Exhibitionism

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Photo by: Sandman

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 (such as 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 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.

Causes and symptoms

Causes

Several theories have been proposed regarding the origins of exhibitionism. As of 2002, however, 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.
• Psychoanalytical theories. These are based on the 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.

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.

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 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

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:

• 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.

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:

• 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.
• Female hormones. Estrogens have been used to treat sexual offenders since the 1940s. Medroxyprogesterone acetate, or MPA, is the most widely used hormonal medication in the U.S. for the treatment of people with exhibitionism. Medroxyprogesterone acetate works by stimulating the liver to produce a chemical that speeds up the clearance of testosterone from the bloodstream. It is effective as long as patients are take their MPA as prescribed by their physicians. Unfortunately, MPA can cause several troublesome side effects in some patients. These include nausea, vomiting, weight gain, and headache.
• Luteinizing hormone-releasing hormone (LHRH) agonists. These drugs are sometimes described to be the equivalent of pharmacologic castration. They work by reducing the release of gonadotropin hormones. The LHRH agonists include such drugs as triptorelin (Trelstar), leuprolide acetate, and goserelin acetate.
• Antiandrogens. These drugs block the uptake and metabolism of testosterone and reduce the blood levels of testosterone. The antiandrogens include cyproterone acetate (CPA) and flutamide. Cyproterone acetate has been used in Germany to treat exhibitionists since the early 1970s, and most long-term studies of the CPA have been done by German psychiatrists. The drug appears to have minimal side effects in long-term use and significantly reduces recidivism (relapse and repetition of the deviant behavior).

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).

Other treatment methods

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.

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 re-arrested 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 edition, text revised. Washington, DC: American Psychiatric Association, 2000.

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

"Exhibitionism," Section 15, Chapter 192. In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

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): 485-492.

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): 302-318.

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): 459-465.

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): 664-670.

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.

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

ORGANIZATIONS

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.