(See also Overview of Paraphilic Disorders.)
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 months.
Estimated prevalence in men is not more than 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. Although it is reported to occur, the vast majority of those with exhibitionism do not engage in physically aggressive sexual behaviors.
Most exhibitionists are married, but the marriage is often troubled by poor social and sexual adjustment, including frequent sexual dysfunction (see Male Sexual Function and Sexual Dysfunction in Women).
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.
Diagnosis of exhibitionistic disorder requires the following:
Patients have been repeatedly and intensely aroused by exposing their genitals to an unsuspecting person or being observed by other people during 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 months.
When laws are broken and sex offender status is conferred, treatment of exhibitionistic disorder usually begins with psychotherapy, support groups, and SSRIs.
If SSRIs 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.
Most exhibitionists do not meet the clinical criteria for an exhibitionistic disorder.
About 30% of apprehended male sex offenders are exhibitionists; about 20 to 50% of them are re-arrested.
Diagnose exhibitionistic disorder only if the condition has been present for ≥ 6 months and if patients have acted on their sexual urges with a nonconsenting person or their behavior causes them significant distress or impairs functioning.
If patients have committed a sexual offense, treat with psychotherapy and SSRIs first; if additional treatment is needed and if informed consent is obtained, antiandrogen drugs may be considered.