PARAPHILIC DISORDERS

Exhibitionistic Disorder

Exhibitionistic disorder is diagnosed in a person with recurrent, intense urges, fantasies, or behaviors that involve exposing his/her genitals to others (usually strangers) in inappropriate circumstances and without their consent.

Like voyeuristic disorder, exhibitionistic disorder is also regarded as a form of atypical sexual interest and is one of the eight disorders grouped under Paraphilic Disorders (for those interested, the other 7 conditions are: voyeuristic disorder, fetishistic disorder, frotteuristic disorder, paedophilic disorder, sexual masochism disorder, sexual sadism disorder, and transvestic disorder).

Diagnosis

According to the Diagnostic and Statistical Manual, 5th edition (DSM-V), the diagnosis of exhibitionistic disorder is given with the following:

• Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges or behaviors.

• The individual has acted on these sexual urges with a non-consenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

The DSM-5 also classifies exhibitionistic disorder into several subtypes, depending on the age of the non-consenting person and whether the individual with exhibitionistic disorder is currently in a controlled environment (i.e individuals living in institutional or other settings where opportunities to expose one’s genitals are restricted) or in full remission (has not acted on the urges with a non-consenting person, and there has been no distress or impairment in social, occupational or other areas of functioning, for at least 5 years while in an uncontrolled environment). Some individuals may exhibit a preference to expose their genitals to either prepubertal children or physically mature individuals, or both.

Prevalence and Development

The age of onset of exhibitionistic disorder is usually in the early to mid-20s, with the prevalence of it being 2-4% among males. The prevalence rate for females, however, is unknown due to limited research.

Males with exhibitionistic disorder typically become aware of their interest in exposing their genitals to unsuspecting persons during their adolescence. Therefore, it might be difficult to differentiate between age-appropriate sexual curiosity in adolescents and true exhibitionistic behaviors. That said, there’s still much to be researched regarding the developmental trajectory of exhibitionistic disorder.

Comorbidity and Risk Factors

Similar to the state of research on the developmental trajectory of exhibitionistic disorder, there is limited research on this too. Most existing research on comorbidities are largely conducted on individuals (almost all males) convicted for criminal acts involving genital exposure to non-consenting individuals. Therefore, some comorbidities might not apply to all individuals who qualify for a diagnosis of exhibitionistic disorder.

Nevertheless, what’s currently known is that common comorbidities for exhibitionistic disorder include: depression, bipolar disorder, anxiety and substance use disorder, ADHD, antisocial personality, and other paraphilic disorders (with voyeuristic disorder being especially common).

While the exact cause(s) for exhibitionistic disorder is unknown, what’s known is that there are temperamental and environmental risk factors that contribute to the presence of exhibitionistic disorder. Temperamental risk factors include antisocial history, antisocial personality disorder, alcohol misuse, and pedophilic sexual preference, all of which might increase risk of sexual recidivism in exhibitionistic sexual preferences and behavior. Environmental factors that might put one at risk of having exhibitionistic disorder include being a victim of childhood sexual and emotional abuse, sexual preoccupation, or hypersexuality.

Addressing it

Unfortunately, similar to voyeuristic disorder, people with exhibitionistic disorder usually do not seek help on their own and do not find their behavior problematic until they run into trouble with the law. When they are charged by the court and are told that they must seek professional help, it’s usually the first time they consider it. Common modes of addressing it include psychotherapy and pharmacological interventions – ideally, it would be best to include both modes.

Cognitive-behavioral therapy (CBT) is aimed at relapse prevention. This is achieved through two segments – cognitive restructuring and coping skills training. Cognitive restructuring is aimed at guiding the individual in identifying and changing thoughts that cause the behavior. Coping skills training is conducted to guide clients on adaptive coping mechanisms when feelings of arousal occur. As relapse prevention is the underlying goal of CBT, therapy is also aimed at helping the individual find ways to avoid high-risk situations. Intimacy deficits and boundaries are also addressed.

Group therapy is also a viable option in addressing exhibitionistic disorder. It can function as a social-skills training session and a support group. While individuals do learn social skills, they also find out that they are not alone and there are others to help and support them. For instance, there are 12-step support group programs that can help an individual learn from others (it might also be comforting for them to realize that they are not in this journey alone). It also provides an opportunity for individuals to discuss exhibitionistic activities in an atmosphere of accountability.

Medication can be used in tandem with these therapeutic modalities. Common medication includes SSRIs, which help reduce one’s libido. However, if the disorder is severe, such that SSRIs are ineffective, drugs that reduce testosterone levels can be considered (anti-androgens).

Prognosis

While there is limited research on the prognosis of exhibitionistic disorder, what’s currently known is the recidivism rates can be quite high, ranging from 18.6% - 56.9%. Some individuals might even go on to commit more violent sexual crimes.

However, there are still some factors that can help improve the prognosis for exhibitionistic disorder, such as the number of arrest records an individual has for crimes related to exhibitionism. During intervention, it’s important to explain to such individuals that while nudity is normal, it can be traumatizing to non-consenting victims. Given that they expose to strangers, there is the possibility of them exposing themselves to someone who might have experienced sexual assault (or has PTSD from it). This might result in the victim experiencing flashbacks or other forms of harm. Once these consequences are explained to the individual receiving therapy, it might reduce their interest in exposing.

For the overall management plan to be as effective as possible, management of paraphilia must be provided on a long-term basis. It is also recommended that individuals attend therapy regularly to learn how to cope with the disorder effectively.

What to do if you’re a victim of crimes related to exhibitionism?

If you’ve been at the receiving end of crimes related to exhibitionism (e.g flashing), understand that the incident was not your fault. It’s also normal to feel a range of emotions too – a significant number of victims have reported feeling traumatized, shocked or afraid following the incident. While they might be unpleasant, know that these emotions are normal and do not avoid experiencing them. Accepting these emotions is the first step to feeling better. This can be made easier by expressing your emotions and thoughts via various channels, such as through journaling, art or music.

Another viable option is to reach out to your family, friends or support groups for their support. Not only does it help release pent-up emotions, it can also be comforting to find out that you are not alone in this journey. Alternatively, here’s an article that we did previously on coping with sexual assault, where there are tips on how you can cope with negative effects and emotions after the incident.

One thing to take note about local laws though – cyber-flashing is now considered a crime in Singapore. Cyber-flashing refers to non-consensual exposure of genitals in the virtual space, such as sending unsolicited images of genitals over an electronic medium to another person (e.g AirDrop). If you have been a victim of cyber-flashing and would like to report it to the police, here’s what you can do.

1. Take a screenshot of the material with your device. While it might be repulsive to have such materials on your device, it helps act as evidence that you can send to the police, following which you can delete it from your device.

2. Call 999 or if it’s not safe to do so, SMS 71999 to the police instead. This applies to flashing outside of the virtual space as well.