Exhibitionism

Exhibitionistic disorder is a condition marked by the urge, fantasy, or behavior of exposing one’s genitals to non-consenting people, particularly strangers.

From Psychology Today (4/18/17)

Definition
Exhibitionistic disorder involves exposing one’s genitals or sexual organs to a non-consenting person. This condition falls under the psychiatric category of paraphilic disorders, which refer to persistent and intense atypical sexual arousal patterns that are accompanied by clinically significant distress or impairment. Exhibitionistic disorder was referred to as exhibitionism in previous versions of the DSM.

There are several subtypes of exhibitionistic disorder, and these depend on the age of the non-consenting person to whom someone with exhibitionistic disorder prefers to show their genitals. For example, the preference could be to show genitals to prepubescent children, adults, or both. Some people may deny that they show their genitals to unsuspecting others or deny that this act causes them distress; if they have indeed exposed themselves repeatedly to non-consenting people, they may still receive a diagnosis of exhibitionistic disorder.

The prevalence of exhibitionistic disorder is unknown, but is thought to be approximately two to four percent in the male population. This condition is less common in females, although prevalence estimates are unknown.

Symptoms
A diagnosis of exhibitionistic disorder can be made if the following criteria are met:

• Over a period of at least six months, a person has recurrent and intense sexually arousing fantasies, behaviors, or urges involving exposing the genitals to an unsuspecting person
• The person has acted on these sexual urges with a non-consenting person, or the urges or fantasies cause marked distress or interpersonal difficulty in the workplace or in everyday social situations.

Exhibitionistic disorder is categorized into subtypes based on whether a person prefers to expose him or herself to prepubescent children, adults, or both.

The onset of this condition typically occurs sometime in late adolescence or early adulthood. Similar to other sexual preferences, exhibitionistic sexual preferences and behavior may lessen as people get older.

Causes
Risk factors for the development of exhibitionistic disorder in males include antisocial personality disorder, alcohol abuse, and an interest in pedophilia. Other factors that may be associated with exhibitionism include sexual and emotional abuse during childhood and sexual preoccupation in childhood.

Treatments
Most people with exhibitionistic disorder do not seek treatment on their own, and don’t receive treatment until they are caught and are required to by authorities. If you or someone you care about may have exhibitionistic disorder, early treatment is strongly advised. The treatment for exhibitionism typically includes psychotherapy and medication.

Research suggests that behavioral models are effective in treating exhibitionistic disorder by providing individuals with tools to control their impulses and find more acceptable ways of coping with their urges than showing their genitalia to others. Cognitive behavioral therapy may help individuals identify the triggers that cause their urges and then manage these urges in healthier ways. Other psychotherapy approaches include relaxation training, empathy training, coping skills training and cognitive restructuring (identifying and altering the thoughts that lead to exhibitionism).

Medications that may be helpful in treating exhibitionistic disorder include medications that inhibit sexual hormones, resulting in a decrease in sexual desire. Some medications that are commonly used to treat depression and other mood disorders, such as SSRI’s, can also reduce sexual desire.

References

• American Psychiatric Association, Diagnostic and Statistical Manual, Fifth Edition
• DSM-IV Made Easy: The Clinician’s Guide to Diagnosis
• Treating Mental Disorders: A Guide to What Works
• First, M. B. (2014). DSM-5 and paraphilic disorders. Journal of the American Academy of Psychiatry and the Law Online, 42(2), 191-201.

Last reviewed 04/18/2017

Research on Exhibitionism

Why Do Some Men Engage in Sexual Exhibitionism?  It has to do with anxiety, not just power.
Michael Bader, Psychology Today (12/10/17)

Among the weirdest peccadilloes to emerge in the recent flood of stories of sexual harassment are those situations in which a man invites or coerces a woman to watch him masturbate. Analyzing the psychology of such a man can potentially help us understand the various forms of toxic masculinity currently filling the headlines. As a therapist, I’ve seen a few men who have done this kind of thing and most are driven by intolerable anxiety. The exhibitionistic fantasy—that’s what this is—originates in the man’s need to reassure himself that his penis, his manhood, is not bad, defective, or insignificant. A key part of the imagined scenario is that the woman is fascinated and excited by the display, which affirms the man’s positive sense of masculinity and momentarily relieves his anxiety. This dynamic is usually unconscious.

Of course, the actual woman complaining about this behavior invariably feels controlled, degraded, or ashamed. But her experience of humiliation does not necessarily imply that the exhibitionist’s main goal is to humiliate her. He needs to set up a situation, over and over, in which he can escape anxiety; he’s not primarily out to make women suffer. He uses women as a kind of mirror that, in his mind, reflects back admiration and excitement, not horror or disappointment; the women just feel used.

Normal masculinity in our culture is shot through with anxiety. For reasons that can only be discerned on an analyst’s couch, the normal stresses of growing up male become so extreme to some men, and their particular life circumstances make women so “available,” that sexual exhibitionism becomes a compelling fantasy to enact. When these ingredients are present, you get someone like Louis C.K.

In what ways is masculinity riddled with anxiety? First, for boys, the challenge of separating and individuating from a (usually female) caretaker becomes intertwined with the formation of masculinity. Boys not only have to become separate from their mothers, but to become masculine at the same time. The problem is that masculinity becomes defined as something that is not feminine. Further, our patriarchal culture leads the boy to devalue femininity in order to reinforce this separation process. The resulting personality structure in boys and, later, men, therefore tends to be rigid, competitive, intolerant of dependency and vulnerability, and guilty about rejecting or otherwise hurting women. This type of personality is inherently threatened by intimacy and tormented by fears of fraudulence, of being revealed as insufficiently masculine. Doubts about one’s masculinity abound.

Freud called this anxiety castration anxiety; most people know it as male insecurity. It drives a man to overcompensate with narcissistic displays of ego and with competitive aggression, especially with women, in order to reassure himself that he is powerful and important, masculine, rather than weak and vulnerable, that is, feminine. One only has to read the daily news coming out of the Trump White House to see this dynamic in action.

When a man’s anxiety is high enough, the masturbatory sexual fantasy becomes a compulsion and blots out any genuine empathy he might feel. High levels of anxiety cause such men, desperate for anything that will bring them relief, to become especially self-centered. In the search for relief, empathy falls by the wayside. In fact, a man’s inability to grasp the effect of his exposure on others is a good measure of his psychological disturbance. It’s impossible to say why anxiety that is commonly seen in most men might lead one of them, Louis C.K., for example, to sexually act out with women when another man deals with it by, say, showing off in competitive sports. That’s for his therapist to figure out.

This internal struggle does not excuse C.K. for abusing his power. But from a psychological point of view, power is a crucial part of the picture as men like Louis C.K. have the social, economic, and professional means to put their fantasies into practice—to coerce their sexual objects to behave in ways that fit their fantasies. For the powerful, their wishes become the world’s command.

To understand these men, we need to understand how sexual fantasies function to reduce or mitigate anxiety. In addition to being a private daydream, a fantasy is usually embedded and expressed in a person’s sexual preferences: the particular scenarios, positions, body types, and storylines that turn them on. The job of the fantasy in a person’s psychology is to counteract, usually unconsciously, the inhibiting effects of guilt, shame, worry, helplessness, or inferiority. These feelings threaten to evoke anxiety, which always dampens arousal. When the fantasy lifts the roadblock to pleasure, the result is excitement. All fantasies work this way, regardless of how emotionally healthy the person is.

For example, some people especially enjoy being playfully dominated in bed. The fantasy and, if they can get it, the act help such people momentarily transcend their guilt and anxiety about hurting or overwhelming a partner. The sexual scenario of being overpowered “works” because the partner’s apparent strength counteracts the inhibiting effects of worry and guilt. Unconsciously speaking, it reduces anxiety.

In a similar way, when a man masturbates in front of a captive audience and can believe she is enjoying the sight, it “works” for him because it offers reassurance that his penis, the symbol of his masculinity, is desirable, not noxious. There is nothing inherently pathological about exhibitionistic scenarios if they are part of consensual erotic play.

With Louis C.K., however, as with other men who are compulsively drawn to this type of situation, the underlying anxiety is likely so intense that their judgment becomes grossly impaired. Swept away are all other considerations, like the woman’s feelings and the possibility of getting caught.

An explanation is not an excuse. Men like Louis C.K. have a responsibility to deal with their neuroses in ways that do not harm other people. That is what therapists are for. But if we want to understand why such a man is aroused by masturbating in front of women, the answer lies not in the power he is exercising but in the anxiety he is attempting to assuage. Such anxiety makes him unable to understand and respect women as people but instead drives him to use women as a means to a psychological and erotic end.

The treatment of sexual paraphilias: A review of the outcome research.
Kilmann, Peter R., Sabalis, Robert F., Gearing, Milton L., Bukstel, Lee H., Scovern, Albert W.
Journal of Sex Research, Vol 18(3), Aug, 1982. pp. 193-252.
Abstract:
Reviews research on the impact of treatment on Ss with singular and multiple sexual paraphilias (e.g., exhibitionism, fetishism, pedophilia, transvestism, voyeurism). A methodological evaluation was conducted with attention to 6 categories: design, Ss, therapists, treatment, time periods, and outcome measures. The methodological shortcomings included the failure to control for social desirability factors, especially in the case of sex offenders, and the reliance on verbal self-report in outcome evaluation. Most studies found positive treatment effects. Periodic booster treatment sessions sometimes were necessary with paraphilias of long duration. Tentative support was found for the efficacy of a multiple behavioral treatment package tailored to the patient’s sexualarousal pattern. Elimination of variant sexual responses in conjunction with fostering appropriate, nonvariant sexual behavior is considered a relevant treatment strategy. Future research should use homogeneous experimental and control Ss, obtain a pretherapy assessment of sexual and social functioning, specify treatment goals, and use multiple outcome measures. To promote successful S–treatment matches, a checklist is derived that notes the psychological and situational correlates of the 5 predominant sexual paraphilias.

Exhibitionism: Findings from a Midwestern police contact sample.
Bader, Shannon M., Schoeneman-Morris, Katherine A., Scalora, Mario J., Casady, Thomas K..
International Journal of Offender Therapy and Comparative Criminology, Vol 52(3), Jun, 2008. pp. 270-279.
Abstract:
This study used a police sample to examine offense characteristics, recidivism rates, and other types of sexualoffending among individuals suspected of exhibitionism. The sample consisted of 202 incidents of indecent exposure perpetrated by 106 identified individuals. Demographic information showed that one quarter of the sample had symptoms of a mental illness and one quarter had a history of substance abuse. More than 84% of the sample had other nonsexual criminal charges. Approximately 30% of the perpetrators were charged for more than one exposure incident. Masturbating during the offense, exposing to child victims, and speaking to the victim did not show any relationship to the occurrence of more sexually aggressive behaviors. However, individuals who had subsequent rape or molestation charges (16.9%) were more likely than those who did not to have had multiple exposure incidents and a history of physical assault charges.

Voyeurism, exhibitionism and other non-contact sexual offences.
Hocken, Kerensa., Thorne, Karen.
A psychologist’s casebook of crime: From arson to voyeurism. Winder, Belinda, (Ed); Banyard, Philip, (Ed); pp. 243-263; New York, NY: Palgrave Macmillan; 2012. xx, 330 pp.
Abstract:
Non-contact sex offences involve a sexual offence, occurring in the absence of physical contact between perpetrator and victim. The absence of physical contact is intended by the offender The three most common non-contact sex offences after Internet child abuse are voyeurism, exhibitionism and telephone scatologia (making obscene telephone calls). Compared with other sexual offences, non-contact sexual offending is under researched and so relatively little is known or understood about these behaviors. Much of the research surrounding these behaviors is over 20 years old and has less relevance to current theory. This chapter will focus primarily on voyeurism, exhibitionism and telephone scatologia as these are some of the most commonly occurring non-contact sex offences.

Assessment of the paraphilias.
Seto, Michael C., Kingston, Drew A., Bourget, Dominique.
Psychiatric Clinics of North America, Vol 37(2), Jun, 2014. pp. 149-161.
Abstract:
Paraphilias are recurrent, persistent, and intense sexual interests in atypical objects or activities. The most commonly encountered paraphilias in sexological or forensic settings are pedophilia, sexual sadism, exhibitionism, and voyeurism. Paraphilias are often comorbid with other sexual, mood, and personality disorders. Assessment and diagnosis require an integration of multiple sources of clinical information, given the limits and biases of self-report (through clinical interview or questionnaires). Clinicians ideally have access to more objective assessment methods, such as phallometric testing of sexualarousal. The accurate assessment and diagnosis of paraphilias is essential to effective treatment and management. (

Exhibitionistic disorder.
Balon, Richard.
Practical guide to paraphilia and paraphilic disorders. Balon, Richard, (Ed); pp. 77-91; Cham, Switzerland: Springer International Publishing; 2016. xi, 287 pp.
Abstract:
There have been numerous attempts to define exhibitionism. The element of sexual relevance and direct or indirect sexual gratification for the exhibitionist are usually, though not always, indicated or implied. Definitions differ on whether erection must be present. Though exhibitionism/exhibitionistic disorder is, as most paraphilias/ paraphilic disorders are, infrequent among females, the modern era diagnostic criteria are gender-neutral and use the general term of exposing one’s genitalia to an unsuspecting subject. Thus psychiatry, sexology, and sexualmedicine conceptualize exhibitionism (and exhibitionistic disorder) in terms of what DSM-5 describes as ‘recurrent and intense sexual fantasies from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.’

Exhibitionists, so much inhibition…
Hanafy, I., Clervoy, L., Brenot, P.
Sexologies: European Journal of Sexology and Sexual Health / Revue européenne de sexologie et de santé sexuelle, Vol 25(4), Nov, 2016. pp. e61-e63.
Abstract:
Sexual exhibitionism is a form of human behavior that surprises and challenges us. The French Criminal Code punishes this offence in the section devoted to sexual aggressions. It is indeed a hetero-aggressive action without direct contact with the victim. In the eyes of the public, the perpetrator of such aggressions is often mocked or seen as ‘crazy’. In profiling the personality of an exhibitionist or of this particular behavior itself, a very different structure appears, where the scopic functions used (show something off to be seen), result from a common characteristic in all these individuals: inhibition. By realizing this and taking it into account, we can improve prevention at both a primary level (education) and secondary level (management to avoid repeat offences).