• Definition
• Symptoms
• Causes
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Exhibitionism, which involves exposing one's genitals or sexual organs to a stranger, falls under the psychiatric sexual disorders category of paraphilias, "abnormal or unnatural attraction." The exhibitionist might masturbate (or fantasize about masturbating) while exposing himself but makes no further attempt at sexual activity with the stranger. The individual is sometimes aware of a desire to startle or upset the observer. At times, the individual might fantasize that the observer will become sexually aroused. Exhibitionism, though often discussed as a humorous topic, is a very serious behavior that can frighten the victim. The exhibitionist is typically male, and the victim is usually a female (adult or child), and usually an unsuspecting stranger.

Social and sexual relationships may suffer if the behavior is found disturbing or if the individual's sexual partner refuses to cooperate with this particular preference. In some instances, the unusual behavior may become the major sexual activity in the individual's life. These individuals rarely seek help on their own and are likely to get professional assistance only when their behavior has brought them into conflict with sexual partners or society.

The key features of true exhibitionism are these:

• There is sexual arousal directly related to surprising the victim
• The victim is unwilling
• No further sexual contact is desired

Clinical diagnosis is made if the patient:

• Over a period of at least six months, has recurrent sexually arousing fantasies or behavior involving exposing the genitals to an unsuspecting stranger
• The person has acted on these sexual urges or the fantasies cause marked distress or interpersonal difficulty in the workplace or in everyday social situations.

The onset of this condition usually occurs before age 18, although it can begin later. Few arrests are made in the older age groups, which may suggest that the condition becomes less severe after age 40.

The vast majority of exhibitionists are male. Female exhibitionists may seek employment where the condition can be exploited, such as topless dancing, although most people in such jobs are not exhibitionists.

Behavioral learning models suggest that a child who is the victim or observer of inappropriate sexual behaviors learns to imitate and later receives reinforcement for the behavior. These children are deprived of normal social sexual contacts and search for gratification through less socially acceptable means. Physiological models focus on the relationship between hormones, behavior and the central nervous system, with a particular interest in the role of aggression and male sexual hormones.

Most exhibitionists do not receive treatment until they are caught by the authorities and are ordered into treatment. If you or someone you care about is an exhibitionist, early treatment is strongly advised. Discuss the matter of confidentiality with your mental health professional. The treatments for exhibitionism include cognitive behavioral therapy, aversion and positive condition approaches, medications, reconditioning and restructuring techniques, and empathy training.

Neither an individual's intensity of sex drive nor a male's level of circulating testosterone predispose a person to paraphilias. That said, hormones such as medroxyprogesterone acetate (Depo-Provera) and cyproterone acetate decrease the level of circulating testosterone, thus reducing sex drive and aggression. These hormones result in reduction of frequency of erections, sexual fantasies and initiations of sexual behaviors including masturbation and intercourse. Hormones are typically used in tandem with behavioral and cognitive treatments. Antidepressants such as fluoxetine (Prozac) have also successfully decreased the sex drive but have not effectively targeted sexual fantasies.

Research suggests that cognitive-behavioral models are effective in treating paraphiliacs: Aversive conditioning involves using negative stimuli to reduce or eliminate a behavior. Covert sensitization entails the patient relaxing, visualizing scenes of deviant behavior followed by a negative event such as getting his penis stuck in the zipper of his pants. Assisted aversive conditioning is similar to covert sensitization except the negative event is made real most likely in the form of a foul odor pumped in the air by the therapist. The goal is for the patient to associate the deviant behavior with the foul odor and take measures to avoid the odor by avoiding said behavior.

Aversive behavioral reversal, commonly known as "shame therapy," involves shaming the offender into stopping the deviant behavior. For example, the offender might be made to watch videotapes of their crime with the goal that the experience will appear distasteful and offensive. An exhibitionist may be forced to expose himself to hospital staff for a period of three minutes on three separate occasions while the staff is instructed to watch but not respond in any way. The goal is that the offender will be shamed by the forced exposure and avoid exposing himself again. Vicarious sensitization entails showing videotapes of deviant behaviors and their consequences such as victims describing desired revenge or perhaps even watching surgical castrations.

There are also positive conditioning approaches that might center on social skills training and appropriate alternate behaviors the patient might take. Reconditioning techniques are designed to provide immediate feedback to the patient to encourage a fast change of behavior. For example, a person might be connected to a biofeedback machine that is connected to a light and taught to keep the light within a specific range of color while the person is exposed to sexually stimulating material. Or masturbation training might focus on separating pleasure in masturbation and climax from the deviant behavior.

Cognitive therapies include restructuring cognitive distortions and empathy training. Restructuring cognitive distortions involves correcting beliefs by the patient, such as that the victim deserves to be party to the deviant act. Empathy training involves helping the offender take on the perspective of the victim to understand the harm that has been done.

Sources:

• American Psychiatric Association
• DSM-IV™ Made Easy: The Clinician's Guide to Diagnosis
• Treating Mental Disorders: A Guide to What Works