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Voyeuristic Disorder

(Voyeurism)

By George R. Brown, MD, Professor and Associate Chairman of Psychiatry;Adjunct Professor of Psychiatry, East Tennessee State University;University of North Texas

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Patient Education

Voyeurism is achievement of sexual arousal by observing people who are naked, disrobing, or engaging in sexual activity. When observation is of unsuspecting people, this sexual behavior often leads to problems with the law and relationships. Voyeuristic disorder involves acting on voyeuristic urges or fantasies with a nonconsenting person or experiencing significant distress or functional impairment because of such urges and impulses.

Voyeurism is form of paraphilia, but most people who have voyeuristic interests do not meet the clinical criteria for a paraphilic disorder, which require that the person's behavior, fantasies, or intense urges result in clinically significant distress or impaired functioning or cause harm to others (which in voyeurism includes acting on the urges with a nonconsenting person). The condition must also have been present for ≥ 6 mo.

Desire to watch others in sexual situations is common and not in itself abnormal. Voyeurism usually begins during adolescence or early adulthood. Adolescent voyeurism is generally viewed more leniently; few teenagers are arrested. When voyeurism is pathologic, voyeurs spend considerable time seeking out viewing opportunities, often to the exclusion of fulfilling important responsibilities in their life. Orgasm is usually achieved by masturbating during or after the voyeuristic activity. Voyeurs do not seek sexual contact with the people being observed.

In many cultures, voyeurs have ample legal opportunities to watch sexual activity (eg, digital or print pornography). However, voyeuristic behaviors are the most common of sexual behaviors that may result in a brush with the law.

Viewing sexually explicit pictures and shows, now widely available in private on the Internet, is not considered voyeurism because it lacks the element of secret observation, which is the hallmark of voyeurism.

Up too 12% of males and 4% of females may meet clinical criteria for voyeuristic disorder; most do not seek medical evaluation and treatment.

Diagnosis

  • Specific Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria

Diagnosis of voyeuristic disorder requires the following:

  • Patients have been repeatedly and intensely aroused by observing an unsuspecting person who is naked, undressing, or engaging in sexual activity; arousal is expressed in fantasies, intense urges, or behaviors.

  • Patients have acted on their urges with a nonconsenting person, or these fantasies, intense urges, or behaviors cause significant distress or impair functioning at work, in social situations, or in other important areas.

  • The condition has been present for ≥ 6 mo.

Voyeuristic disorder is not diagnosed in patients < 18 yr.

Treatment

  • Psychotherapy, support groups, and SSRIs

  • Sometimes antiandrogen drugs

When laws are broken and sex offender status is conferred, treatment usually begins with therapy, support groups, and SSRIs.

If these drugs are ineffective and if the disorder is severe, drugs that reduce testosterone levels and thus reduce libido should be considered. These drugs are referred to as antiandrogens, although the most commonly used drugs do not actually block the effects of testosterone. Drugs include

  • Gonadotropin-releasing hormone (GnRH) agonists (eg, leuprolide)

  • Depot medroxyprogesterone acetate

Both decrease pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) and thus reduce testosterone production. Full informed consent and appropriate monitoring of liver function and serum testosterone levels are required.

Key Points

  • Most voyeurs do not meet the clinical criteria for a voyeuristic disorder.

  • Voyeuristic behaviors are the most common sexual behaviors likely to involve law enforcement.

  • Diagnose voyeuristic disorder only if the condition has been present for ≥ 6 mo and if patients have acted on their sexual urges with a nonconsenting person or their fantasies, intense urges, or behavior causes significant distress or impair functioning.

  • If patients have committed a sexual offense, treat with psychotherapy and SSRIs first, and if additional treatment is needed and if informed consent is obtained, treat with antiandrogen drugs.