Exhibitionism Escalation

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Examining Risk of Escalation: A Critical Review of the Exhibitionistic Behavior

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Article in Aggression and Violent Behavior · July 2014

DOI: 10.1016/j.avb.2014.07.001
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Running Head: ESCALATION IN EXPOSING BEHAVIOR 1
Examining Risk of Escalation:
A Critical Review of the Exhibitionistic Behavior Literature
Matthew R. McNally, M.S.a
William J. Fremouw, Ph.D., A.B.P.P.b
West Virginia University

a,b
Department of Psychology
PO Box 6040
Morgantown, WV 26505
United States
Phone: + 1 304 293 2001
Fax: + 1 304 293 6606
Corresponding author: Matthew R. McNally

Email: mmcnall2@mix.wvu.edu
Phone: + 1 304 293 2001
Fax: + 1 304 293 6606
ESCALATION RISK IN EXPOSING BEHAVIOR 2
Abstract
While forensic mental health professionals frequently are asked to assess the risk that
exhibitionistic offenders will increase the severity of their sexual offending, disparate
perspectives exist reflecting the perceived dangerousness of those who engage in exhibitionistic
behavior. The present paper critically reviews the literature regarding the reported link between
male exhibitionistic behavior and contact sexual offending in 12 peer-reviewed, English-
language studies published since 1981. A history of exhibitionistic behavior was prevalent in a
minority of perpetrators of various contact sexual offenses. Over an average follow-up period of
greater than five years, an estimated 5-10% of exhibitionistic perpetrators were found to escalate
to contact sexual offending, while approximately 25% recidivated with a subsequent
exhibitionistic offense. The most supported risk factor for escalation was a general clustering of
antisocial behavior, including a history of sexual and nonsexual convictions. Common
methodological limitations of the research and recommendations for improved validity are
provided, along with suggestions for future research directions.
Keywords: exhibitionistic behavior, indecent exposure, recidivism, escalation, sexual
offending
1. Examining Risk of Escalation:
A Critical Review of the Exhibitionistic Behavior Literature
Sexual offenses are commonly divided into contact (hands-on) and noncontact (hands-
off) types of offending (MacPherson, 2003). Contact sexual offenses include those in which a
perpetrator makes physical contact with a victim, such as during a forcible rape or other forms of
sexual assault. Perpetrators typically do not physically touch their victims during noncontact
sexual offenses. Noncontact offenses include exhibitionistic behavior, voyeuristic behavior,
making obscene phone calls, communicating with a child online or in person for sexual purposes,
and possession and/or distribution of child pornography. Exhibitionistic behavior—broadly
defined as the exposing of the genitals to an unsuspecting stranger—is the most commonly
reported of all sex offenses (Abel, Becker, Cunningham-Rathner, Mittelman, & Rouleau, 1988;
Firestone, Kingston, Wexler, & Bradford, 2006; Gebhard, Gagnon, Pomeroy, & Christenson,
1965). Exhibitionistic behavior is estimated to occur at rates as high as 2-4% in the general
population (American Psychiatric Association, 2013; Långström & Seto, 2006; Murphy & Page,
2008).
Psychologists and psychiatrists often are asked to assess the risk of future sexual offense
in perpetrators of noncontact sexual offenses. As part of such risk assessments mental health
professionals may be asked to assess not only the risk of continued noncontact sexual offending,
but also the risk that an individual will advance to contact sexual offending (Rooth, 1973).
Evaluating a noncontact offender’s risk of future contact offense is not a simple task. While a
portion of individuals who commit noncontact sexual offenses are also found to commit contact
sexual offenses, historical perceptions of risk of future contact sexual offending for those
charged with and convicted of noncontact sexual offenses have been mixed. Regarding a
progression from noncontact to contact offending, West (1987) reported that noncontact
offenders, perpetrators of exhibitionistic behavior, are “generally harmless” (p. 39).
Alternatively, Lea, Auburn, and Kibblewhite (1999) surveyed professionals working with sex
offenders and found that 87% of them viewed noncontact sex offenders as having the potential to
escalate in their crimes. Psychololegal professionals have also been divided when assessing risk
of escalation to contact sexual offending, specifically among individuals who expose. For
example, the predominant view in the late 19th century and early 20th century was that
individuals who exposed were “not sexually aggressive” (Rooth, 1973; p 705). Conversely,
various publications in the 1960s and 70s from Australia, Europe, and North America began to
associate exhibitionistic behavior with prior, concurrent, or subsequent acts of sexual violence
including attempted rape, forcible rape, pedophilia, and sexual murder (Cabanis, 1966; Gebhard
et al., 1965; Rooth, 1973). Rooth (1973) and Snaith (1983) have suggested that sexual violence
among persistent exhibitionists is rare. Rooth (1973) cited research indicating that
approximately 10% of persistent exhibitionists progressed to more serious sexual offending
(Cabanis, 1966; Grassberger, 1964). Longo and McFadin (1981) stated that exhibitionistic
behavior has often been handled as a “nuisance offense” by the legal system, but that such
behavior may “progress into other sexually deviant, potentially dangerous behaviors” if untreated
(p. 21). West (1987) detailed that “in rare cases [exhibitionistic behavior] can be a prelude to
more serious crime” (p. 39).
Psycholegal professionals have also debated the risk of future contact offending among
exhibitionistic offenders. A Massachusetts appellate court recently considered whether a
persistent exhibitionist and voyeur with no prior contact sexual offenses could legally be civilly
detained as a sexually dangerous person (Commonwealth v. Almeida, 2013). Among the issues
discussed was whether an individual with only noncontact sexual offenses was likely to commit
future contact sexual offenses, thus warranting civil commitment as a sexually dangerous person.
Ultimately, the court ruled that the perpetrator’s noncontact sexual offense behavior was enough
to warrant civil commitment on the grounds that such behavior “objectively put [a] victim in fear
of bodily harm by reason of ... a contact sex crime" (Commonwealth v. Almeida, 2013). Such
reports demonstrate that concerns that exhibitionistic offenders will escalate to contact sexual
offending has been, and continues to be, a relevant topic of debate in the realms of psychology
and law.
A literature review by Blair and Lanyon (1981) summarized methodological limitations
of studies on the etiology and treatment of exhibitionistic behavior from 1960 to 1980, but did
not address escalation to contact sexual offending. Furby, Weinrott, and Blackshaw (1989)
reviewed the literature on sexual offender recidivism including six studies with exhibitionist
samples (none of which met criteria for inclusion in the present review), finding sexual reoffense
rates ranging from 0-71% for exhibitionists with regard to both contact and noncontact offense
types. Since the Blair and Lanyon (1981) review, a number of studies have emerged that allow
for the examination of the relation between exhibitionistic behavior and contact sex offending.
One such study found greater than a quarter of 561 non-incarcerated males had
committed both contact and noncontact sexual offenses (Abel et al., 1988). While some contact
sexual offenders recidivate with noncontact offenses, the present review is primarily concerned
with contact recidivism following a specific noncontact offense—exhibitionistic behavior. Of
particular interest are the rates at which perpetrators of exhibitonistic behavior recidivate by
escalating to a more serious sexual offense involving contact, and the identification of factors
that may differentiate those exhibitionistic offenders who escalate in their sexual offending.
With regard to such factors, researchers have hypothesized a multitude of mechanisms by which
perpetrators of exhibitionistic behavior progress to contact sexual offending. After reviewing the
literature regarding exhibitionism and indecent exposure, Rooth (1971) developed a two-pronged
typology of perpetrators of exhibitionistic behavior. The first type is described as inhibited,
displaying a flaccid penis during the exposure. The second type, labeled “sociopathic,” is
frequently characterized by the exposure of an erect penis (Rooth, 1971; p. 213). While
individuals who expose frequently have features of both types, Rooth (1971) states that the more
an individual approximates the sadistic and sociopathic type II exhibitionist, the more likely he is
to have other sexual disorders that may include contact sexual offending.
An alternate explanation for escalation to contact offending is the courtship disorder
hypothesis, which purports that exhibitionism is part of a progression of sexual behaviors that are
socially aberrant, but functionally-equivalent to a typical pattern of dating (Freund, 1990). For
instance, the deviant progression of voyeurism, exhibitionism, frotteurism, and rape is analogous
to characteristic stages of courtship: locating a partner, interacting with a partner prior to
physical touch, establishing physical contact, and sexual intercourse. In courtship disordered
individuals, the preference for rape over consensual sexual intercourse is referred to as a
“preferential rape pattern” (p. 198, Freund, 1990). Courtship disorder has been proposed as an
explanation for both high comorbidity among various paraphilic behaviors and the relation
between the less severe noncontact sexual offenses and more severe contact sexual offending.
Furthermore, Kafka (2003a, b) has suggested hypersexuality as an underlying mechanism that
may explain a link between noncontact and contact sexual offenses (Morin & Levenson, 2008).
Other researchers have attempted to identify variables that differentiate which perpetrators of
exhibitionistic behavior progress to contact sexual offending. Some reported predictors of

contact sexual offending include: preferential exposure toward children (Mohr, Turner, & Ball,
1962); convictions for previous nonsexual offenses (Rooth, 1971); masturbating while exposing,
communicating with the victim while exposing, or touching a victim while exposing (Petri,
1969; Sugarman, Dumughn, Saad, Hinder, & Bluglass, 1994); and low intelligence, features of
conduct disorder, or personality disorders (Bluglass, 1980). The present review examines the
evidence for the purported mechanisms by which perpetrators of exhibitionistic behavior
progress to contact sexual offending with respect to the methodological rigor of the examined
studies.
1.1 Purpose and Procedure
By synthesizing and evaluating the relevant literature relating to escalation from
exhibitionistic behavior to contact sexual offending among males1 from 1981 to 2013, the
present review fills a gap in the literature. Rates of recidivism and escalation to contact offenses
are examined among exhibitionistic offenders, and methodological strengths and weaknesses are
evaluated with respect to internal, external, statistical conclusion, and construct validities
(Kazdin, 2003). Conclusions, relevant variables, and conceptual issues relating to a progression
from exhibitionistic behavior to contact sexual offending are discussed in light of methodological
strengths and weaknesses. The goals of the present critical review are to inform psycholegal
clinicians and researchers of the present state of the literature regarding contact sexual offending
among exhibitionistic offenders in order to: 1) clarify rates of escalation to contact sexual
offending and associated risk factors to inform clinical risk assessment, and 2) promote and
guide future research into risk of contact sexual offending among exhibitionistic offenders.
1
The study by Bader et al. (2008) includes 5 females (4.7%) in a sample of 106 exhibitionistic
perpetrators. This is the only reviewed sample to include females.
Pertinent studies were obtained by searching the Google Scholar, EBSCO Host, and
PubMed databases for combinations of the key terms “exhibitionism,” “exhibitionist,” “indecent
exposure,” “recidivism,” “progression,” and “escalation.” Additionally, reference sections of
obtained articles were scoured for relevant studies. A study was included in the critical review if
it: (a) was published in a peer-reviewed journal after 1980, (b) was written in English, (c)
examined individuals charged, adjudicated, or believed to have committed acts of public
exposure2, and (d) provided information regarding at least one type of contact sexual offense
(i.e., not recidivism via further exhibitionistic behavior or other noncontact offending)
perpetrated by individuals believed to have committed acts of public exposure. Twelve studies
satisfied the inclusion criteria and were included in the present critical review 3. Studies were
divided into two subtypes: correlational studies and recidivism studies. Correlational studies
explored all associations among exhibitionistic behavior and contact sexual offending, while
recidivism studies examined exhibitionistic behavior as an index offense occurring prior to
contact sexual offending. The reviewed studies were organized chronologically within the
correlational and recidivism sections respectively. Geographic and demographic information
2
This is an inclusive definition that captures the breadth of psychological and legal studies
relating to exhibitionistic behavior, encompassing samples of individuals clinically diagnosed
with exhibitionism/exhibitionistic disorder as well as individuals who are legally charged with or
convicted of indecent exposure, public exposure, or a similar offense resulting from genital
exposure.
3
Despite meeting inclusion criteria, one study (Romero & Williams, 1985) was excluded after
the sample sizes of genital exhibitionists (n = 48 in the introduction and n = 39 in the results) and
pedophiles (n = 39 in the introduction and n = 48 in the results) were reported in an inconsistent
manner throughout the manuscript. Such inconsistency threatened the validity of conclusions
that could be derived regarding genital exhibitionists (e.g. recidivism rates, variables associated
with reoffense) in the Romero and Williams (1985) article and thereby limited the utility of
including the article in the current review.
regarding the recidivism and correlational studies, along with summaries of the major findings
can be found in Table 1 and Table 2. Table 3 contains a summary of the methodological
concerns relating to the four types of validity across all studies and provides suggested
methodological corrections to guide future research.
2. Critical Review of Relevant Literature
2.1 Review of Correlational Studies (n = 6)
Longo and Groth (1983) examined juvenile histories of exhibitionism, voyeurism, and
compulsive masturbation in 231 males from United States correctional and treatment centers
who were convicted of sexual assaults. Individuals were either convicted of sexual assault
against adults (n = 103) or against children (n = 128). Interviews regarding juvenile sexual
behaviors and experiences were conducted with each individual, and each individual’s medical
and legal records were reviewed. Overall, 50 (22%) males convicted of sexual assault reported
engaging in repetitive exhibitionistic behavior as juveniles. Of these individuals, 35 were
convicted of sexual assault against children and 15 were convicted of sexual assault against
adults. An additional four males convicted of sexual assault against adults were suspected of
persistent exhibitionistic behavior by researchers.
While the researchers obtained an adequate sample size to perform various statistical
difference tests among groups, only descriptive statistics were reported. The sample was
obtained from two geographically-distinct areas of the United States, but the external validity of
the study is questionable because the researchers did not report the basic demographic
characteristics of their sample. The interview procedure was not adequately described, nor was
the procedure used to determine whether exhibitionistic behavior was present, suspected, or
absent in an offender’s history. The age range during which sex offenses were counted as
“juvenile” was not defined. Despite these limitations, Longo and Groth (1983) found that
approximately one quarter (n = 54) of their sample of males convicted of sexual assault had a
history of persistent exhibitionistic behavior.
In a subsequent study, Lang, Langevin, Checkley, and Pugh (1987) compared the sexual
histories of 34 repetitive exhibitionists with a control group of 20 offenders without mental
illness who were never convicted of sexual or violent crimes. All individuals completed four
questionnaires: A personal history form regarding demographic information and social and
criminal history; an abbreviated version of the Clarke Sexual History Questionnaire (SHQ;
Freeman, Mann, & Handy, 1977) to examine exhibitionistic frequency and behavior; a
transvestism questionnaire (Blanchard, 1985); and the Feminine Gender Identity Scale (Freund,
Langevin, & Satterberg, 1977). The Shipley Institute of Living Scale (Shipley-Boyle, 1967) was
administered as a measure of intelligence, and MMPI L, K, and F scales (Dahlstrom, Welsh, &
Dahlstrom, 1972) were used to assess socially desirable responding. The groups did not
significantly differ with regard to age, education, marital status, IQ, or socially desirable
responding. The control group had a significantly greater mean number of nonsexual offenses.
Of the exhibitionists, 24 (70.6%) reported engaging in voyeuristic behavior, 13 (38.2%)
in frotteurism, nine (26.5%) in toucherism, 11 (32.4%) in obscene phone calls, and six (17.7%)
admitted to rape. There was a low base rate of similar behaviors reported among the control
group, however significant differences were not always observed as small group sample sizes
often did not provide enough statistical power to detect a mean difference. Seven (20.59%)
exhibitionists had a history of violent criminal charges; five were charged with indecent assault,
three with common assault, and two with attempted rape. The seven violent exhibitionists were
found to be significantly older, to have more lifetime sexual offense convictions, and to be more
likely to touch victims or use “vulgar” language during exposure than the 27 nonviolent
exhibitionists.
The Lang et al. (1987) study identified a correlation between exhibitionistic behavior and
other self-reported contact and noncontact sexual offenses, and demonstrated that self-reported
sexual offending rarely occurred among a sample of nonviolent, nonsexual offenders. The small
sample size is the greatest limitation of the study. With such small group sample sizes, the study
did not have the statistical power to detect but the most sizeable of significant differences. For
example, six exhibitionists admitted to rape compared to zero controls; yet, a significant
difference was not observed. Because of the small sample size, the results obtained in the violent
versus nonviolent exhibitionist comparisons must also be interpreted with caution and are most
meaningful in the context of corroborating evidence from other studies.
Lifetime comorbidity among various paraphilias, rape, homosexuality, and
transsexualism were determined by Abel et al. (1988) via structured interviews of 561
nonincarcerated males voluntarily seeking treatment and/or evaluation for paraphilias at two
United States treatment centers in Tennessee and New York from 1977 to 1985. All individuals
in the study watched a video-taped presentation emphasizing the present and future
confidentiality of information obtained during the interview procedure before providing their
written consent to participate. A structured interview was then administered to participants to
diagnose them with paraphilias using DSM-II or DSM-III criteria while allowing for co-
occurring paraphilia diagnoses. Abel et al. (1988) found that 146 (26%) of their sample
participated in both assaultive/touching behaviors (such as child molestation, rape, and
frotteurism) and nonassaultive/nontouching behaviors (such as voyeurism, exhibitionism, and
public masturbation). It is important to note that, in this study, public masturbators (n = 17) were
differentiated from exhibitionists in that exhibitionists achieved maximal arousal from being
witnessed by an unsuspecting individual while no such condition was placed on individuals
masturbating in public. Of 142 individuals diagnosed as exhibitionists in the sample, 93% had
more than one paraphilia. Exhibitionists in the study had a mean of 4.2 lifetime paraphilias. In
potentially overlapping categories, 65 (46%) of these individuals were diagnosed with female
nonincestuous pedophilia, 31 (22%) with male nonincestuous pedophilia, 31 (22%) with female
incestuous pedophilia, and 7 (5%) with male incestuous pedophilia. Thirty-five exhibitionists
(25%) had raped before, and 23 (16%) had incidences of frottage.
The Abel et al. (1988) study had several methodological strengths including a substantial
sample size, using samples from two different geographic locations, and using a structured
interview procedure with stringent criteria—recurrent and repetitive urges and at least one
incidence of a behavior—to diagnose exhibitionism. The authors emphasized the confidentiality
and voluntary nature of the study as attempt to mitigate the participants’ underreporting for
social desirability reasons. Weaknesses of the Abel et al. (1988) study include threats to internal
validity resulting from a failure to report any of the following: the name or psychometric
properties of the structured interview used, procedures used to train interviewers in the structured
interview protocol, and a measure of interrater reliability. An additional weakness was the
reliance on self-reports without external validation. The authors note that the sample of
exhibitionists reported approximately 150 times the number of exhibitionistic behaviors as were
found in their arrest records. The potential for inaccuracy based on uncorroborated self-reports
is a threat to both internal and external validity in the Abel et al. (1988) study. A further threat to
the external validity was the use of a restricted sample. Although individuals from two separate
evaluation and treatment centers were interviewed, data from nonincarcerated individuals who
voluntarily report for evaluation or treatment may not generalize to all exhibitionists.
Furthermore, an uncommon distinction was made between exhibitionists and public masturbators
that further restricted the exhibitionist sample. The population of perpetrators of exhibitionistic
behavior includes nonincarcerated, treated perpetrators as well as individuals incarcerated for
exhibitionistic behavior (including public masturbation) and individuals who have neither been
incarcerated nor have sought treatment or evaluation. Finally, the Abel et al. (1988) study was
descriptive in nature and did not employ statistical procedures to test for differences among
groups.
The Abel et al. (1988) investigation highlights the co-occurrence of various paraphilias
(e.g., exhibitionism) and related behaviors like rape. This particular study does not provide
relative temporal information regarding the participation in paraphilic behaviors. The way in
which paraphilias were counted reflected paraphilic comorbidity in the sample, but not at the
individual level. While correlations among exhibitionism, rape, pedophilia, and frottage are
observed at the group level, conclusions regarding progression from exhibitionism to contact
sexual offenses among individuals are not able to be drawn from this study.
Later, Stermac and Hall (1989) reviewed the criminal and psychiatric histories of 50 adult
male inpatients at a Toronto psychiatric facility who were charged with or convicted of a sexual
offense against an adult female. Each perpetrator’s current and prior sexual offenses were coded
on a seven-point scale from least serious (e.g., indecent exposure or obscene phone calls) to most
serious (e.g., kidnapping/abduction with sexual assault) by two researchers. A strength of the
study was the report of measures of interrater reliability, which ranged from .67 to .94 across
coded variables. Perpetrators were assigned to one of three escalation categories. Escalators (n =
16) were perpetrators whose most recent offense was rated as more severe than any prior sexual
offense. Nonescalators (n = 16) were perpetrators whose most recent offense was lower than or
equal to the rated severity of any past sexual offense, and first time offenders (n =18) were those
with no prior sexual offenses. Six escalators (37.5%) had previously been convicted of obscene
telephone calling or exhibitionism, while one (6.2%) escalator had a current charge of
exhibitionism or obscene telephone calls. This difference indicates that that five (31.3%)
escalators currently convicted of contact offenses, ranging from indecent assault and rape to
abduction with sexual assault, had a prior conviction for exhibitionism or obscene telephone
calls. Four (25%) nonescalators had index offenses of obscene telephone calls or exhibitionistic
behavior compared to two (12.5%) nonescalators who were previously convicted of the same
offenses, indicating that two of these individuals were previously convicted of a contact sexual
offense.
While the sample used in the Stermac and Hall (1989) study was small and restricted, the
most notable limitations involve definitional issues that threaten validity of constructs discussed
in the study. A progression from exhibitionistic behavior to contact sexual offending cannot be
accurately evaluated because exhibitionistic behavior was not treated as a separate construct
from obscene telephone calls. Furthermore, the categories used (e.g., escalator, nonescalator)
were dependent on the nature of the most recent offense in comparison to all past offenses.
Classifying escalation in this way may exclude individuals who have previously escalated in
severity of sexual offenses, but did not do so during the current offense. In summary, the
Stermac and Hall (1989) study provides correlational evidence that seven of 11 individuals
convicted of either exhibitionistic behavior or obscene telephone calls had also committed a
contact sexual offense.

A study of 45 male pedophilic sex offenders in residential treatment programs examined
Axis I and Axis II psychiatric comorbidities (Raymond, Coleman, Ohlerking, Christenson, &
Miner, 1999). Each individual was assessed by one of the study’s authors using the Structured
Clinical Interview for DSM-IV Axis I Disorders: Patient Edition (SCID-P; First, Spitzer,
Gibbon, & Williams, 1995) along with semi-structured interviews developed by the authors to
assess sexual disorders and impulse disorders. Three individuals (6.7%) met criteria for
exhibitionism at the time of the study, while six individuals (13.3%) met lifetime criteria for
exhibitionism. Of exhibitionistic individuals, the mean age of onset for exhibitionism was eight
years (SD = 5.8), the earliest mean age of onset of all paraphilias examined. Raymond et al.
(1999) used pedophilia as the reference diagnosis. In doing so, only correlational information—
that 13.3% of the pedophilic sample had ever met criteria for exhibitionistic behavior—can be
garnered from the study. A significant strength of the study is the use of a structured interview
(SCID-P). Limitations include a small, homogenous sample, the omission of a discussion of
interviewer training techniques or measures of interrater reliability, and the lack of reporting of
intercorrelations among diagnoses. While the sample was identified based on meeting the
criteria for a pedophilia diagnosis, enough information was gathered to describe intercorrelations
among Axis I and Axis II disorders. The excluded reporting of such intercorrelations limits the
applicability of the study to the current review.
A recent study examined police reports of indecent exposure and sexual offenses in 106
individuals in Lincoln, Nebraska from September 1998 to September 2003 (Bader, Schoeneman-
Morris, Scalora, & Cassady, 2008). Indecent exposure incidents were identified by graduate
students who reviewed police reports. To be included in analyses, incidents had to include the
exposing of genitals “to an unsuspecting stranger with implied sexual intent,” excluding
“consensual sexual activity in a vehicle, public urination, mooning, or violation(s) of decency
statutes in dance clubs” (p. 274). A total of 254 incidents meeting the criteria were identified.
Of the incidents, 152 were committed by unknown individuals and excluded from analyses,
while the remaining 202 incidents were committed by 106 known offenders.
The sample of 106 offenders ranged from 16 to 76 years and included 101 (94.3%)
males. The majority of individuals exposed to one victim during each exposure event (M = 2.5,
SD = 3.9). A minority of the sample (31.1%) had more than one recorded exposure incident. Of
the sample of indecent exposure perpetrators, seven (6.6%) had rape charges and seven (6.6%)
had molestation charges4. The 12 indecent exposure perpetrators charged with contact
offenses—rape and molestation—had a higher mean number of indecent exposure incidents and
physical assault charges than those perpetrators without rape or molestation charges. A review
of criminal histories indicated that the total sample averaged 30 (SD = 44.4) nonsexual charges,
most frequently for traffic violations.
The strengths of the Bader et al. (2008) study include obtaining a sample of 106
perpetrators of indecent exposure, reporting criteria for selecting indecent exposure incidents,
and measuring and reporting interrater reliability for coded demographic and offense
characteristics. The Bader et al. (2008) investigation suffers from several flaws. The use of a
restricted sample limits the generalizability of the results. The sample was restricted in two
ways; it was limited to a single geographic area, and it was limited to perpetrators of indecent
exposure who were identified by law enforcement. The validity of the subsequent offense rates
and types is threatened by variable and occasionally brief follow-up times for each perpetrator.
4
One individual could be counted in both rape and molestation categories.
For instance, individuals who committed an act of indecent exposure in September of 1998 had a
five-year follow-up period, while individuals who committed the same act in March of 2003
were followed for a mere six months. A measure of interrater reliability was provided for the
coding of perpetrator, victim, and incident demographics, but no such statistic was provided for
the initial identification of cases. The absence of this statistic presents a threat to the reliability
of incident selection, which impacts the internal validity of the study. No measures of effect size
were provided to give context to observed difference scores, threatening statistical conclusion
validity. Although the authors reported that they correctly refrained from attempting
multivariate analyses due to small cell sizes, such a problem could be rectified by increasing the
sample size in the study. And while the authors reported including a unique subsample of five
female perpetrators of indecent exposure, no descriptive or statistical analyses were reported
about the female perpetrators.
In summary, the Bader et al. (2008) found that indecent exposure perpetrators with rape
or molestation charges were significantly more likely to have physical assault charges and had
significantly more indecent exposure charges than indecent exposers without rape or molestation
charges. Nevertheless, the study does not indicate whether the contact offending charges
occurred prior or subsequent to indecent exposing, allowing for conclusions regarding
correlation between contact sexual offending and indecent exposure, but not escalation from
exposure to contact offending.
2.1.1. Summary of methodological strengths and concerns in correlational studies.
The magnitude of obtained samples, as well geographic diversity, were significant
strengths in many of the correlational studies. Additionally, correlational investigations using
interviews did so utilizing structured instruments. The reviewed correlational studies shared
several common methodological flaws. In many of the studies, a percentage of the total sample
was reported to have a particular diagnosis or legal charge (e.g., pedophilia or indecent assault);
however it was not clear how many of the reported diagnoses or charges overlapped within an
individual and how many were unique. For example, if 6.6% of the sample was charged with
rape and 12.7% was charged with indecent exposure, it was unclear how many of the indecent
exposure perpetrators were also rape perpetrators. This lack of explication of offense or
diagnosis overlap clouds the precision of the reviewed correlational studies. Similarly,
aggregating various types of noncontact offenses (e.g., combining voyeurism, obscene phone
calls, and exhibitionistic behavior) was not uncommon and obstructed an analysis of the unique
relation between exhibitionistic behavior and contact sexual offending. The temporal order of
offenses was not frequently reported, limiting the conclusions that could be drawn with regard to
escalation in sexual offending.
Furthermore, in some studies, terms for charges or diagnoses were not operationally
defined, leaving a reader to speculate about whether an individual described as an exhibitionist
met criteria for formal psychiatric diagnosis, had a criminal charge of exhibitionistic behavior, or
reported exhibitionistic behavior. Other persistent concerns across the reviewed correlational
studies include not clearly reporting study procedures, interrater reliability, or sample
characteristics, and not adequately discussing assessment instruments that were used. The
majority of the reported samples were homogenous, consisting of individuals incarcerated or in
treatment at a single facility in one geographic location, thus limiting the generalization of the
obtained results to more diverse populations. Finally, the studies had inconsistent follow-up
times threatening the validity of reported reoffense rates. Employing either minimum or
equivalent follow-up times would improve the validity of measured rates of reoffending.
2.1.2. Conclusions from correlational studies.
Despite the stated methodological concerns, the reviewed correlational studies provide
evidence to draw several conclusions relating to escalation from exhibitionistic behavior to
contact sexual offending. First, contact sexual offending does occur among perpetrators of
exhibitionistic behavior. Second, perpetrators of contact sexual offenses and related behaviors
(including rape, sexual assault, frotteurism, and pedophilia) report histories of exhibitionistic
behavior. It is clear that incidences of exhibitionistic behavior occur both prior and subsequent
to incidences of contact sexual offending. Still, the correlational information provided by this set
of studies is not sufficient to determine whether exhibitionistic behavior or contact sexual
offending is more commonly the initial sexual offense type.
With regard to risk factors, one study found those who exposed and committed contact
offenses had a higher mean number of exposure incidents and were more likely to have a
physical assault charge than individuals who exposed but did not have contact offenses (Bader et
al., 2008). Another study cited more historical sex offense convictions as a risk factor for
escalation (Lang et al., 1987). Equivocal evidence was found supporting and refuting
communication with the victim during an exposure incident as a risk factor (Bader et al., 2008;
Lang et al., 1987).

Table 1
Demographic Information and Relevant Findings from Correlational Studies

Authors (Year)Number and Type Location(s) Age (years) and Relevant Findings
of Subjects Race/Ethnicity
Longo & Groth N = 231 males Connecticut NR N = 54 (23%) exposed repeatedly as juveniles
(1983) convicted of and Florida
sexual assault (United States)
Lang et al. N = 54 male Edmonton, Exhibitionist: Self-reported contact offense history (exhibitionists):
(1987) offenders Alberta M = 26.65 n = 6 (17%) rape; n = 9 (26.5%) toucherism; n = 13 (38.2%)
(n = 34 persistent (Canada) SD = 7.50 frotteurism
exhibitionists;
n = 20 nonviolent Control: N = 7 (20.6%) violent exhibitionists (convicted of 5 indecent
controls) M = 25.28 assaults, 2 attempted rapes, 1 assault) were older, had more sex
SD = 7.43 offense convictions, made more obscene phone calls, were
more likely to touch female strangers and use vulgar language
during exposure, and were less likely to expose to pubescent
females than nonviolent exhibitionists
Abel et al. N = 561 males New York and Full sample: N = 132 exhibitionists (93%) had >1 paraphilia (M = 4.2)
(1988) seeking treatment Tennessee M = 30.5
for paraphilias (United States) Range 13-76 Contact offenses: n = 65 (45.8%) nonincestuous pedophilia
(n = 142 with female; n = 31 (21.8%) nonincestuous pedophilia with
exhibitionists) 62.1% White male; n = 31 (21.8%) incestuous pedophilia with female; n = 7
23.8% Black (4.9%) incestuous pedophilia with male; n = 35 (24.6%) rape;
11.2% Hispanic n = 23 (16.2%) frotteurism
Stermac & N = 50 male sex Toronto, M = 27 years n = 5 (10%) escalated from exhibiting/obscene phone calls
Hall (1989) offenders (n = 16 Ontario (range 17 – 42) (category not disaggregated) to contact sex offenses
escalators, n =16 (Canada)
nonescalators, n n = 2 (4%) convicted of exhibiting/obscene phone calls had
previously been convicted of contact sexual offending
= 18 first time
offenders) n = 4 (8%) convicted of exhibiting/obscene phone calls had
never been convicted of a contact sexual offense
Raymond et al. N = 45 males Minnesota M = 37 n = 6 (13.3%) met lifetime criteria for exhibitionism; N = 3
(1999) diagnosed with (United States) (6.7%) met criteria for exhibitionism at the time of evaluation
pedophilia 89% Caucasian;
7% African
American; 2.2%
Hispanic; 2.2%
Other
Bader et al. N = 106 Lincoln, M = 35.6 n = 12 (11.3%) had rape or molestation charges.
(2008) individuals (n = Nebraska SD = 12.1 12 contact offenders committed more mean indecent exposure
101 males) in (United States) incidents and were more likely to be charged with physical
police reports for 81.1% assault than noncontact offenders
indecent exposure Caucasian; 8.5%
African Contact offenders no more likely than noncontact offenders to
American; communicate with victims, expose to child victims, or
4.7% Asian; masturbate during exposure
2.8% Latino
Note. NR = Characteristics of the sample were not reported; M = Mean; SD = Standard Deviation.
2.2. Review of Recidivism Studies (n = 6)
Like Bader et al. (2008), Berah and Myers (1983) also employed the use of law
enforcement records to examine exhibitionistic behavior. Berah and Myers (1983) reviewed
police records of prior and subsequent offenses perpetrated by 151 males convicted of “willful
and obscene exposure in Melbourne, Australia” (p. 366). Individuals were followed for a mean
period of 7.13 years (SD = 4.39) past the date of their first conviction for indecent exposure. The
number of indecent exposure convictions in the sample ranged from one to 18 (M = 2.94; SD =
3.11). Fifty-seven percent of the sample had two or more indecent exposure convictions.
Approximately one-third (n = 47; 31%) of the sample had convictions for indecent exposure
only. Those convicted of charges other than indecent exposure averaged 9.33 (SD = 14.89)
convictions. Of 78 individuals with other convictions prior to a first indecent exposure
conviction, 19 were convicted of indecent assault, 13 of offensive behavior, 7 of indecent
behavior, 21 of assault, 35 of property crimes, and 35 of driving offenses and parole violations.
Of 665 individuals with other convictions subsequent to a first indecent exposure conviction, 15
were convicted of indecent assault, 16 of offensive behavior, five of indecent behavior, 15 of
assault, 22 of property crimes, and 43 of driving offenses and parole violations. One individual
was convicted of assault with intent to rape prior to a first indecent exposure conviction, while
one individual was convicted of the same charge after the first indecent exposure conviction.
The authors note that the definitions of “indecent behavior,” “indecent assault,” and
“offensive behavior” are broad enough to include offenses that are and are not “of a more serious
nature than indecent exposure” (p.368-9). A major limitation of the Berah and Myers (1983)
5
40 individuals were convicted of crimes both before and after their first incidence of indecent
exposure.
study is that the lack of specific offense information makes it impossible to ascertain whether an
escalation or progression in sexual offending occurred in the sample. A further limitation is the
inclusion of only those convicted of indecent exposure, as opposed to those charged with the
same offense. Strengths of the Berah and Myers (1983) study include obtaining a sample of 151
individuals, exploring legal history both prior and subsequent to the indecent exposure offense,
and following offenders for a mean of seven years after the index indecent exposure conviction.
Berlin, Hunt, Malin, Dyer, Lehne, and Dean (1991) examined recidivism in a sample of
626 males who admitted to “inappropriate sexual acts,” “desire(d) to receive help,” and attended
at least one outpatient group psychotherapy session (p. 12). The sample of 406 pedophiles, 111
exhibitionists, and 109 sexual aggressives—males who sexually assaulted women—was drawn
from 2,259 individuals treated at the Johns Hopkins Sexual Disorders Clinic in Baltimore,
Maryland between 1978 and 1990. Pedophiles and exhibitionists were diagnosed using DSM-III-
R criteria, while sexual aggressives were diagnosed by the presence of sexual assault behavior.
Of the 111 exhibitionists, 66% had no prior sexual offenses and 79% had no prior nonsexual
charges. All individuals were treated as outpatients with a combination of individual therapy,
family therapy, and group outpatient therapy. Approximately 40% were treated with medication
used to lower testosterone production.
Period at risk (PAR) for recidivism for each individual was defined as the time from the
first day of treatment until follow-up survey data was obtained or death occurred, not including
time spent incarcerated. Recidivism was defined as a charge of a subsequent offense regardless
of conviction. Over a mean PAR of 5.59 years, 26 (23.4%) of 111 exhibitionists sexually
recidivated compared to less than five percent of pedophiles and sexual aggressives over a
similar period. The 26 recidivists accounted for 72 (81.9%) sexual offenses including 59
incidences of indecent exposure, eight (11.1%) incidences of another noncontact sexual offense
(e.g. voyeurism), one (1.4%) incidence of sexual contact without penetration or force, and six
(5.5%) incidences without a description. Sexual recidivism was examined in the context of
treatment compliance. Since the beginning of treatment, 14 of 43 (32.6%) noncompliant
exhibitionists sexually recidivated and 18 (41.9%) nonsexually recidivated over a mean PAR of
5.94 years. Of 42 compliant exhibitionists, six (12.5%) sexually recidivated and five (10.4%)
nonsexually recidivated over a mean PAR of 5.77 years.
Berlin et al. (1991) examined recidivism in 111 exhibitionists sampled from a single
Maryland clinic over a period of 12 years. The substantial mean follow-up time (5.59 years) did
not include time served for incarcerations during or subsequent to treatment. In this study, the
lack of a randomized control group and the concurrent use of testosterone-lowering medication
for some of the sample limit the inferences that can be drawn regarding the effectiveness of
treatment. The lack of reporting of demographic characteristics specific to exhibitionists or
minimum and maximum follow-up times limit the generalizability of the results to other
samples. The desire to receive help was an inclusion criterion that may differentiate the sampled
exhibitionists from the population of exhibitionists. Furthermore, the definition of recidivism
was based solely on legal records and used legal charges as opposed to convictions as the
threshold for recidivism. In summary, approximately one quarter of sampled exhibitionists
recidivated sexually over a mean follow-up time of 5.59 years, but less than one percent of
exhibitionists escalated to contact offending over the same period at risk.
Mair and Stevens (1994) reviewed records of criminal convictions of 75 Scottish
individuals charged with sex crimes (38 hands-on charges, 37 hands-off charges) in 1981 or
1982. Convictions occurring prior to the index charge, as well as convictions occurring in the 10
years following the index charge were reviewed. Twenty-five of the 37 hands-off offenders
exposed their genitals during the index offense resulting in 17 charges of indecent exposure and
eight charges of breach of peace or lewd and libidinous practices and behavior. Zero hands-on
offenders exposed their genitals during the index offense.
Prior to the index offense, more hands-off offenders (n = 21; 57%) were convicted of sex
offenses than hands-on offenders (n = 7; 18%), p < .001. A substantial percentage of offenders
committing hands-off index offenses had previously committed hands-on offenses such as lewd
and libidinous practices and behavior ( 8%)6, gross indecency ( 2%), indecent assault (
13%), and unlawful sexual intercourse ( 2%). Similarly, more hands-off offenders (n = 10;
27%) were convicted of sex crimes than hands-on offenders (n = 2; 5%) after the index offense,
p = .008. Subsequent convictions in the hands-off offenders were limited to breach of the peace,
indecent exposure, and lewd and libidinous practices and behavior offenses. The authors state
that behavioral descriptions of convictions occurring before and after the index offenses were not
available, but that the nature of such charges was less severe after the index offenses in the total
sample and in the hands-on and hands-off subsamples.
Mair and Stevens’ (1994) use of either criminal charges or convictions as an indicator of
the index offense was a methodological strength employed to enhance the generalizability of
results to samples other than those criminally convicted. Conversely, recording only convictions
in the subjects’ prior and subsequent criminal histories served to limit the generalizability of
results regarding prior and subsequent offense rates among these offenders. The lack of
specificity in defining the behaviors an offender performed that resulted in the reported legal
6
Percentages are approximate as they were derived from a graph and not reported elsewhere in
the study.
charges threatens construct validity in the study. Finally, determining index offense by date of
commission is not amenable to the study of escalation from exhibitionistic behavior to contact
sexual offending. In doing so, the authors labeled several men as hands-off offenders based on
their index offense when these individuals had previously committed hands-on crimes. Using the
first identifiable charge or conviction provides the necessary temporal precedence from which to
examine possible escalation in sexual offending and reduces the risk that an individual who has
previously perpetrated a hands-on offense will be mislabeled a hands-off offender.
Meanwhile, Sugarman et al. (1994) examined criminal records of 210 English males
convicted of indecent exposure. Eight to 25 years of follow-up data on subsequent offenses was
available for all individuals in the study, while records of prior offenses were also examined. Of
the 210 individuals, 54 (26%) had at least one conviction for a contact sexual offense (37% prior,
63% subsequent to first exposure)—defined as “convictions other than indecent exposure and
obscene telephone calls” (p. 289). Individuals with contact sexual offenses were compared to the
156 offenders without contact sexual offenses on a variety of domains. Individuals perpetrating
contact offenses were more likely to have a family histories of substance abuse, criminality, or
intellectual impairment, but less likely to have family histories of mental illness. Contact
offenders were more likely to have personality disorder and childhood conduct disorder
diagnoses, and were more likely to have an excessive libido—defined as an average of more than
one orgasm per day. Contact offenders were less likely to report dysphoric mood at the time of
the exposure, more likely to expose at more than one site, speak to victims, corner or pursue
victims, touch victims during exposure, and have a penile erection or masturbate during an
exposure than noncontact offenders. Finally, contact offenders had exposed to younger victims,
were themselves younger at the age of their first offense of any kind, and were more likely to be
convicted of property crimes or criminal damage offenses than noncontact offenders.
While Sugarman et al. (1994) obtained a substantive sample size, and tracked individuals
for eight to 25 years beyond the first exposure conviction, it is not without limitations. In threats
to construct validity, several individuals were reported to have touched victims during their
offenses, but incurred charges of indecent exposure resulting in a classification as a noncontact
offender. Additionally, the definition of contact sexual offenses as “convictions other than
exposure and obscene phone calls” (p. 289) makes it possible that individuals convicted of other
offenses that are traditionally considered noncontact offenses (e.g., voyeurism, possession of
child pornography) were classified as contact offenders. Variable follow-up times threaten
statistical validity of comparisons of subsequent offending. Finally, the authors did not identify
the test statistic used to make group comparisons.
Rabinowitz-Greenberg, Firestone, Bradford, and Greenberg (2002) reviewed records of
221 males referred to a Canadian sexual disorders clinic after diagnoses, convictions, or self-
referrals of exhibitionistic behavior. None of the individuals had prior charges or convictions of
hands-on sexual offenses. Each individual was assessed with the following instruments:
Michigan Alcoholism Screening Test (MAST; Seltzer, 1971), Buss-Durkee Hostility Inventory
(BDHI; Buss & Durkee, 1957), Derogatis Sexual Functioning Inventory (DSFI; Derogatis &
Melisaratos, 1979), and Psychopathy Checklist Revised (PCL-R; Hare, 1991). Additionally, all
individuals were phallometrically tested to measure arousal to auditory descriptions of various
pedophilic, rape, and assault scenarios. Prior and subsequent criminal, violent, and sexual
offenses were reviewed for each individual. Individuals were followed for a period of one to 15
years (M = 6.8; SD = 4.3) after either the self-referral or the conviction of the index offense. The
variable follow-up rates reflect that individuals were followed until the first subsequent offense
using survival analysis. Survival analyses are statistical approaches “used to analyze the length
of time until a specified event (in this case recidivism) occurs” (Chung, Schmidt, & Witte, 1991;
p. 59).
Forty-one (18.6%) of the individuals committed a subsequent sexual offense, 14 of which
were considered hands-on sexual offenses. The 14 hands-on recidivists had significantly more
prior sexual, violent, and criminal offenses, and scored significantly higher in psychopathy and
phallometric arousal to rape and pedophilia auditory scenarios than the 27 hands-off recidivists.
An optimal discriminant function including only phallometric arousal to rape correctly classified
78.9% of the recidivists into hands-on or hands-off groups. The strengths of the study include
the variety of measures, the sample size, and appropriate univariate and multivariate statistical
procedures. The authors were able to examine escalation from exhibitionistic behavior to contact
sexual offending by ensuring that all members of the sample had no prior hands-on sexual
offense charges. The greatest limitation of the study was the variable follow-up time. Ceasing
follow-up after the first offense of any kind limits the validity of the obtained recidivism rates.
The single location of data collection, the lack of sample demographic information reported, and
the reliance on criminal records as the sole source of offense information are also limitations.
In order to address the main limitation in the Rabinowitz-Greenberg et al. (2002) study,
Firestone et al. (2006) used the same data and measures to examine all subsequent recidivism in
an extended follow-up time among 208 male perpetrators of exhibitionistic behavior. Data on 13
individuals were lost between the studies. Exhibitionists were followed for a minimum of one
year and a maximum of 19 years (M = 13.24, SD = 3.82). Over the course of the study, 49
(23.6%) exhibitionists recidivated with a sexual offense. Within the group of 49 sexual
recidivists, 19 escalated to a hands-on sexual offenses (including sexual touching, exploitation,
and assault) while 30 of the exhibitionist sexual reoffenders recidivated with hands-off offenses.
Individuals who escalated to hands-on sexual offenses had significantly more prior violent and
criminal charges and convictions than those who recidivated with hands-off sexual offenses.
Contrary to Rabinowitz-Greenberg et al. (2002), neither phallometric arousal nor psychopathy
(PCL-R score) discriminated hands-on recidivists from hands-off recidivists. Using a
discriminant function analysis, the number of prior violent offenses significantly predicted of
group membership (hands-on v. hands-off) for 67.3% of sexual recidivists.
In many domains, the Firestone et al. (2006) study is a model study of escalation in
sexual offending among exhibitionists. The authors obtained a sample size of 208 exhibitionists,
including incarcerated and nonincarcerated individuals, and followed them for a mean of 13.24
years. Recidivism was not limited to a single type of offense, and included all subsequent
charges whether or not they were of a sexual nature. Additionally, the authors improved upon
the Rabinowitz-Greenberg et al. (2002) study by including more than the first reoffense in their
examination of recidivism. The authors again used appropriate univariate and multivariate
statistics to examine differences and predict group membership between hands-on and hands-off
sexual reoffenders. Like other studies, this study was limited in that it obtained a restricted
sample of individuals who presented to a single clinic in one geographic location. While the
average follow-up period was a strength of this study, follow-up periods were inconsistent
ranging from 1-19 years. These weaknesses, along with an absence of reported demographic
information regarding race and ethnicity, limit the generalizability of the results. Overall, the
methods employed by Firestone et al. (2006) make this study an exemplar upon which to base
future studies of sexual escalation among exhibitionists.

2.2.1. Summary of methodological strengths and concerns in recidivism studies.
Strengths of the recidivism studies included substantial sample sizes and mean follow-up periods
in each study. Many of the studies reported on the offense histories both prior and subsequent to
the index exhibitionistic act. Finally, Rabinowitz-Greenberg et al. (2002) and Firestone et al.
(2006) established an exhibitionistic act as the first recorded sexual offense and recorded various
types of recidivism—criminal, violent, and sexual. Nevertheless, such studies were not without
methodological concerns. Despite using an exhibitionistic act as an index offense, many of the
recidivism studies failed to establish temporal precedence in an offender’s offense history. In
several studies (Berah & Myers, 1983; Berlin et al., 1991; Mair & Stevens, 1994; Sugarman et
al., 1994) an exhibitionistic offense was not the first recorded sexual offense perpetrated by an
individual. Prior sexual offenses were reported for a number of offenders, but it was not clearly
indicated whether the earliest sexual offenses involved contact. Therefore, such studies do not
accurately characterize the contact sexual recidivism risk among those exhibitionistic offenders
without a prior contact offense history.
An additional methodological concern relates to inconsistencies in follow-up time within
studies. Only one recidivism study (Sugarman et al., 1994) had a defined minimum follow-up
period. The variable follow-up times in the studies limit the validity of the reported recidivism
and escalation rates. For instance, one offender followed for one year without reoffense could be
considered a nonrecidivist, whereas another offender followed for 19 years recidivating in the
penultimate year of follow-up would be considered a recidivist. More accurate recidivism rates
employ consistent criteria to evaluate offender reoffense. A related concern is what constitutes
recidivism. Rabinowtiz-Greenberg et al. (2002) used the first conviction after the index offense
as a measure of recidivism, while Firestone et al. (2006) used all convictions during the follow-
up time as measures of reoffense. Recidivism can be measured as self-reports, charges, or
convictions of sexual and nonsexual crimes. Contact sexual recidivism is most relevant to the
present review, however measures of noncontact sexual recidivism and nonsexual recidivism
may be of interest to the study of risk and reoffense among exhibitionistic offenders.
In the reviewed studies, offenses were frequently defined by the legal charge rather than
by the behavior resulting in the charge. The behaviors encompassed by a single legal charge are
potentially disparate enough to include both contact and noncontact sexual offenses. In many
cases, accessing and reading police reports are a more valid measure of an offender’s behavior
than a legal charge alone. The generalizability of the recidivism studies was threatened in two
major ways. First, the samples obtained were neither random nor representative of the general
population. Second, authors of the studies failed to report demographic information regarding
their samples. While the first of these threats is much more difficult to remedy, reporting
demographic information regarding samples is among the most basic elements of a scientific
manuscript (American Psychological Association, 2010; p. 29).
2.2.2. Conclusions from recidivism studies.
Sexual offense recidivism rates among perpetrators of exhibitionistic behavior were
reported in five of the six recidivism studies ranging from 18.6% to 56.9%. Rates of escalation
to contact sexual offending among perpetrators of exhibitionistic behavior in the six recidivism
studies ranged from 0.9% to 16.2%. The mean follow-up time for each study exceeded five
years. The studies with the highest escalation and recidivism rates included individuals who had
contact sexual offense convictions prior to the index exhibitionistic behavior offense (Berah &
Myers, 1983; Sugarman et al., 1994). The study with the lowest escalation rate included
individuals receiving treatment, including pharmacological treatment, for sexual offending

(Berlin et al., 1991). In such studies, sample characteristics likely distorted the obtained
recidivism and escalation rates. Two studies with the strongest methodologies sampled the same
set of individuals who had no prior hands-on sexual offenses and obtained escalation rates of
6.3% over a mean of six years of follow-up and 9.1% over a mean of 13 years of follow-up
(Firestone et al., 2006; Rabinowitz-Greenberg et al., 2002). The results of the recidivism studies
indicate that sexual recidivism of any kind occurs in approximately 25% of exhibitionistic
offenders over five or more years of follow up time. Escalation from exhibitionistic behavior to
subsequent contact offending occurs in approximately 5-10% of individuals over more than five
years of follow-up time. Contact sexual offending occurs both prior and subsequent to
exhibitionistic behavior. Past contact sexual offending is a risk factor for future contact sexual
offending. The studies in which individuals had contact sexual offenses prior to an instance of
exhibitionistic behavior obtained the highest rates of escalation to subsequent contact sexual
offending (Berah & Myers, 1983; Sugarman et al., 1994).
Evidence from multiple studies suggested that those perpetrating contact sexual offenses
subsequent to exhibitionistic acts were more likely to have had prior criminal charges or more
prior criminal charges than noncontact recidivists (Firestone et al. 2006; Rabinowitz-Greenberg
et al., 2002; Sugarman et al., 1994). Mixed evidence was obtained linking psychopathy, prior
violent offending, prior hands-off sexual offending, and phallometric arousal to scenes of rape
and pedophilia to subsequent contact offending (Firestone et al. 2006; Rabinowitz-Greenberg et
al., 2002; Sugarman et al., 1994). In each case, one study found support for the given risk factor
while another study did not. A single study found treatment noncompliance to be a risk factor
for sexual recidivism, though not specifically for sexual escalation (Berlin et al., 1991). A single
study (Sugarman et al., 1994) found a history of personality disorder or conduct disorder
diagnoses, excessive libido (mean of more than one orgasm per day), exposing at more than one
site, touching, or pursuing victims, and having a penile erection or masturbating during exposure
to be risk factors for future contact sexual offending. Risk factors identified by single studies
should be considered potential risk factors pending independent replication.

Table 2
Demographic Information and Relevant Findings from Recidivism Studies
Authors Number and Type Location(s) Age and Follow-up Relevant Findings
(Year) of Subjects Race/Ethnicity (years)
Berah & N = 151 males Melbourne Age at first M = 7.13 n = 86 (56.9%) recidivated with indecent exposure
Myers convicted of (Australia) exposure SD = 4.39 n = 20 (13.2%) convicted of indecent assault or
(1983) “willful and conviction attempted rape prior to first exposure conviction
obscene exposure” M = 25.78 years n = 16 (10.6%) convicted of indecent assault or rape
(SD = 11.99) after first exposure conviction
Berlin et al. N = 626 male sex Maryland NR M = 5.59 n = 26 (23.4%) exhibitionists recidivated, totaling
(1991) offenders (111 (United 72 incidents
exhibitionists) States) 1 exhibitionist (0.9%) recidivated with escalation
(physical contact without force or penetration)
Treatment-noncompliant exhibitionists recidivated

more sexually (32.6% v. 12.5%) and nonsexually
(41.9% v. 10.4%) than treatment-compliant
exhibitionists.
Mair & N = 75 males Grampian, NR “Approximately Over ≈10 years of follow up, 27% of hands-off
Stevens charged with sex Scotland ten years” for offenders recidivated with a sex offense conviction.
(1994) offenses: 38 (United each offender < 4% escalated (convicted of crime—lewd,
hands-on, 37 Kingdom) (p. 84) indecent, and libidinous practices and behavior—in
hands-off—28 which physical contact was implied).
exposed)
Many of those labeled as hands-off offenders had
prior hands-on offenses.
Sugarman et N = 210 males West NR Range 8-25 n = 54 (26%) had contact sexual offense prior (n =
al. (1994) arrested for Midlands, 20; 9.5%) or subsequent (n = 34; 16.2%) to first
indecent exposure England exposure conviction.
(54 contact ; 156 (United

noncontact sex Kingdom) Individuals with prior/subsequent contact sexual
offenders) offense more likely than noncontact offenders to:
have personality disorder or conduct disorder
diagnoses or excessive libido; expose at more than
one site; speak to, touch, or pursue victims; have
penile erection/masturbate during exposure; be
convicted of property or criminal damage offenses;
expose to younger victims; be younger when
committing first offense of any kind
Rabinowitz- N = 221 males Ottawa NR M = 6.8; n = 41 (18.6%) sexually recidivate

Greenberg et arrested, (Canada) SD = 4.3 14 (6.3%) escalate to hands-on offenses.
al. (2002)a diagnosed, or self- Range 1-15
referred for Hands-on recidivists have more prior criminal,
exhibiting (no hands-off sexual, and violent charges and score
prior contact sex higher in psychopathy (PCL-R) and phallometric
offending) arousal to rape and pedophilia scenarios than hands-
off recidivists.
Firestone et N = 208 males Ottawa NR M = 13.24, n = 49 (23.6%) sexually recidivate

al. (2006)a arrested, (Canada) SD = 3.82 19 (9.1%) escalate to hands-on offenses.
diagnosed, or self- Range 1-19
referred for Hands-on recidivists had more prior violent and
exhibiting (no criminal convictions.
prior contact sex Phallometric arousal, prior hands-off sexual
offending) charges, and psychopathy score (PCL-R) did not
distinguish hands-on recidivists from hands-off
recidivists.
Note. NR = Characteristics of the sample were not reported; M = Mean; SD = Standard Deviation.
a
Rabinowitz-Greenberg et al. (2002) and Firestone et al. (2006) used the same sample, but the follow-up period was extended in
Firestone et al. (2006).
3. Conclusions and Future Directions
The correlational studies reveal that a portion (frequently in excess of 10%) of contact
sexual offender samples have histories of exhibitionistic behavior. The recidivism studies
indicate that approximately 5-10% of those perpetrating exhibitionistic behavior escalate to
contact sexual offending, while around one quarter of exhibitionistic perpetrators will recidivate
with the same or another hands-off sexual offense. The 5-10% escalation rate supports similar
historical findings (Bluglass, 1980; Cabanis, 1966; Grassberger, 1964; Rooth, 1973; West,
1987), while the approximate 25% noncontact sexual recidivism rate helps to clarify the wide
recidivism range (0-71%) reported by Furby et al. (1989). The investigations with the highest
escalation and recidivism rates in the current review were those that included individuals with
prior contact sexual offenses, indicating that past contact sexual offenses are likely predictive of
subsequent sexual offenses (Berah & Myers, 1983; Sugarman et al., 1994). Identification of
escalation and recidivism rates can assist forensic mental health professionals in making
judgments regarding risk of contact and noncontact sexual reoffense among exhibitionistic
offenders.
It is important to note that while the current review focused on exhibitionistic offenders
who escalated to contact sexual offending, approximately 90% of exhibitionistic offenders did
not progress to such offenses in the reviewed studies. While exhibitionistic behavior does not
cause subsequent contact sexual offending, the two behaviors may be associated through
numerous explanatory or contributory variables. Although such variables may not account for
both exhibitionistic offending and later contact offending in all individuals, it is important to
attempt to identify those variables (risk factors) that contribute to both types of sexual offenses in
the majority of exhibitionistic offenders escalating to contact sexual offenses.

With regard to risk factors in the reviewed studies, the most pervasive risk category that
differentiated those who escalated to contact sexual offending from those who remained
noncontact sexual offenders was prior criminality. The relative numbers of criminal charges
prior to the first exposure, prior sex offenses, exposure incidents, and physical assaults
differentiated contact sexual recidivists from noncontact sexual recidivists in several studies
(Bader et al., 2008; Firestone et al., 2006; Lang et al., 1987; Rabinowitz-Greenberg et al., 2002).
This category of risk factors is relative, meaning that both noncontact sexual recidivists and
contact sexual recidivists had prior criminal charges, physical assaults, exposure incidents, and
sex offenses. Further study is required to determine whether a meaningful absolute number of
such offenses can indicate elevated escalation risk. Additional research may also help to validate
and clarify the other previously discussed potential risk factors that either were identified in only
a single study or had equivocal evidence.
The previously discussed explanatory mechanisms can be evaluated in light of the present
review. Evidence was found to partially support the two-pronged Rooth (1971) typology of
exhibitionistic offenders who are either compulsive, anxious, flaccid (penis) exposers with little
co-morbid psychopathology or criminal history (Type I) or uninhibited, sociopathic, sadistic, and
erect (penis) exposers with other sexual or psychological disorders (Type II). General antisocial
behavior was found to be associated with those who progressed from exhibitionism to contact
sexual offending. Having a penile erection during exposure was identified as a potential risk
factor for future contact sexual offending by a single study (Sugarman et al., 1994). Mixed
evidence was found linking psychopathy to future contact sexual offense. Additional research
has found the affective and interpersonal component of psychopathy to be predictive of contact
reoffense among non-contact sexual offenders (MacPherson, 2003).

The frequent co-morbidity among paraphilic behaviors lends some support to both the
courtship disorder and hypersexuality hypotheses. Nevertheless, many individuals in the
reviewed studies were found to expose after committing contact sexual offenses, and the
majority of exhibitionistic offenders did not progress to contact sexual offending. These findings
do not support a progression toward a preferential rape pattern for the vast majority of
perpetrators of exhibitionistic behavior. Pertaining to the hypersexuality hypothesis (Kafka
2003a, b), excessive libido was found to be a risk factor for contact sexual offending in one study
(Sugarman et al., 1994). Nearly 40% of perpetrators of exhibitionistic behavior who recidivated
were found to reoffend with only nonsexual offenses over a lengthy follow-up time, thereby
threatening the likelihood that such deviant behavior can be primarily explained by
hypersexuality (Firestone et al., 2006). The mixed findings for each of the proposed mechanisms
for exhibitionistic behavior indicate that exhibitionistic behavior is multi-faceted. Much of the
currently reviewed research points toward a clustering of deviant behavior that includes both
sexual and nonsexual crimes and rule violations as a substantial risk factor for escalation from
exhibitionistic behavior to contact sexual offending. Future research into such escalation should
compare the relative contributions of these and other potential risk factors by using measures of
effect size.
Despite a dearth of recent studies regarding escalation from exhibitionistic behavior to
contact sexual offending, this area of research has great potential for growth. In addition to
correcting common methodological concerns found in the reviewed research (Table 3), future
directions for research include: investigating predictive factors for escalation to contact sexual
offending among those who expose, examining the incidence of exhibitionistic behavior in
general population and female samples, examining exhibitionistic offender’s time at risk for
reoffense or escalation, and exploring the evolution of exhibitionistic behavior via emerging
technologies. A primary associated research direction involves determining sets of risk factors
that can reliably distinguish individuals who will escalate from exposing to contact sexual
offending. A related interest involves determining those factors that reliably differentiate those
perpetrators of exhibitionistic behavior who recidivate with further exposure only, those who
recidivate with criminal or violent—but not sexual—offenses, and those who do not recidivate.
Currently, only crude estimates of incidence rates of exhibitionistic behavior in the
general population exist. The individuals examined in the reviewed studies represent those who
have come into contact with the criminal justice or mental health systems. Determining the
incidence of exhibitionistic behavior will aid in the calculation of odds ratios and development of
related risk assessment tools. Surveying general population samples may lead to comparisons
between exhibitionistic samples who have contact with the criminal justice system and those
who do not—sometimes referred to as “Dunkelfeld 7 offenders” (Schaefer et al., 2010). Similarly,
information regarding female perpetrators of exhibitionistic behavior is sparse. It is unknown
how long exhibitionistic offenders should be considered at risk for future offending after an
incidence of exhibitionistic behavior. Using survival analysis, Firestone et al. (2006) found very
little risk of violent or sexual reoffense among exhibitionistic perpetrators after eight offense-free
years. Recent research suggests that even the highest risk sex offenders had a low likelihood of
sexual reoffense (4.2%) after a period of 10 offense-free years (Hanson, Harris, Helmus, &
7
Dunkelfeld is a word of German origin that translates to “dark field.” The term has been
applied to cases of sexual crimes that occur, but are not officially reported or recorded because
the perpetrator is not known to legal authorities. The term has been popularized by the Berlin
Prevention Project Dunkelfeld (PPD), which seeks to reach and treat pedophiles who are not
currently known to the legal system (Beier et al., 2009).
Thornton, in press). Further examination of time-dependent reoffense factors will provide a
more accurate assessment of risk among perpetrators of exhibitionistic behavior.
Finally, advances in technology (e.g., cell phones, Internet, video and image-sharing services)
have provided increasing avenues for exhibitionistic behavior (Donnelly, 2010; Haines, 2005).
To date, retrievable research has not investigated the role of technology in exhibitionistic
behavior or the individuals who employ such technology for exposure.
In conclusion, a minority of exhibitionistic offenders progress to subsequent contact
sexual offending. Though further research is needed, several potentially useful risk factors for
escalation to contact sexual offending among these offenders have been identified. It is the hope
of the author that the synthesis of current literature, suggested methodological improvements,
and outlined areas of future research will revive interest in and improve the rigor of the study of
exhibitionistic offenders and their risk of contact sexual offending.

Table 3
Summary of methodological concerns affecting validity and suggested methodological remedies.
Primary Validity Methodological Concern—[Affected Studiesa] Suggested Methodological Remedy
Affected
Internal Failure to establish temporal precedence of Use the first sexual offense as the index offense,
exhibitionistic behavior and use individuals with a first offense of
(e.g., having a sexual offense history prior to the exhibitionistic behavior to study escalation from
index offense makes it difficult to determine exhibitionistic behavior
whether subsequent sexual offenses are an
escalation in severity)—[1, 2, 3, 4, 5, 6, 7, 8, 9, 10]
Single index of exhibitionistic behavior (e.g., legal Use multiple reports to corroborate exhibitionistic
charges, medical files, self-report, other-report)— behavior
[3, 5, 6, 8, 9, 11, 12]
Failure to report instrumentation procedures or Report instrumentation procedures including the

psychometric properties—[1, 3, 5, 6] name of the instrument and psychometric
properties. If an interview is used, report training
procedures and measures of agreement among
interviewers.
Ceasing follow-up at first instance of re-offense— Track offenses for the duration of designated
[11] follow-up period (e.g., an offender may recidivate
multiple times in multiple domains over a specified
10-year follow-up period)
Inadequate differentiation of behaviors/offenses Remove ambiguity regarding offense commission

attributable to individuals in the sample (e.g., 13% by identifying how many individuals who have
of sample has raped and 10% has exposed, but offended in one way have also offended in alternate
ways (e.g., Thirteen males (13%) were charged
ambiguity remains regarding how many individuals with rape, while n = 10 (10%) were charged with
overlap by fitting into both categories)—[3, 5, 9] indecent exposure. Eight of these individuals were
charged with both rape and indecent exposure.)
Use of tables is recommended for concise
presentation of such data.
External Failure to report sample characteristics—[1, 8, 9, Report characteristics of samples (e.g., age, gender,
10, 11, 12] race/ethnicity)
Use of Restricted Samples (from a single treatment Strive to use diverse samples without a systematic
facility or location; only convicted offenders)—[1, sampling bias related to age, race/ethnicity,
2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] geographic location, contact with a specific facility,
contact with the criminal justice system, etc.
Variable recidivism follow-up times (e.g., 1-15 Implement a standard follow-up time (e.g., 5 years)
years)—[6, 7, 8, 9, 11, 12] or a minimum follow-up time (e.g., at least 5 years)
for tracking recidivism
Statistical Inadequate sample size and low statistical power— Obtain an adequate sample for planned analyses as
Conclusion [2, 4, 5, 6] determined by a priori power analyses
Failure to identify statistical tests conducted—[10] Identify the test statistic
Drawing conclusions without statistical tests—[1, Use appropriate statistical difference tests or other
3, 5, 7, 8] univariate or multivariate analyses to support stated
conclusions
Failure to report effect sizes—[4, 6, 7, 9, 10] Report effect size statistics in order to indicate the
magnitude of the obtained effect
Construct Inadequate explication of Operationally define exhibitionism/exhibitionistic

exhibitionism/exhibitionistic behavior—[2, 4] behavior (e.g., self-report, observer-report, a
charge, a conviction, diagnosis)
Separate independent exhibitionistic behavior from

incidental exhibitionistic behavior that occurs in the
progress of another sexual act (e.g., exposing
immediately prior to an act of rape) or as part of
another mental illness (e.g., psychosis or dementia)
Separate exhibitionistic behavior from other sexual

and hands-off offense clusters (e.g., obscene phone
calls, voyeurism)
Inadequate explication of legal charges—[6, 7, 9, Operationally define the behaviors that result in
10] specific legal charges. If a single behavior may
result in various legal charges, examine police
reports to report and appropriately classify the
behavior (e.g., exhibitionistic behavior versus
frotteurism)
Note. Types of validity are reported as outlined in Kazdin (2003).
a
Affected studies are numbered in the following order: 1 = Longo & Groth (1983); 2 = Lang et al. (1987); 3 = Abel et al. (1988); 4 =
Stermac & Hall (1989); 5 = Raymond et al. (1999); 6 = Bader et al. (2008); 7 = Berah & Myers (1985); 8 = Berlin et al. (1991); 9 =
Mair & Stevens (1994); 10 = Sugarman et al. (1994); 11 = Rabinowitz-Greenberg et al. (2002); 12 = Firestone et al. (2008).
Acknowledgements
The authors wish to thank Daniel W. McNeil, Ph.D. for his careful proofreading and thoughtful
feedback on a previous version of this manuscript.

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Examining Risk of Escalation: A Critical Review of the Exhibitionistic Behavior

Article in Aggression and Violent Behavior · July 2014

Matthew McNally William J Fremouw

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Examining Risk of Escalation:

A Critical Review of the Exhibitionistic Behavior Literature

Matthew R. McNally, M.S.a

William J. Fremouw, Ph.D., A.B.P.P.b

West Virginia University

Corresponding author: Matthew R. McNally

male exhibitionistic behavior and contact sexual offending in 12 peer-reviewed, English-

to contact sexual offending, while approximately 25% recidivated with a subsequent

antisocial behavior, including a history of sexual and nonsexual convictions. Common

provided, along with suggestions for future research directions.

Keywords: exhibitionistic behavior, indecent exposure, recidivism, escalation, sexual

1. Examining Risk of Escalation:

A Critical Review of the Exhibitionistic Behavior Literature

sexual offenses. Noncontact offenses include exhibitionistic behavior, voyeuristic behavior,

and possession and/or distribution of child pornography. Exhibitionistic behavior—broadly

offenders, perpetrators of exhibitionistic behavior, are “generally harmless” (p. 39).

approximately 10% of persistent exhibitionists progressed to more serious sexual offending

more serious crime” (p. 39).

exhibitionistic offenders. A Massachusetts appellate court recently considered whether a

A literature review by Blair and Lanyon (1981) summarized methodological limitations

with contact recidivism following a specific noncontact offense—exhibitionistic behavior. Of

typology of perpetrators of exhibitionistic behavior. The first type is described as inhibited,

An alternate explanation for escalation to contact offending is the courtship disorder

to characteristic stages of courtship: locating a partner, interacting with a partner prior to

Furthermore, Kafka (2003a, b) has suggested hypersexuality as an underlying mechanism that

exhibitionistic behavior progress to contact sexual offending. Some reported predictors of

evidence for the purported mechanisms by which perpetrators of exhibitionistic behavior

1.1 Purpose and Procedure

By synthesizing and evaluating the relevant literature relating to escalation from

exposure,” “recidivism,” “progression,” and “escalation.” Additionally, reference sections of

examined individuals charged, adjudicated, or believed to have committed acts of public

recidivism studies examined exhibitionistic behavior as an index offense occurring prior to

correlational and recidivism sections respectively. Geographic and demographic information

methodological corrections to guide future research.

2. Critical Review of Relevant Literature

2.1 Review of Correlational Studies (n = 6)

engaging in repetitive exhibitionistic behavior as juveniles. Of these individuals, 35 were

persistent exhibitionistic behavior by researchers.

history of persistent exhibitionistic behavior.

histories of 34 repetitive exhibitionists with a control group of 20 offenders without mental

Of the exhibitionists, 24 (70.6%) reported engaging in voyeuristic behavior, 13 (38.2%)

meaningful in the context of corroborating evidence from other studies.

Lifetime comorbidity among various paraphilias, rape, homosexuality, and

written consent to participate. A structured interview was then administered to participants to

participated in both assaultive/touching behaviors (such as child molestation, rape, and

frotteurism) and nonassaultive/nontouching behaviors (such as voyeurism, exhibitionism, and

witnessed by an unsuspecting individual while no such condition was placed on individuals

(25%) had raped before, and 23 (16%) had incidences of frottage.

incidence of a behavior—to diagnose exhibitionism. The authors emphasized the confidentiality

behavior includes nonincarcerated, treated perpetrators as well as individuals incarcerated for

contact sexual offense.

A study of 45 male pedophilic sex offenders in residential treatment programs examined

(SCID-P). Limitations include a small, homogenous sample, the omission of a discussion of

applicability of the study to the current review.

“consensual sexual activity in a vehicle, public urination, mooning, or violation(s) of decency