Exhibitionistic Disorder

What Causes Exhibitionistic Disorder?

The cause of exhibitionistic disorder is unknown, but different factors likely trigger it in various cases. Scientists believe that physical, medical, and psychological factors may all play a role in producing the disorder’s decreased behavior. Possible risk factors include:

• Alcohol abuse
• Antisocial personality disorder
• Conduct disorder
• History of emotional or sexual abuse
• High testosterone levels

Is Exhibitionistic Disorder Hereditary?

Some studies have attempted to explain why sexual disorders such as exhibitionistic disorder sometimes seem to cluster in individual families. While these studies suggest that a genetic component could play a role in the development of the disorders, no specific link between genes and exhibitionistic disorder has been found.

How Is Exhibitionistic Disorder Detected?

Exhibitionistic disorder usually emerges in late adolescence or early adulthood. Warning signs can include:

• Unusual preoccupation with sex during childhood
• Sexual fantasies that cause distress or impairment
• Only being aroused by exhibitionistic fantasies or acts

How Is Exhibitionistic Disorder Diagnosed?

Diagnosis of exhibitionistic disorder begins by ruling out medical problems that may be causing symptoms. After these exams, if the doctor suspects that exhibitionistic disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment.

Diagnostic steps may include:

• A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

After medical causes are ruled out, medical professionals can consider whether the patient meets the diagnostic criteria for exhibitionistic disorder. These criteria include:

• The patient is consistently aroused by fantasies, urges, or acts that involve exposure of the genitals to an unsuspecting person or performing sex acts before a non-consenting audience.
• The patient has acted on the urges, or the symptoms cause significant impairment in social situations, work, or elsewhere.
• The symptoms have been present for at least six months.

It is important to note that being aroused by exhibitionistic acts for a consenting adult audience is not a sign of the disorder. Doctors will consider the diagnosis only if the urges or acts involve non-consenting audiences (adults or children) or the symptoms cause distress.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Exhibitionistic Disorder Treated?

People with exhibitionistic disorder typically will not seek out treatment on their own. Often, treatment does not begin until a person has illegally acted on their urges and been arrested.

Treatment of exhibitionistic behavior may include both psychotherapy and medications. Common treatment options include:

• Cognitive-behavioral therapy, which teaches a person to recognize the situations that trigger their exhibitionistic urges and develop new, healthy ways to cope with those situations.
• Group therapy or support groups
• Relaxation therapy
• Antidepressant medications, typically serotonin reuptake inhibitors (SSRIs)
• Antiandrogen drugs such as gonadotropin-releasing hormone (GnRH) agonists and depot medroxyprogesterone acetate work to lower testosterone levels

How Does Exhibitionistic Disorder Progress?

Even with treatment, exhibitionistic disorder has a high rate of recurrence. As many as half of all men arrested for exhibitionism are arrested again for the same behavior at a later date.

Men with the disorder are not often violent toward the target of their behavior, but violence and assault are possible in some cases.

In addition to the impact of the disorder on the target of the behavior, it can also result in long-term complications for the person with the disorder, including:

• Arrest and incarceration
• Depression or other mental health-related issues
• Loss of healthy interpersonal relationships
• Low self-esteem

How Is Migraine Disorder Prevented?

There is no known way to prevent exhibitionistic disorder. However, treatment may relieve the effects of the condition and make it less likely that the sufferer will experience severe complications over time.

Exhibitionistic Disorder Caregiver Tips

Some people with exhibitionistic disorder also suffer from other brain and mental health-related issues, a situation called co-morbidity. Here are a few of the issues commonly associated with the disorder:

• Many people with exhibitionistic disorder also suffer from depression.
• Some people with the disorder have a co-existing anxiety disorder.
• Attention-deficit/hyperactivity disorder (ADHD) is sometimes associated with exhibitionistic disorder.
• Alcohol and substance use disorders are commonly associated with exhibitionistic disorder.
• Bipolar disorder, personality disorders, and other paraphilic disorders are more common in people with exhibitionistic disorder.

Exhibitionistic Disorder Brain Science

Exhibitionistic disorder is classified as a paraphilic disorder. These disorders involve sexual arousal induced by unusual situations, objects, or targets of arousal. Common paraphilias include:

• Fetishes (e.g., sexual arousal triggered by specific objects or situations)
• Voyeurism
• Sexual sadism/masochism
• Pedophilia

Paraphilias are not inherently considered to be disorders. Some people have sexual interests or urges that others may regard as unusual but don’t cause distress or harm. Factors that make a paraphilic interest cross the line to a disorder include:

• The urges or acts are illegal (e.g., pedophilia).
• The urges or actions involve non-consenting targets (either children or non-consenting adults).
• The urges or acts have the potential to cause harm.
• The urges or acts cause significant distress or impairment to the person experiencing them.

Exhibitionistic Disorder Research

Title: Lupron Sex Offender Therapy

Stage: Completed

Principal Investigator: Justine M. Schober, MD

Hamot Medical Center

Erie, PA 

This study compared cognitive-behavioral psychotherapy with leuprolide acetate (LA) to cognitive-behavioral psychotherapy with saline injections for 12 months. Five white male pedophiles (M age, 50 years; range, 36-58) volunteered for a two-year study. LA was administered by Depo injection (7 mg initially, then 22.5 mg every three mos) for 12 months, followed by a saline placebo. Effects of LA on testosterone levels, sexual interest preference by visual reaction time (Abel Assessment), penile tumescence (Monarch PPG), as well as strong urges, and masturbatory frequency to children (polygraph), were measured every three months. Subjects were treated with weekly cognitive-behavioral psychotherapy. On LA, testosterone decreased to castrate levels. Because of the suppression of testosterone, physiologic arousal response as measured by penile plethysmography (penile tumescence) was significantly suppressed compared with baseline. However, sufficient response remained to detect pedophilic interest. This pedophilic interest was also detected by visual reaction times. All subjects self-reported a decrease in strong pedophilic urges and masturbation. When asked about having pedophilic urges and masturbating to thoughts of children, polygraph responses indicated subjects were not deceptive when they reported decreases. On placebo, testosterone and physiologic arousal eventually rose to baseline levels. At baseline and on placebo, subjects were consistently deceptive regarding increased pedophilic urges and masturbatory frequency, as noted by the polygraph. Interest preference, as measured by Abel Assessment and Monarch PPG, was generally unchanged throughout the study. Cognitive-behavioral psychotherapy augmented with LA significantly reduced pedophilic fantasies, urges, and masturbation but did not change pedophilic interest during one year of therapy. Deceptive responses by polygraph suggested that self-report was unreliable. Follow-up utilizing objective measures is essential for monitoring treatment efficacy in pedophilia. Our study supports the supposition that modification of pedophilic behavior is possible. LA may augment cognitive-behavioral psychotherapy and help break the sequence leading to a reoffense.

Title: Descriptive Epidemiology Study for Patients With Paraphilia Sex Offenders and Receiving Androgen Antagonists (EPIPARA)

Stage: Completed

Principal investigator: Florence Thibaut, MD/PhD

University Hospital

Rouen, France 

The study’s main objective is to describe the French population of individuals with paraphilia who have committed a sexual offense in whom androgen antagonists were prescribed. The secondary objectives are the description of social demographic profiles, personal and family histories, psychiatric co-morbidities, and the side effects of androgen antagonists treatment. This study, the first of its kind in France, may allow us to understand better the social demographic and clinical profile of sexual offenders with paraphilias treated with androgen antagonists.

 To be included, the subject must have committed a sexual offense and must present a diagnosis of paraphilia with an indication of treatment with androgen antagonists. Paraphilia is defined by the Diagnostic and Statistical Manual as a sexual behavior disorder characterized by “sexually arousing fantasies, needs or recurrent and intense sexual behaviors generally involving (1) of non-human objects, (2) the suffering or humiliation of oneself or partner, (3) children or other persons without their consent, occurring during a period of at least six months “(Criterion A). This disorder is responsible for sexual behavior which is “clinically significant disturbances in social, occupational or other important areas of functioning” (Criterion B).

The inclusion of approximately 200 subjects is expected in this study. The inclusion period will last for 12 months.

Data will be codified, and only a few investigators will have access to these data. The statistical analysis will use the usual descriptive parameters: mean, standard deviation, median, interquartile range, the range for quantitative variables, frequencies, and cumulative frequencies (if applicable) for qualitative variables.

Title: Study of Maintenance of the Efficiency and Adverse Effects of Pharmacological Treatments in Sex Offenders With Paraphilia (ESPARA)

Stage: Not Yet Recruiting

Study Chair: Florence Thibaut, MD/PhD

Hospital Cochin

Paris, France 

This research concerns the evaluation of the maintenance of the efficiency and incidence of adverse effects of pharmacological treatments in sex offenders with paraphilia.

Despite the increasing use of pharmacological treatments in these indications, few data indicate which sex offender populations benefit from which pharmacological treatments and which adverse events are observed, particularly with antiandrogens or antidepressant treatments that are widely used in these subjects. A recent Cochrane study showed that psychodynamic treatment is less effective in terms of sexual delinquency compared to probation alone and has not demonstrated significant efficacy of cognitive-behavioral therapy (CBT) compared to the lack of treatment, except for a study in which antiandrogen therapy was associated with CBT. Another recent study concluded that the tolerance, even of anti-androgenic drugs, was uncertain, as all studies were small and of limited duration, and new research is needed in the future. Further research demonstrating the efficacy of SSRIs in treating paraphilic disorders is still needed, and long-term studies are lacking. Their use for this indication is still off-label.

As far as we know, this cohort should be the largest population of paraphilic sex offenders studied for the longest time to date in a field where research is insufficient. This large sample receiving routine care and followed for three years should allow for analyzing the maintenance of the effectiveness of the pharmacological treatments received (SSRIs or antiandrogens) and their tolerance. In addition, this analysis of clinical practices should be crucial to improve the knowledge of the indications for these treatments, which could be reviewed concerning their effectiveness and tolerance, especially in the most serious cases of paraphilic sex offenders.