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 months.
Although the true prevalence is unknown, estimated prevalence in men is approximately 2 to 4% (1); prevalence appears to be lower in women. Few females are diagnosed with exhibitionistic disorder. Thomas et al (2) suggest that sex differences in sociosexuality may be relevant in this long-observed sex difference.
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 at a wider range of ages, during preadolescence or middle age.
About 30% of apprehended male sex offenders are exhibitionists (3). Recidivism rates as high as approximately 40% have been reported (4). Although it is reported to occur, the vast majority of those with exhibitionism do not engage in physically aggressive sexual behaviors.
Although many exhibitionists marry, the marriage is often troubled by poor social and sexual adjustment, including frequent sexual dysfunction (see Male Sexual Function and Dysfunction and Female Sexual Function and Dysfunction).
Exhibitionists may also have a personality disorder (usually antisocial) or conduct disorder (5).
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 rarely experience distress or impairment due to this desire and thus may not have a psychiatric disorder.
General references
1. Långström N, Seto MC: Exhibitionistic and voyeuristic behavior in a Swedish national population survey. Arch Sex Behav 35(4):427-435, 2006. doi: 10.1007/s10508-006-9042-6
2. Thomas AG, Stone B, Bennett P, et al: Sex differences in voyeuristic and exhibitionistic interests: Exploring the mediating roles of sociosexuality and sexual compulsivity from an evolutionary perspective. Arch Sexual Behav 50:215102162, 2021. doi: 10.1007/s10508-021-01991-0
3. Abel GG, Becker JV, Cunningham-Rathner J: Multiple paraphilic diagnoses among sex offenders. Bull Am Acad Psychiatry Law 16(2):153-168, 1988. PMID: 3395701
4. Firestone P, Kingston DA, Wexler A, et al: Long-term follow-up of exhibitionists: psychological, phallometric, and offense characteristics, J Am Acad Psychiatry Law 34(3):349-359, 2006. PMID: 17032959
5. Grant JE: Clinical characteristics and psychiatric comorbidity in males with exhibitionism. J Clin Psychiatry 66(11):1367-1371, 2005. doi: 10.4088/jcp.v66n1104.
Diagnosis of Exhibitionistic Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) criteria
Diagnosis of exhibitionistic disorder requires the following (1):
Patients experience recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.
Patients have acted on their sexual urges with a nonconsenting person, or these sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The condition has been present for ≥ 6 months.
The clinician must specify whether the patient is sexually aroused by exposing genitals to prepubescent children or to physically mature individuals, or both.
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC.
Treatment of Exhibitionistic Disorder
Psychotherapy and support groups
Selective serotonin reuptake inhibitors (SSRIs)
Sometimes antiandrogen medications
When laws are broken and sex offender status is conferred, treatment of exhibitionistic disorder usually begins with psychotherapy, support groups, and SSRIs (1, 2 ).
If SSRIs are ineffective and if the disorder is severe, medications that reduce testosterone levels and thus reduce libido should be considered. These medications are referred to as antiandrogens, although the most commonly used medications do not actually block the effects of testosteronetestosterone levels are required.
Recidivism rates are high. Effectiveness of treatment is monitored based on self-report, penile plethysmography, and arrest records.
Treatment references
1. Garcia FD, Thibaut F: Current concepts in the pharmacotherapy of paraphilias. Drugs 71(6):771-790, 2011. doi: 10.2165/11585490-000000000-00000
2. Thibaut F: Pharmacological treatment of paraphilias. Isr J Psychiatry Relat Sci 49(4):297-305, 2012. Isr J Psychiatry Relat Sci 2012;49(4):297-305. PMID: 23585467
Key Points
Most people with exhibitionist behaviors do not meet the clinical criteria for an exhibitionistic disorder.
About 30% of apprehended male sex offenders are exhibitionists; sex offenses often recur.
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 clinically significant distress or impairs functioning.
Many people with exhibitionistic behaviors do not seek treatment; treat patients who have committed a sexual offense with psychotherapy and SSRIs first; if additional treatment is needed and if informed consent is obtained, treat with antiandrogen medications.
