Exhibitionism

Exhibitionism is a condition marked by the urge to expose one’s sexual organs to others, particularly strangers.

Definition

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" or obsession with unusual sexual practices or with sexual activity involving nonconsenting or inappropriate partners.

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.

Symptoms

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.

Causes

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.

Some other theories have been proposed. Biological theories 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. Several studies suggest that emotional abuse in childhood and family dysfunction are both significant risk factors in the development of exhibitionism. Psychoanalytical theories are based on the idea 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. This theory suggests 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. There are a small number of documented cases of head trauma amongst 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) has been proposed as a possible 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.

Treatments

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. Luteinizing hormone-releasing hormone (LHRH) agonists are drugs that work by reducing the release of gonadotropin hormones. These include such drugs as triptorelin (Trelstar), leuprolide acetate, and goserelin acetate. These hormones act as pharmacologic castration which 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.

Other therapies include the group dynamic. Group therapy is a form of therapy 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.

Sources

  • American Psychiatric Association
  • DSM-IV™ Made Easy: The Clinician's Guide to Diagnosis
  • Treating Mental Disorders: A Guide to What Works
  • 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): 485-492.
  • Lee, J. K., and others. "Developmental Risk Factors for Sexual Offending." Child Abuse and Neglect 26 (January 2002): 73-92.
  • 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): 567-580.
Last reviewed 11/24/2014