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 (such as children or animals). The term paraphiliais 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.
Exhibitionism is described in theDSM-IV-TRas 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 expression, "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.
Several theories have been proposed regarding the origins of exhibitionism. As of 2002, however, none are considered conclusive They include:
In general, psychiatrists disagree whether exhibitionism should be considered a disorder of impulse control or whether it falls within the spectrum of obsessive-compulsive disorders (OCDs). Further research into the anatomical structure and neurochemistry of the brain may help to settle this question.
As of 2002, there are no genes that have been associated with an increased risk of exhibitionism or other paraphilias. Such chromosomal abnormalities as Klinefelter's syndrome (where males have an extra X chromosome and are usually sterile) were at one time thought to be a risk factor for the development of paraphilias, but research has not yet proved a connection.
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):
Because exhibitionism is a hands-off paraphilia, it rarely rises above the level of moderate severity in the absence of other paraphilias.
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 lowcut 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 U.S., most exhibitionists are Caucasian males. About half of exhibitionists are married.
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 suffer from 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:
Exhibitionism is usually treated with a combination of psychotherapy, medications, and adjunctive treatments.
Several different types of psychotherapy have been found helpful in treating exhibitionism:
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.
As of 2002, medications are the only form of treatment for patients with exhibitionism that have the capability to suppress deviant behaviors. The categories of drugs used to treat exhibitionism are as follows:
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).
Another method of treating patients with exhibitionism disorder, used more frequently in the 1970s and 1980s than today, is electroshock aversion. While a mild electric shock was administered, the patient was shown pictures, projected onto a screen, of men exposing themselves. In 2002, aversion therapy involves asking the patient to fantasize a sequence of events leading up to his exhibitionism. Then, a very unpleasant scene is inserted at a crucial point in the sequence. The patient might, for example, be asked to imagine a police officer approaching as he exposes himself, or to think of his target fighting back or laughing at him.
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.
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.
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 re-arrested within two years.
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.
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Augustine Fellowship, Sex and Love Addicts Anonymous. PO Box 119, New Town Branch, Boston, MA 02258. (617) 332-1845.
National Association on Sexual Addiction Problems (NASAP). 22937 Arlington Avenue, Suite 201, Torrance, CA 90501. (213) 546-3103.
Rebecca J. Frey, Ph.D.
The following comments are not guaranteed to be that of a trained medical professional. Please consult your physician for advice.
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