Keywords

Historically, exhibitionism comes from the Latin word exhibere meaning “to show or to present” (Hanafy, Clervoy, & Brenot, 2016, p. e61). In 300 B.C., Theophrastus coined the term exhibitionist; however, it was not until 1824 that this behavior became illegal in England under the Vagrancy Act (Hanafy et al., 2016). In 1877, exhibitionism was specifically defined by French physician, Ernest-Charles Lasègue, as an individual revealing parts of his body, but going no further (Lasègue, 1877; Murphy & Page, 2008). Further acknowledgement of exhibitionism as a deviant sexual act resulted from the publication Psychopathia Sexualis by German psychiatrist Richard von Krafft-Ebing (Långström, 2010; von Krafft-Ebing, 1965).

Although exhibitionism dates back to 300 B.C., it was not included in the Diagnostic and Statistical Manual of Mental Disorders [DSM] until 1980 (American Psychiatric Association) (APA, 1980; Grant, 2005). Consequently, there is a dearth of literature on this specific type of sexual offense. The limited research on the topic may be reflective of the perception that exhibitionism is considered more of a nuisance behavior as opposed to a sexual crime (Långström, 2010; Morin & Levenson, 2008; Murphy & Page, 2008). This chapter comprehensively examines exhibitionism including how it is defined, gaps in the literature, best practices for working with those who engage in exhibitionistic behaviors, future research directions, and prevention measures.

Definition

Exhibitionism was first introduced into the DSM in its third edition in 1980 and was defined as “repetitive acts of exposing the genitals to an unsuspecting stranger for the purpose of achieving sexual excitement, with no attempt at further sexual activity with the stranger” (APA, 1980, p. 272). Since that time, the clinical definition of exhibitionistic disorder in the DSM has remained relatively unchanged (Långström, 2010). The latest edition, the DSM-5, now refers to this behavior as exhibitionistic disorder, which is one of eight conditions classified in the DSM-5 as a paraphilic disorder, referring to persistent and intense atypical sexual arousal which causes clinically significant distress or impairment (American Psychiatric Association, 2013; Hanafy et al., 2016).

According to the DSM-5, exhibitionistic disorder involves persistent and intense sexual arousal from exposing one’s genitals to a nonconsenting person, typically a stranger, as manifested by fantasies, urges, or behaviors (APA, 2013). Over a period of at least 6 months, individuals with this disorder must have “acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies have caused clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2013, p. 689). There are several subtypes of exhibitionistic disorder depending upon the age of the nonconsenting person. For example, exhibitionists may prefer to expose themselves to prepubescent children, adults, or both (APA, 2013).

Some individuals with exhibitionistic disorder may deny that they expose their genitals to others or they may deny that acting on these fantasies causes distress. Regardless of the denial component of this disorder, an individual can still be diagnosed with exhibitionistic disorder if they have exposed themselves repeatedly to nonconsenting persons (APA, 2013). Recurrent genital exposure is typically interpreted as three or more victims on separate occasions. If there are fewer than three victims, the diagnostic criteria can still be met if there were multiple occasions of exposure to the same victim (APA, 2013).

The International Classification of Diseases 10th revision [ICD-10] defines exhibitionism as “recurrent or persistent tendency to expose one’s genitals, without desiring or attempting to obtain closer contact” (World Health Organization, 1992). This definition specifies that exposures may be limited to times of emotional distress and may disappear for long periods of time (Hanafy et al., 2016; WHO, 1992). This chapter relies on the DSM-5 definition of exhibitionistic disorder.

Legally, exposing one’s genitals is considered to be a sexual offense. Sexual offenses can be divided into two categories: contact (hands-on) and noncontact (hands-off) offenses (MacPherson, 2003). During a contact offense, the perpetrator makes physical contact with a victim and encompasses acts such as forcible rape and other forms of sexual assault. Conversely, exhibitionism is considered a noncontact sexual offense as the perpetrator does not touch their victim during the commission of the offense (McNally & Fremouw, 2014).

Exhibitionism and Gender

Prevalence

The exact prevalence for exhibitionistic disorder is unknown; however, researchers have estimated that based upon exhibitionistic acts in the general population that the highest possible prevalence for this condition in males is 2–4% (APA, 2013). Even less is known about the prevalence for exhibitionistic disorder in females, yet it is assumed to be much lower than that of males (Murphy & Page, 2008). Interestingly, although we do not know the exact prevalence for this disorder, exhibitionistic behavior it not uncommon (Firestone, Kingston, Wexler, & Bradford, 2006; Rabinowitz-Greenberg, Firestone, Bradford, & Greenberg, 2002). Researchers believe exhibitionistic acts are the most commonly reported of all sex offenses, accounting for one-third (Rooth, 1973) to two-thirds of all reported sexual offenses (Abel, Becker, Cunningham-Rathner, Mittelman, & Rouleau, 1988; Firestone et al., 2006; Gebhard, Gagnon, Pomeroy, & Christenson, 1965; McNally & Fremouw, 2014). Estimating the incidence of exhibitionism is difficult as the majority of research has been drawn from clinical samples, which may only represent individuals with chronic and serious sexual offense histories or comorbid mental health disorders (Bader, Schoeneman-Morris, Scalora, & Casady, 2008; Murphy, 1997).

There appears to be gender differences in the prevalence of exhibitionism. A national survey completed on 4800 randomly selected Swedish individuals ranging from 18–60 years of age, revealed 4.3% of men and 2.1% of women admitted to acts of exhibitionism (Långström & Seto, 2006). Despite this data showing females do engage in exhibitionism, the vast majority of exhibitionists who are apprehended by authorities are male (Blair & Lanyon, 1981; Gebhard et al., 1965; McGrath, 1991; Swindell et al., 2011). Some researchers go as far as considering exhibitionism to be exclusively a male disorder (Rickles, 1955); however, most recognize the existence of female exhibitionists, but highlight that it is a rare phenomenon (Schneider, 1982; Stekel, 1952). Although the bulk of available research describes male exhibitionists, Carnes (2001) found that females in treatment for sexual addiction reported higher levels of exhibitionistic behavior compared to their male counterparts. Yet, many of these women describe receiving few legal ramifications for their exhibitionistic behavior and were often rewarded in the form of sexual attention from others (Carnes, 2001; Hopkins, Green, Carnes, & Campling, 2016). Of note, this study revealed that although the proportion of females in treatment who reported exhibitionistic acts were higher than males, the total number of women in treatment was far less than the total number of men (Carnes, 2001).

In another study comparing men and women in treatment for problematic sexual behaviors, female exhibitionists scored above males on measures of prostitution, forcible sex, pimping, exploitation of authority figures, and engagement in illegal behaviors (Hopkins et al., 2016). While female exhibitionists reported engaging in illegal behaviors at a greater frequency, men are disproportionately arrested for sexual offenses (Hopkins et al., 2016). Explanations for the disproportion in arrest rates may be accounted for by different laws (e.g., it is not illegal to show breasts in certain jurisdictions), gender bias (i.e., men are considered to be more dangerous), or low reporting rates against women by men who welcome seductive behavior (Hopkins et al., 2016). Stekel (1952) describes exhibitionism as more socially acceptable in women via occupations that involve exotic dancing, strip tease, burlesque, and fashion (Schneider, 1982). Contrary to explanations of exhibitionism in men, the primary motivation for women is thought to be attention seeking rather than sexual gratification, which by definition would not meet criteria for exhibitionistic disorder (Hollender, Brown, & Roback, 1977; Schneider, 1982). Additional research needs to be done on females who expose themselves to understand their motivations to determine whether this behavior would meet criteria for exhibitionistic disorder or if this behavior is a form of attention seeking.

One of the challenges in estimating the prevalence of exhibitionistic disorder is significant underreporting (Långström & Seto, 2006). According to Grant (2005), many exhibitionists have exposed themselves on numerous occasions without arrest (Swindell et al., 2011). Researchers believe that acts of exhibitionism may occur up to 150 times more often that what is reflected in official police statistics (Abel et al., 1988; Bader et al., 2008). To further support this claim, a study conducted by Riordan (1999) revealed that 43% of individuals who had been subject to an exhibitionistic act did not report the crime to the police. Perpetrator self-reports may also underestimate the frequency of these behaviors as they may be motivated to underreport these acts in clinical or criminal justice settings (Abel et al., 1987; Bader et al., 2008; Bhugra, Popelyuk, & McMullen, 2010; Clark, Jeglic, Calkins, & Tatar, 2016). In spite of measurement challenges, the available research using official and perpetrator reports suggest that not only does exhibitionistic exposure take place frequently (Firestone et al., 2006; Rabinowitz-Greenberg et al., 2002), but also that each perpetrator has a large number of victims (Abel & Rouleau, 1990; Clark et al., 2016; Kafka & Hennen, 1999; Långström & Seto, 2006).

Due to the combination of a high number of victims per perpetrator and the low frequency of reporting, rates of exhibitionism may be more accurately calculated through the use of victim self-reports (Clark et al., 2016). In stark contrast to official police statistics, victim self-report studies estimate that lifetime victimization for exhibitionistic acts range from 33% to 52% (Clark et al., 2016; Cox, 1988; Rhoads & Borjes, 1981; Riordan, 1999). Exhibitionism studies have revealed that perpetrators primarily target young females with no relationship to the perpetrator (Clark et al., 2016; Riordan, 1999). One study found that 88.5% of female victims of exhibitionism were under the age of 21 at the time of the incident (Riordan, 1999). In addition to being young and female, many exhibitionists (68.1%) prefer exposing themselves to strangers (Cox, 1988; Freund, Watson, & Rienzo, 1988). Since incidences of exhibitionism are rarely reported to the authorities, it has been hypothesized that girls and young women are purposely targeted because they may believe that due to their age, they are more scared and timid, and thus less likely to yell/scream, or report the exposure (Clark et al., 2016). Underreporting exhibitionistic acts may result from younger victims not recognizing this behavior as a crime or having the ability to report to offense to the police (Bader et al., 2008; Clark et al., 2016).

Location

The location of exhibitionistic crimes varies based upon geographic locale of the study. For instance, police reports from a Midwestern police department revealed 25% of genital exposure occurred in parking lots, 21% occurred on a public street, and in 20.8% of the cases, the perpetrator exposed himself while inside a vehicle (Bader et al., 2008; Clark et al., 2016). Another study completed in a major U.S. city found that many instances of exhibitionism occur at public transportation stops (i.e., subway station) (53%) (Clark et al., 2016). Moreover, a study completed on 100 female nurses in the United Kingdom found that 39% of reported exhibitionistic acts occurred in parks or wooded areas (Clark et al., 2016; Gittleson, Eacott, & Mehta, 1978). Exhibitionism offenses may also take place in the victim’s neighborhood or near their residence (Clark et al., 2016).

Development and Course

Adult males with exhibitionistic disorder often report that their interest in exposing their genitals to nonconsenting persons began during adolescence or early adulthood. There is no minimum age requirement for exhibitionistic disorder, thus it can be difficult to differentiate exhibitionistic behavior with age-appropriate sexual curiosity in adolescence (APA, 2013; Murphy & Page, 2008). Impulses to expose oneself typically begin in adolescence or young adulthood and are thought to decrease with age. Little information is available on the persistence and progression of this disorder over time (APA, 2013).

Etiology

Little is known about the development of exhibitionistic disorder (Swindell et al., 2011). This section will review popular etiology theories of exhibitionistic disorder including the behavioral theory, psychoanalytic theory, physiological approach, and the courtship disorder hypothesis.

Behavioral Theory

The most common etiological theory for the development of exhibitionistic disorder is the behavioral theory of classical conditioning. According to classical conditioning theory, a stimulus that would not usually initiate a response (in this case, the stimulus is exposing one’s genitals to an unsuspecting person) is presented shortly before the unconditioned stimulus that will initiate the response (in exhibitionism, the stimulus is masturbation to achieve and maintain an erection with or without ejaculation) and this pattern of events is repeated often enough for the individual to associate these acts together (Hoffmann, Janssen, & Turner, 2004; Kantorowitz, 1978a, 1978b; Lalumi’ere & Quinsey, 1998; Plaud & Martini, 1999; Rachman, 1966; Rachman & Hodgson, 1968; Swindell et al., 2011). It is common for a perpetrator to masturbate during an exhibitionistic act, thus masturbating both before and after each exhibitionistic episode will result in classical conditioning to the exposure behavior (Firestone et al., 2006; Freund et al., 1988; Grant, 2005; Swindell et al., 2011).

Researchers who subscribe to the behavioral theory of conditioning believe that the first step towards developing exhibitionism occurs by random chance at an early age in which the individual exposes his or her genitals to someone and finds the experience to be pleasurable and sexually stimulating (Bandura, 1982; Kinsey, Pomeroy, Martin, & Gebhard, 1953; Kinsey, Reichert, Cauldwell, & Mozes, 1955). Since the individual found that experience to be pleasurable, the act will likely be repeated. The next step towards developing exhibitionistic disorder occurs when the individual begins to fantasize about exposing themselves, planning on how to engage in this behavior without being caught by the authorities, and masturbating to fantasies about exposing oneself (Langevin et al., 1979; Swindell et al., 2011). According to this theory, the urge to engage in exhibitionistic acts becomes more powerful and the frequency of exposing oneself increases (Grant, 2005).

Three categories of events were hypothesized to initiate exhibitionism and start the conditioning process: sharing a bathtub, appearing nude before family members, and children looking at one another’s genitals during early sex play (Swindell et al., 2011). Moreover, the experience of a post-pubertal male seeing his mother naked was considered to be a form of modeling exhibitionism on the mother’s part (Bandura, 1986). Such an experience is hypothesized to lead to sexual arousal in response to the mother’s exhibitionism and serve as the foundation for incorrectly concluding that if he exposes himself to women, they will also become sexually aroused (Swindell et al., 2011).

When developing exhibitionistic disorder, exposing oneself is pleasurable; however, when exposing one’s genitals follows an aversive feeling this behavior is used to self-soothe. Eventually, an aversive mood, feeling, or specific location (e.g., stress, boredom, sadness, feelings of inadequacy, interpersonal conflict, attractive person, and particular location) become the conditioned stimulus that evokes an urge to expose oneself (Grant, 2005; Grob, 1985; Swindell et al., 2011). A cycle in formed in which engaging in exhibitionism results in urges to expose oneself, thus acting on these urges serves as further conditioning (Grant, 2005). Therefore, a mood, feeling, urge, or location can all trigger the conditioned response of exhibitionistic behavior.

Psychoanalytic Theory

Historically, exhibitionism and other sexual deviations were first explained by psychoanalytic theory. This approach emphasizes interacting motives, intrapsychic forces, drives, conflicts, past behavior, and unconscious impulses in an effort to account for genital exposure (Blair & Lanyon, 1981). Psychoanalytic theory posits that exhibitionistic behavior in males is a defense against castration anxiety. By exposing oneself, the exhibitionist receives verification via the victim’s response that his penis does exist (Blair & Lanyon, 1981; Enelow, 1969; Fenichel, 1964; Freud, 1905, 1914; Holtzman & Kulish, 2012; Rosen, 1964). Freud describes exhibitionism in women as defense against a narcissistic wound from castration by instead accentuating other parts of her body, particularly breasts, to display her attractiveness and draw attention away from her lack of penis (Blair & Lanyon, 1981; Freud, 1905, 1914; Holtzman & Kulish, 2012). Another factor thought to contribute to exhibitionistic behavior is a masochistic need to be caught and punished by the police (Blair & Lanyon, 1981; Enelow, 1969; Stekel, 1952).

Physiological Approach

Neuroscientists believe exhibitionistic behavior is a result of excessive neuronal discharges in the subcortical areas of the brain, particularly in the limbic system (Blair & Lanyon, 1981; Monroe, 1976). Excessive neuronal discharges are thought to account for impulsively acting upon deviant sexual urges (Monroe, 1976). Neuroscientists conceptualize sexual paraphilias to be on the obsessive-compulsive spectrum and encourage selective serotonin reuptake inhibitors (SSRIs) as the treatment of choice for this disorder (Abouesh & Clayton, 1999).

Courtship Disorder Hypothesis

Another explanation for the development of sexual paraphilias is the courtship disorder hypothesis, which postulates that exhibitionism is part of a larger progression of sexual behaviors that are socially abnormal yet are thought to function as the equivalent to normal dating patterns (Freund, 1990). Freund and Watson (1990) describe a typical sexual courtship beginning with visually selecting an appealing partner, followed by a nonphysical interaction, leading to physical touching, and culminating in sexual intercourse. According to this hypothesis, voyeurism can be conceptualized as a disturbance in the visual selection stage, exhibitionistic disorder can be understood as a disturbance in the second stage of nonphysical exchange, frottuerism and toucherism are disturbances in the touching phase, and rape as the nonconsensual final step (Clark et al., 2016; Freund, 1990; Freund & Watson, 1990; Hopkins et al., 2016). The courtship disorder hypothesis has been used to explain the highly comorbid nature of sexual paraphilias as well as the escalation to more severe sexual offending (McNally & Fremouw, 2014).

The primary goal of exhibitionism is to forcefully attract the attention of others (Carnes, Delmonico, & Griffin, 2007; Murphy & Page, 2006). There is debate as to whether exhibitionists experience sexual gratification without the wish for sexual contact (Hopkins et al., 2016; Murphy & Page, 2006). There are studies that provide support for the courtship disorder hypothesis, whereby exhibitionistic acts are an invitation for sexual contact (Freund et al., 1988; Hopkins et al., 2016; Lang, Langevin, Checkley, & Pugh, 1987). The overlap of various paraphilias may be better conceptualized from the courtship disorder hypothesis, where voyeurism, exhibitionism, frotteurism, toucherism, and rape are all progressive expressions of the same disorder (Freund & Watson, 1990).

Risk Factors and Comorbidity

Childhood emotional and sexual abuse as well as a preoccupation with sex/hypersexuality have been cited as risk factors for developing exhibitionistic disorder (APA, 2013). Acting on exhibitionistic impulses goes against both social norms as well as criminal law, thus a risk factor for engaging in exhibitionism may be a propensity for risk-taking (Långström & Seto, 2006; Quinsey, Skilling, Lalumière, & Craig, 2004). An inclination for risk-taking behavior may be explained by sex differences, drug and alcohol usage, and antisocial tendencies (Lalumère, Harris, Quinsey, & Rice, 2005; Långström & Seto, 2006; Seto & Barbaree, 1997; Quinsey, Skilling, & Lalumi’ere, & Craig, 2004).

Much of the information on known comorbidities is largely based on research on individuals who have been convicted for exposing themselves. Therefore, these comorbidities may not apply to everyone meeting criteria for exhibitionistic disorder. According to the DSM, exhibitionistic disorder is highly comorbid with anxiety, depression, substance use, bipolar disorder, attention-deficit/hyperactivity disorder, other sexual paraphilias, hypersexuality, and antisocial personality disorder (APA, 2013). Moreover, characteristics most often seen in individuals with exhibitionistic disorder are poor social skills and difficulty controlling their anger or hostility (Bader et al., 2008; Lee, Pattison, Jackson, & Ward, 2001; Raymond, Coleman, Ohlerking, Christenson, & Miner, 1999). A study by Bader et al. (2008) found that based on police reports from 106 exhibitionists: 37 were thought to have been abusing illegal drugs, 29 were suspected of abusing alcohol, 26 individuals showed symptoms of a mental disorder, and four perpetrators showed signs of developmental disabilities at the time they were arrested for exposing themselves.

Exhibitionism is highly comorbid with other sexual paraphilias (Bader et al., 2008; Kafka & Hennen, 1999; Price, Gutheil, Commons, Kafka, & Dodd-Kimmey, 2001). In a study of 241 individuals with exhibitionistic disorder, 32% also engaged in voyeurism and 30% also engaged in frotteurism (Bader et al., 2008; Freund, 1990). Another study of 142 exhibitionists found that 93% of the sample also engaged in pedophilia, rape, or voyeurism (Abel et al., 1988; Bader et al., 2008). Literature on exhibitionism suggests a high comorbidity with telephone scatologia, which entails calling unsuspecting individuals but does not involve physical touching for the perpetrator to become aroused. Scatologia is considered to be a verbal form of exhibitionism (Bader et al., 2008; Dalby, 1988; Price et al., 2001).

Recidivism and Escalation

Historically, exhibitionistic behavior was considered a nuisance and individuals exposing themselves were not considered to be sexually aggressive; however, empirical research has provided evidence that not only do exhibitionists recidivate at high rates but some also escalate to contact sexual offenses (Rabinowitz-Greenberg et al., 2002; Rooth, 1973). Measuring recidivism can be a challenge since many exhibitionists may not come into contact with authorities (Bader et al., 2008; Bartosh, Garby, Lewis, & Gray, 2003; Doren, 2002). Those exhibitionists who do come into contact with the criminal justice system or treatment programs typically have committed a contact offense (Bader et al., 2008; Sugarman, Dumughn, Saad, Hinder, & Bluglass, 1994). Despite the difficulty in measuring recidivism, there is evidence to support that exhibitionists recidivate at a very high rate—estimates range from 18.6% to 56.9% (Bader et al., 2008; Berlin et al., 1991; Gebhard et al., 1965; Swindell et al., 2011). Furthermore, exhibitionists who masturbated during exposure had more exhibitionism charges compared to those who did not masturbate during exposure (Bader et al., 2008). According to the American Psychiatric Association (2013), pedophilic sexual preference, antisocial history, alcohol misuse, and antisocial personality disorder may increase the risk of recidivism in individuals with exhibitionistic disorder.

Not only is exhibitionism highly comorbid with other sexual paraphilias, but also there is evidence to suggest that some exhibitionists may escalate to more serious sexual crimes. McNally and Fremouw (2014) found that approximately 25% of exhibitionists will recidivate with any type of sexual offense; whereas, 5–10% of exhibitionists will escalate to a subsequent contact offense during a five-year follow-up period. Exhibitionistic behavior has been associated with past, current, and future acts of pedophilia, attempted and completed rape, and sexual murder (Gebhard et al., 1965; McNally & Fremouw, 2014; Rooth, 1973). A study completed by Abel et al. (1988) found that 46% of exhibitionists also sexually assaulted children or engaged in an incestuous offense. Moreover, in a sample of 241 exhibitionists, 15% admitted to raping an adult (Bader et al., 2008; Freund, 1990).

Researchers have been working to identify risk factors that may contribute to the escalation from noncontact genital exposure to contact sexual offenses. Both hypersexuality and excessive libido have been posited as the underlying mechanism that lead to more serious contact offenses (Kafka, 2003a, 2003b; McNally & Fremouw, 2014; Morin & Levenson, 2008; Sugarman et al., 1994). Moreover, exhibitionists who masturbated during exposure, touched, or communicated with their victims were found to be more likely to escalate to sexually assaultive acts (Bader et al., 2008; Petri, 1969; Sugarman et al., 1994). Another predictor of escalation to contact offending is a preference toward exposing oneself to children (McNally & Fremouw, 2014; Mohr, Turner, & Ball, 1962). Bluglass (1980) has suggested that low intelligence as well as features of conduct or personality disorders pose a risk for escalation (McNally & Fremouw, 2014).

In an effort to better understand risk factors for exhibitionistic behavior, Sugarman et al. (1994) analyzed criminal records of 210 English males convicted of indecent exposure. The exhibitionists who went on to commit contact offenses were more likely to be intellectually impaired and have a family history of substance use. Moreover, escalated offenders were more likely to have a personality disorder, excessive libido (as measured by more than one orgasm per day), and a childhood diagnosis of conduct disorder (Sugarman et al., 1994). Contact offenders were also found to expose themselves at more than one location, corner, touch, and speak to victims, display an erect penis, and masturbate during exposure compared to exhibitionists who did not escalate to contact offenses (McNally & Fremouw, 2014; Sugarman et al., 1994).

There exists some data to suggest that exhibitionists also engage in other nonsexual criminal behaviors (Abel et al., 1988; Bader et al., 2008; Maletzky, 1997). It is estimated that between 17% and 30% of exhibitionists who are arrested for exposing themselves have a conviction history for committing other nonsexual crimes (Bader et al., 2008; Berah & Myers, 1983; Blair & Lanyon, 1981). An Australian study of 151 male exhibitionists found that 69% were also convicted for another offense other than exposing oneself, including violating parole, driving infractions, assault, and property crime (Bader et al., 2008; Berah & Myers, 1983). Furthermore, evidence from several studies suggest that exhibitionists who later committed contact sexual offenses were more likely to have prior criminal charges compared to noncontact recidivists (Firestone et al., 2006; McNally & Fremouw, 2014; Rabinowitz-Greenberg et al., 2002; Sugarman et al., 1994). These findings suggest that those who engage in exhibitionism may also be engaging other criminal acts (Hackett, 1971; Murphy, 1997; Rooth, 1971).

Assessment

Mental health professionals are often asked to assess recidivism risk. Determining whether an exhibitionist will escalate to a contact sexual offense can be a challenge, especially since research is lacking and available data have historically found mixed results (McNally & Fremouw, 2014; Rooth, 1973). There is no standardized risk assessment battery for those engaging in exhibitionistic behavior; however, a battery of tests including psychological, behavioral, self-report, and collateral information is recommended as best practice (Adams & Sturgis, 1977; Adams, Webster, & Carson, 1980; Barlow, 1977; Blair & Lanyon, 1981).

The cornerstone of an accurate assessment is understanding the behavior of interest (Bader et al., 2008). Important information for determining risk hinges upon the frequency, severity, and extent of deviant sexual behaviors. Especially when assessing exhibitionists, it is critical to obtain a comprehensive history of exposure, masturbation during exposure, libido levels, touching or communicating with victims during exposure (Bader et al., 2008; Petri, 1969; Sugarman et al., 1994). Since many exhibitionistic acts do not come to the attention of authorities, self-report is the primary method of data collection. However, given sexual offenders tend to underreport their offense history, accurate assessment can be challenging (Maletzky, 1997; McConaghy, 1993). Collateral information can be acquired from police reports, victim statements, and other sources of information (Bader et al., 2008). Other risk factors for escalation include substance use and abuse and thus gathering information on the offender’s drug and alcohol usage is another an important component of the risk assessment (Bader et al., 2008). If the assessment is being completed for treatment purposes, information pertaining to cognitive distortions, denial of behavior, and instances of minimization should also be gathered in an effort to manage risk (Bader et al., 2008; Doren, 2002; Marshall, Anderson, & Fernandez, 1999).

Since there is not a specific psychological assessment battery given to exhibitionists, evaluators often pull assessment measures from tests completed with contact sex offenders. Due to the lack of exhibitionist-specific literature, it is recommended that similar assessment procedures completed on general sex offenders be followed until more research is conducted. A commonly used measure for discriminating between recidivists and nonrecidivists for criminal and violent crimes is the Psychopathy Checklist—Revised [PCL-R], which has been touted as a superior measure for predicting violent behavior (Fulero, 1995; Hare, Forth, & Strachan, 1992; Harris, Rice, & Quinsey, 1993; Rabinowitz-Greenberg et al., 2002; Serin, Malcolm, Khanna, & Barbaree, 1994). The PCL-R is a 20-item semi-structured interview, which takes into consideration the offender’s personality traits and criminal history to assess for the presence of psychopathy (Venables, Hall, & Patrick, 2013). While it has been suggested that exhibitionists may engage in fewer antisocial behaviors compared to contact sex offenders, obtaining an accurate offense history is critical in determining risk for recidivism. Previous research has revealed that sexual recidivists had significantly more offenses in the sexual and criminal categories compared to nonrecidivists (Rabinowitz-Greenberg et al., 2002). Moreover, there is a growing body of literature suggesting those with elevated PCL-R scores are at a higher risk to recidivate, will reoffend sooner, and the next offense is more likely to be violent in nature compared to nonpsychopaths (Hare et al., 1992; Harris et al., 1993; Rabinowitz-Greenberg et al., 2002; Serin et al., 1994).

Phallometric assessment, also known as penile plethysmography, is an objective assessment measure used to identify deviant sexual interests in males. Phallometry measures changes in penile circumference in response to both nonsexual and sexual stimuli. Rabinowitz-Greenberg et al. (2002) used audiotaped vignettes depicting sexual activity varying the sex, age, and degree of consent, coercion, and violence on a group of exhibitionists. They found that penile plethysmography arousal to vignettes involving rape, especially those involving children were useful in determining a subgroup of exhibitionists who would escalate their behavior to more serious contact offenses (Rabinowitz-Greenberg et al., 2002). A Canadian study reviewed criminal records for 221 individuals with exhibitionistic disorder found that the contact recidivists scored significantly higher in psychopathy as well as on phallometric arousal to pedophilia and rape audio scenarios compared to noncontact recidivists (Rabinowitz-Greenberg et al., 2002). Overall, exhibitionists high in psychopathy as well as deviant sexual arousal patterns as measured by the phallometric assessment were more likely to escalate to contact offenses (McNally & Fremouw, 2014; Rabinowitz-Greenberg et al., 2002).

Another way exhibitionists have been examined for risk of reoffending and escalating their behavior is through the two-pronged typology of perpetrators (Rooth, 1971). Rooth described the first type of exhibitionists as inhibited through the exposure of a flaccid penis. According to Rooth, these individuals have low levels of comorbid psychopathology and little criminal history (Type I). The second type is described as sociopathic and sadistic through the exposure of an erect penis, these individuals typically have comorbid psychological and sexual disorders (Type II) (McNally & Fremouw, 2014; Rooth, 1971). Type II offenders, who characteristically expose an erect penis, were at higher risk for future contact offenses (Sugarman et al., 1994). Researchers are yet to determine how long an exhibitionist is at risk for future sexual offending after the initial exposure (McNally & Fremouw, 2014). Firestone et al. (2006) found exhibitionists who had been offense-free for 8 years were a very low risk of violent or sexual reoffending.

Electronic Manifestations

The classic image of an exhibitionist is a man in a trench coat who exposes his genitals to unsuspecting strangers. In actuality, exhibitionists may use many techniques to expose themselves such as cutting a hole in the crotch of their pants for men or strategically leaving a shirt unbuttoned for women (Carnes, 1991; Hopkins et al., 2016). The popularity of the Internet and invention of the webcam have given exhibitionists new avenues to engage in deviant sexual behavior similar to that of traditional exhibitionism (Hanafy et al., 2016; Kaylor, Jeglic, & Collins, 2016). When considering electronic manifestations of exhibitionism, we must consider whether the behavior is part of normal adolescent/young adult courtship behaviors, such as sexting, or if this behavior is more indicative of electronic exhibitionism (Kaylor et al., 2016). Retrospectively, individuals with exhibitionistic disorder report that the desire to expose themselves to others began in adolescence/early adulthood (APA, 2013; Murphy & Page, 2008; Kaylor et al., 2016). Moreover, the DSM-5 does not require a minimum age to meet criteria for exhibitionistic disorder; therefore it can become unclear at what point sexting with an unsuspecting person or nonconsenting individual changes from an attempt at flirting to a paraphilic act (APA, 2013; Kaylor et al., 2016; Lang et al., 1987).

When considering adolescent behavior, this population may be more likely to use technology to express their sexuality, since they are experiencing a period of identity development which is notable for increased interest and engagement in sexual exploration (Kaylor et al., 2016; Korenis & Billick, 2013; Sadhu, 2012). Moreover, adolescence is also marked by impulsivity and narcissism (i.e., excessive interest in oneself or one’s physical appearance), thus it is hypothesized that individuals who expose themselves do so for sexual pleasure and erotic satisfaction from an audience rather than from sexual contact (Kaylor et al., 2016; Korenis & Billick, 2013; Lang et al., 1987; Sadhu, 2012).

Kaylor et al. (2016) completed a study on 959 participants ages 18–30 years, who were surveyed about traditional exhibitionistic behaviors as well as technological sexual behaviors, such as sending explicit pictures. Traditional exhibitionism was assessed as flashing one’s nude or partially nude body parts (i.e., breasts, penis, or vagina) in a public place; whereas, digital exhibitionism was assessed as sending a sexually explicit image to a stranger or person known for less than 24 hours (Kaylor et al., 2016). Researchers found a significant proportion of participants reported engaging in both technological and traditional exhibitionistic-like behaviors (e.g., mooning), and they described their motivations for engaging in such behaviors were confidence, excitement, and arousal. While individuals with exhibitionistic disorder report similar motivations for their exposures, this study revealed that many participants’ motivations aligned most closely with normal adolescent/young adult sexual exploration and courtship. Although some exhibitionist behavior amongst adolescents is considered harmless, this study revealed a small group of participants whose behavior went above and beyond that of normal teenage shenanigans, which may be indicative of a nascent paraphilia (Kaylor et al., 2016).

Due to the ever-evolving nature of technology, future research would benefit from gathering information on the motivations behind electronic exhibitionism. Researchers believe the anonymity and distance the Internet provides creates a protective barrier where individuals may feel more confident to expose themselves via the Internet. Moreover, technological exhibitionism may allow the sender to feel safer as the chance of rejection is lower compared to exposing oneself in person (Kaylor et al., 2016). Since the Internet and smartphones can provide exhibitionists with unlimited access to a large number of people to expose their genitals to websites and social media networking services are being misused, such as Snapchat and Chatroulette to expose oneself to unsuspecting victims (Hopkins et al., 2016; Kaylor et al., 2016). It is currently unclear how the use of technology to expose oneself will impact legislation, victims, and the diagnostic criteria for exhibitionistic disorder.

Treatment of Exhibitionistic Disorder

Much of the existing literature on treating exhibitionistic disorder relies heavily on case study subjects with the consensus that this paraphilia is often chronic and refractory to treatment (Blair & Lanyon, 1981; Grant, 2005; Swindell et al., 2011). Many exhibitionists may not come into contact with treatment programs, thus those who voluntarily seek treatment describe an inability to resist powerful urges to expose their genitals that intensify over time. Often times these urges are brought on by sadness, boredom, inadequacy, stress, interpersonal conflict, a specific location, or an attractive person (Grant, 2005; Swindell et al., 2011).

One form of treatment described for those with exhibitionistic disorder is aversion therapy. For instance, ammonia aversion treatment is a combination of aversive relief and punishment in which the exhibitionist carries a small bottle of smelling salts at all times. When the urge to expose oneself arises, the client inhales the ammonia mixture and clears their mind of any offense-related thoughts and replaces those thoughts with a prosocial image (e.g., enjoyable activities) (Marshall, 2006). Ammonia aversion treatment functions as a positive punishment in which the ammonia fumes create a pain-mediated response instead of an olfactory response, thus suppressing one’s exhibitionistic urges (Barker, 2001). Over time, the association of the relief brought on by the ammonia and the prosocial thoughts are believed to reduce the urge to expose. This self-managing technique requires the client to diligently keep daily records of urges and continuously carry the ammonia mixture with them, if clients are inconsistent, the problematic behaviors are likely to return (Marshall, 2006).

Despite many studies describing the difficulties of treating exhibitionism, there has been some support for serotonergic antidepressant treatment. Terao and Nakamura (2000) described a case in which a low dose of trazadone was found to be effective in reducing the impulse to expose one’s genitals in a client with exhibitionistic disorder. The client was administered 50 mg of trazadone daily for 1 year, then the dosage was decreased to 25 mg per day, and decreased further until it was discontinued at the two-year mark. During regular follow-up sessions, the client did not experience any urges or exposures. Although low dose trazadone has been suggested to be the best pharmacological treatment for exhibitionism, trazadone may lead to an overall decrease in sex drive, erectile dysfunction, and reduced libido, which may result in high rates of attrition (Terao & Nakamura, 2000).

Although medication can be helpful in controlling exhibition urges, medication alone will not impact the underlying psychological problem, thus the gold standard treatment is the combination of both psychotherapy and psychopharmacology (Chopin-Marcé, 2001). The success of psychotherapy depends on the client’s motivation for seeking treatment and level of intelligence. Many treatment-seeking exhibitionists report that they do not know why they expose themselves and feel pushed by a force beyond their control that feels obsessive-compulsive in nature (Chopin-Marcé, 2001).

Imagery treatment, which examines deviant fantasies and encourages them to be replaced with appropriate ones, has been a well-established treatment for exhibitionists (Dandescu & Wolfe, 2003). Paraphilic fantasies are seen as a fundamental part of the etiology and maintenance of exhibitionistic behavior (O’Donohue, Letourneau, & Dowling, 1997). Research has found that after their first exposure, exhibitionistic offenders have a greater number of deviant masturbatory offenses compared to the number of fantasies prior to this first exposure. This information suggests a behavior/fantasy loop is created, where exposure triggers fantasies, which in turn leads to more exhibitionistic acts (Abel & Blanchard, 1974). Unfortunately, imagery instructions for exhibitionism are typically incomplete or missing from research reports, making replication difficult (Blair & Lanyon, 1981). Moreover, previous studies have reported conflicting data about the efficacy of this type of treatment (Dandescu & Wolfe, 2003; Marshall & Serran, 2000).

Similar to the behavior/fantasy loop described above, exhibitionism has been hypothesized to be triggered by dysphoric mood states in which the individual exposes oneself to self-soothe leading to a conditioned stimulus (Swindell et al., 2011). In order to break the cycle of dysphoric mood and exhibitionism, the individual needs to learn healthy ways to self-soothe that do not involve exposure or other addictive behaviors. In addition, any cognitive distortions or rationalizations involving exhibitionism need to be addressed (Swindell et al., 2011). Some mental health professionals also conceptualize exhibitionists as being stuck in an immature developmental phase, thus the importance of recognizing the suffering of their victims as people not as objects is highly emphasized (Chopin-Marcé, 2001).

Consequences

The earliest study on victims of exhibitionism reported that victims were not harmed from the exposure, but rather surprised and inconvenienced (Davis & Davis, 1976). More recent research has shown that victims of exhibitionism actually experience considerable distress (Clark et al., 2016; Cox, 1988; Krueger & Kaplan, 2000; Riordan, 1999). Contrary to the long-standing belief that exhibitionism is a nuisance offense, a study revealed that 18% of female victims of exhibitionism reported severe distress from the exposure (Cox, 1988). Moreover, another study found that 28% of female victims endorsed exhibitionism has impacted their social activities and movements, suggesting that exhibitionism has negative long-term consequences for victims (Clark et al., 2016; Riordan, 1999).

Although research has shown that victims of exhibitionism are significantly impacted by exposure, only a small percentage of individuals report the offense to the police. Clark et al. (2016) found that the majority of exhibitionism incidents were not reported to the police; in fact less than 10% of their sample endorsed reporting the offense to authorities. Consistent with research on contact sexual offenses, approximately two-thirds of victims of exhibitionism will disclose their experience to someone in their social network; however, the vast majority will not make an official police report (Clark et al., 2016; Golding, Siegel, Sorenson, Burnam, & Stein, 1989; Koss, Dinero, Seibel, & Cox, 1988; Ullman & Filiaps, 2001).

Prevention Measures

Exhibitionistic acts often occur in public places, thus addressing the problem at a situational level (e.g., posters on public transportation) may increase reporting rates, thereby decreasing the prevalence of the behavior. Such prevention methods are thought to decrease exhibitionistic acts, as well as increase victim disclosure and bystander mobilization (Clark et al., 2016). Moreover, situation crime prevention (SCP) methods such as increased police presence and better lighting have served to deter crime and may discourage exhibitionism (Clark et al., 2016; Farrington & Welsh, 2002; Painter, 1996; Sherman & Weisburd, 1995). By implementing SCP measures, subway crime in the Washington D.C. metro system saw a decrease in paraphilic offenses (Clark et al., 2016). Through the use of other crime prevention strategies, such as removing benches, eliminating public restrooms, and closing stairways during off-peak hours, the Washington D.C. metro was able to prevent offenders from lingering in places where exhibitionism was most likely to occur (La Vigne, 1997). Expanding such SCP efforts to other places where exhibitionism takes place such as parks and parking lots can potentially result in a decreased incidence of exhibitionistic acts (Clark et al., 2016).

Since the majority of exhibitionistic behaviors are not reported to the authorities, public education campaigns directed towards girls and young women may be an effective method to increase reporting rates of exhibitionism (Clark et al., 2016). Educational efforts aimed to identifying boundary violations and uncomfortable sexual situations may decrease guilt or self-blame experienced by victims, which in turn may alleviate negative long-term consequences of exposure (Finkelhor, 2009). Moreover, education on victim-blaming and training in empathic responding for criminal justice, medical, and mental health professionals may make victims feel more comfortable when speaking with individuals in positions of authority (Clark et al., 2016; Ullman & Filiaps, 2001). Through SCP and public education campaigns, the hope is to decrease exhibitionistic acts and increase reporting of such offenses.

Future Directions

Although exhibitionistic disorder has been identified as a crime for centuries, research on this disorder remains sparse. In order to get a better sense of the incidence, prevalence, and scope of this paraphilia large population-based studies are needed. One limitation of assessing exhibitionism remains the lack of standardized assessment tools to evaluate the risk for recidivism. While several methods for assessing exhibitionism exist, there are no gold standard assessment batteries for determining the risk for recidivism or escalation to contact offenses. Moreover, there exists many sexual paraphilias that not only share similar symptoms but are also highly comorbid. The lack of assessment tools for measuring this behavior speaks to the great need for a high level of specificity when evaluating for the presence of other sexual paraphilias. Furthermore, several methods for treating exhibitionism exist in the literature; however, many of these research studies rely on case studies or have little evidence to support the treatment of choice. The literature points to several methods for preventing the act of exhibitionism from occurring (e.g., increased police presence, better lighting), yet there is insufficient research on preventing an individual from developing exhibitionistic disorder. With the recent realization that exhibitionism is much more than a nuisance, we can hope that future research will fill the many gaps in what we know about diagnosing, assessing, and treating this paraphilic disorder.