cause. According to Freudian theory, during the phases of psychosexual development, fixations rooted at one level of sexual adjustment prevent normal progress to the next stage of development. Some behavioral theories state that sexual arousal has been linked with the activity of exposure through either a Pavlovian-type conditioning process or operant conditioning. Some documented cases have shown that some men become exhibitionists after traumatic brain injuries (TBIs).
• Several theories have attempted to explain the etiology of exhibitionism.

• Biological theories – these theories hold that testosterone increases the susceptibility of males to develop deviant sexual behaviors.
• Learning theories – these theories assert that emotional abuse in childhood and family history are both risk factors.
• Psychoanalytical theories – these theories posit that male gender identity requires separation from his mother psychologically so that he does not identify with her as a member of the same sex.

Empirically supported treatments

• Cognitive-behavioral therapy is the most effective form of treatment for exhibitionism. Under C-B treatments, patients are encouraged to recognize and address the irrational justifications and possible punishments for their behaviors and thinking patterns.
• Psychotherapy is typically aimed at finding the hidden or underlying cause of such behavior.
• Group Couples Therapy is usually helpful for those who are married and whose family ties have been strained by exhibitionism. Orgasmic reconditioning has the patient replace the exhibitionist fantasies with more socially acceptable sexual behaviors while masturbating.
• Group Therapy- is typically used to get people past the ” denial” stage that is frequently associated with paraphilias, and acts a form of relapse prevention.
• Twelve-Step programs for sexual addicts. Exhibitionists who feel guilty and anxious about their behavior are often helped by social support and emphasis on a healthy spirituality found in these groups, as well as cognitive restructuring that is built into the twelve steps.

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.