Exhibitionism is characterized by achievement of sexual excitement through genital exposure, usually to an unsuspecting stranger. It may also refer to a strong desire to be observed by other people during sexual activity. Exhibitionistic disorder involves acting on these urges with a nonconsenting person or experiencing significant distress or functional impairment because of such urges and impulses.
Exhibitionism is a form of paraphilia, but most people who have exhibitionism do not meet the clinical criteria for a paraphilic disorder, which require that a person's behavior, fantasies, or intense urges result in clinically significant distress or impaired functioning or cause harm to others (which in exhibitionism includes acting on the urges with a nonconsenting person). The condition must also have been present for ≥ 6 mo.
Estimated prevalence in men is 2 to 4%; it is lower in women. Few females are diagnosed with exhibitionistic disorder; society sanctions some exhibitionistic behaviors in females (through media and entertainment venues).
Exhibitionists (usually male) may masturbate while exposing or fantasizing about exposing themselves to others. They may be aware of their need to surprise, shock, or impress the unwilling observer. The victim is almost always a female adult or a child of either sex. Actual sexual contact is rarely sought, and physical harm to the unsuspecting witness is unusual.
Onset is usually during adolescence; occasionally, the first act occurs during preadolescence or middle age.
About 30% of apprehended male sex offenders are exhibitionists. They have the highest recidivism rate of all sex offenders; about 20 to 50% are re-arrested.
Most exhibitionists are married, but the marriage is often troubled by poor social and sexual adjustment, including frequent sexual dysfunction.
For some people, exhibitionism is expressed as a strong desire to have other people watch their sexual acts. What appeals to such people is not the act of surprising an audience but rather of being seen by a consenting audience. People with this form of exhibitionism may make pornographic films or become adult entertainers. They are rarely troubled by this desire and thus may not have a psychiatric disorder.
When laws are broken and sex offender status is conferred, treatment usually begins with psychotherapy, 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. These drugs include gonadotropin-releasing hormone (GnRH) agonists (eg, leuprolide) and depot medroxyprogesterone acetate; both decrease pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Full informed consent and appropriate monitoring of liver function and serum testosterone levels are required.
Recidivism rates are high. Effectiveness of treatment is monitored based on self-report, penile plethysmography, and arrest records.
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