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Psychologist Anywhere Anytime

Exhibitionism

Psychologist Anywhere Anytime

Exhibitionism is one of the behaviors in a group of sexual problems called paraphilias. Paraphilias are associated with sexual arousal in response to objects or stimuli not associated with normal sexual behavior patterns and that may interfere with the establishment of normal sexual relationships.

Understanding Exhibitionism

Exhibitionism (also known as Lady Godiva syndrome, Apodysophilia, and in the United States and Canada the slang term "flasher") is the psychological need and pattern of behavior to exhibit naked parts of the body to other people. In exhibitionism, the individual shows a tendency, to an extravagant degree, to captivate the attention of others in a display of a body part, or parts, that would otherwise be left covered in nearly all other cultural circumstances.

The part(s) of the body exposed can be the female breasts or the genitals or buttocks of either gender. Displaying one's buttocks for shock value is known as mooning in the U.S. or a browneye in Australia and New Zealand. Anasyrma is lifting up one's skirt to expose bare genitals. Martymachlia is a paraphilia involving sexual attraction to having others watch the execution of a sexual act.

In the U.S., about half of all exhibitionists are married.  Female exhibitionists may seek employment where the condition can be exploited, such as topless dancing, although most people in such jobs are not exhibitionists. About half of adult women have witnessed indecent exposure sometime in their lives. However, genital exhibitionism is rare among women. 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 low cut 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."

Exhibitionists who view exhibitionism as a lifestyle, as opposed to a rare thrill, carefully select their target audience and make the exposure brief, inconspicuous and apparently unintentional.  Many night clubs and goth bars encourage mild exhibitionism to enhance the venue's atmosphere. This contrasts with non-sexualized social nudity, in which the exposure is not connected with sexual expression, such as sunbathing or swimming at nude beaches or other participation in public nudity events where nudity is the norm.

Some exhibitionists wish to display themselves sexually to other people singly or in groups. This can be done consensually as part of swinging or group sex. When done non threateningly, the intent is usually to surprise and/or sexually arouse the viewer, giving the exhibitionist an ego rush. Reasons for the various types of exhibitionism are varied. The person can act on the basis of competing to be the "first" in a trend, on the basis of adhering to a particular fashion, ostentation, posing, being bombastic, and many other instances.

In exhibitionism involving exposing one's genitals or sexual organs to a stranger, the exhibitionist might masturbate (or fantasize about masturbating) while exposing himself but makes no further attempt at sexual activity with the stranger. The individual is sometimes aware of a desire to startle or upset the observer. At times, the individual might fantasize that the observer will become sexually aroused. Exhibitionism, though often discussed as a humorous topic, is a very serious behavior that can frighten the victim. The exhibitionist is typically male, and the victim is usually a female (adult or child), and usually an unsuspecting stranger.

Social and sexual relationships may suffer if the behavior is found disturbing or if the individual's sexual partner refuses to cooperate with this particular preference. In some instances, the unusual behavior may become the major sexual activity in the individual's life. These individuals rarely seek help on their own and are likely to get professional assistance only when their behavior has brought them into conflict with sexual partners or society.

Paraphilias and Exhibitionism

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes the essential feature of  exhibitionism and the other paraphilias as recurrent, intense, sexual urges and sexually arousing fantasies generally involving nonhuman objects, the suffering or humiliation of oneself or partner, or children or other non consenting persons. The diagnostic criteria for Exhibitionism is:

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the exposure of one's genitals to an unsuspecting stranger.

B. The person has acted on these urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

In general, professionals disagree whether exhibitionism should be considered a disorder of impulse control or whether it falls within the spectrum of obsessive-compulsive disorders (OCD's).

The DSM-IV-TR  list of other paraphilias includes:

Fetishism: the use of non-sexual or nonliving objects or part of a person's body to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body.

Frotteurism: the recurrent urges or behavior of touching or rubbing against a non consenting person.

Masochism: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer.

Sadism: the recurrent urge or behavior involving acts in which the pain or humiliation of the victim is sexually exciting.

Voyeurism: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at all.

Transvestite fetishism: a sexual attraction towards the clothing of the opposite gender.

Chronophilias such as Infantophilia: the sexual attraction to infants, Pedophilia: the sexual attraction to prepubescent children, Gerontophilia: the sexual attraction to the elderly.

Other paraphilias: includes rarer behaviors such as telephone scatalogia (obscene phone calls), necrophilia (corpses), partualism (exclusive focus on one part of the body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), urophilia (urine).

For additional "paraphilias", visit the page List of Paraphilias.

Causes of Exhibitionism

There is no consensus on the cause of exhibitionism and causal factors appear to depend on the individual person with each case being different.  We do know that In the U.S., about 50% of all exhibitionists are married and that typically a male is the exhibitionist and the victim is typically a woman, a child, or an unsuspecting stranger.

Biological theories 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. Learning theory studies have shown that emotional abuse in childhood and family dysfunction are both significant risk factors in the development of exhibitionism.

Psychoanalytical theories 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.

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.

Legal Considerations of Exhibitionism

People with an 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.

Treatment of Exhibitionism

My experience has been that exhibitionists rarely seek help on their own and are likely to get professional assistance only when their behavior has brought them into conflict with sexual partners or the legal system.

Several different types of psychotherapy have been found helpful in treating exhibitionism including reality therapy and cognitive behavioral therapy, aversion and positive condition approaches, medications, hormonal treatment, reconditioning and restructuring techniques, and empathy training.

Cognitive-behavioral therapy(CBT) 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. 

Restructuring cognitive distortions involves correcting beliefs by the patient, such as that the victim deserves to be party to the deviant act. Empathy training involves helping the offender take on the perspective of the victim to understand the harm that has been done.

Orgasmic reconditioning is a technique where the patient is conditioned to replace fantasies of exposing himself with fantasies of more acceptable sexual behavior while masturbating.

Group therapy is used to get patients past the denial frequently associated with paraphilias, and as a form of relapse prevention.

Behavioral therapy approaches might center on social skills training and appropriate alternate behaviors the patient might take. Reconditioning techniques are designed to provide immediate feedback to the patient to encourage a fast change of behavior. For example, a person might be connected to a biofeedback machine that is connected to a light and taught to keep the light within a specific range of color while the person is exposed to sexually stimulating material.

Another treatment method that is often offered to people with exhibition disorder is social skills training. It is thought that some people 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.

Twelve-step programs for persons with a sexual addiction have been shown to be helpful in many cases. 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 is particularly helpful for patients who are married and whose marriages and family ties have been strained by their disorder.

Medication and hormones used to treat exhibitionism include the following:

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).

Prognosis

The prognosis for a person with an exhibition disorder depends on a number of factors, including the age of onset, the reasons for the patient's referral to psychiatric care, and the degree of his or her cooperation with the therapist. 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.

Additional Information

For more information about exhibitionism or other sexual problem, please click on the linked websites listed below and the visit the glossary that is listed after these websites.

 Minddisorders: Exhibitionism
 Psychology Today regarding exhibitionism

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