Psychiatric Quarterly

https://doi.org/10.1007/s11126-020-09810-w

REVIEW ARTICLE

Portrait of an Exhibitionist

Mary V. Seeman 1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Exhibitionism has been viewed through many lenses, from the perspectives of sexual
deviance, forensic psychiatry, psychopathology, psychological dynamics, feminism, be-
haviorism, and psychopharmacology. Starting from the description of one psychotherapy
patient, the aim of this paper is to synthesize this disparate literature. The findings of the
synthesis include an estimate of the lifetime male prevalence of exhibitionism, 2–4%,
peaking in late adolescence. Insecure attachment, sexual abuse in childhood, substance
abuse, and sexual dysfunction are acknowledged risk factors. Motives behind the act of
genital exposure remain obscure, constructed of both sexual and non-sexual impulses.
The usual response of women victims is alarm and disgust. Successful treatment relies on
a strong therapeutic alliance with specific psychological and psychopharmacological
interventions - comparative effectiveness not yet determined. In conclusion, precedents
for exhibitionism vary. The frequency of the behavior usually wanes with age and, while
exhibitionists may pose a risk to others, they usually do not. There is, as yet, no gold
standard treatment; the recommendation for therapists is to respond to individual facets of
the patient’s circumstances and history.

Keywords Kurt Freund . Paraphilia . Exhibitionism . Therapy . Technology

Introduction

From 1970 to 1985, Dr. Kurt Freund and I worked at the same psychiatric institute in Toronto,
Canada. Dr. Freund was a well-known Czech behavioral sexologist who emigrated to Canada
in 1968 [1, 2]. While still living in what was then Czechoslovakia, he pioneered the psycho-
physiological measurement of male sexual arousal using phallometry (also known as penile
plethysmography), which measured penile tumescence in response to specific visual stimuli.
This became the standard method for evaluating the paraphilias and monitoring treatment

* Mary V. Seeman
mary.seeman@utoronto.ca

1
Department of Psychiatry, University of Toronto, 260 Heath St. W. Suite #605, Toronto, ON M5P
3L6, Canada
 Psychiatric Quarterly

response, and it continues to this day to influence research and clinical practice in the
interdisciplinary science of sexology.
During the 15 years of our association, Dr. Freund referred many men with paraphilia to
me, perhaps because he thought that a woman therapist could be helpful for conditions that he
christened “courtship disorders” [3]. Freund’s courtship disorder theory does not explain all
paraphilias but works well for exhibitionism [4], which was the diagnosis of the majority of the
men referred to me. Exhibitionists are acknowledged to be a heterogeneous group of individ-
uals, and no overarching causative explanation is likely to apply to all. Dr. Freund knew that.
Nevertheless, when examining the four phases of general courtship rituals: a) search for and
decision about potential sexual partners; (b) pretactile interaction such as smiling and con-
versing and spending time together; (c) tactile interaction, such as kissing, hugging, petting;
and, ultimately, (d) sexual intercourse, Freund found the pretactile interaction phase to be
almost always disturbed in persons affected with exhibitionistic disorder [3].
One reason for the absence of a unifying theory of exhibitionistic disorder is the lack of a
generally accepted definition. The Statistical Manual of Mental Disorders, 5th Edition (DSM
5) defines the disorder as recurrent and describes exhibitionists as deriving intense sexual
arousal from the exposure of their genitals. During the DSM-5 revision process, many
proposed changes to this definition were debated, though not implemented [5] Table 1. First
[6] attributes the difficulties inherent in adopting a universally agreed upon definition of this
disorder to the fact that all paraphilic disorders carry major forensic implications, which makes
the precise wording critical [6].
However it is defined, exhibitionistic disorder is one of the most common of the paraphilias
[7]. Psychological explanations for the behavior vary widely. Men who repeatedly expose their
genitals to strangers appear to differ markedly among themselves with respect to personal
history, personality structure, attitude toward women, and erotic gratification from the act.
Some have comorbid substance abuse disorders or other psychopathology; some do not. No
unifying characteristic explains the behavior of all the men with this diagnosis [8]. Research on
the basic biology (genetics, brain structure, neurochemistry) of the paraphilias has been
relatively sparse, and that which exists tends to focus on pedophilia. Research results from
this field of enquiry may, however, be pertinent to exhibitionism because considerable overlap
exists among the paraphilias.
On the basis of their pilot study of familial paraphilia in Canada, Labelle et al. [9]
concluded that the phenotypic expression of the various disorders included under this rubric
needed to be better clarified before the underlying genetics could be effectively investigated.
Nevertheless, a 2015 study of 5028 men in Sweden convicted of sexual crime reported that
sexual offending tends to run in families and that genes are more implicated in this disorder
than a shared environment [10]. Having a father or a brother convicted of a sexual offence
increased the odds of a similar offense 4–5-fold relative to men from control families.
Although the sample included men convicted of any sexual crime, approximately half of the
men in this sample were exhibitionists.

Table 1 DSM-5 criteria for exhibitionistic disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to
an unsuspecting personas manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or, the sexual urges or fantasies
cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
Psychiatric Quarterly

With respect to neurochemistry, an important clue comes from patients with Parkinson’s
disorder who are treated with dopamine agonists. Such patients are reported to begin showing
hypersexuality and paraphilic tendencies as an aftermath of treatment [11, 12], implicating
excess dopamine activity. With respect to psychophysiology, generalized disinhibition of
neural function has been proposed as a potential explanation for the inability to suppress
sexual urges [13, 14].
Heterogeneity and the variety of sources from which study participants originate (−e.g.
general population questionnaires, forensic samples, treatment samples) explains why research
progress has been slow. Even classification has been difficult. Paraphilias are sometimes
considered as sexual dysfunctions [15], sometimes as obsessive-compulsive disorders
[16–18] and sometimes as addictions [19].
Although phallometry, as pioneered by Freund, needs to be better standardized [20, 21], it
continues to perform reasonably well as a test for pedophilia, but this is not true for
exhibitionism. An early expectation that it would prove useful for diagnosing and monitoring
the effect of treatment for this disorder [22] was not fulfilled. Freund was aware of this and,
therefore, recommended relying on methods better able to predict relapse, namely reports of
law enforcement, of victims, and also of offenders themselves. Mainly from the self-reports
[23], Freund learned important new information. He learned that the age of onset of exhibi-
tionist activity usually starts around the time of puberty and gradually diminishes with age, but
that alcohol can cause a relapse even in older age. One third to one half of exhibitionists report
masturbating during exposure or during fantasies about exposing. Two-thirds sometimes
masturbate in public places when they are alone. About one third report that they desire
intercourse with the target person and hope that genital exposure will sexually arouse the
woman viewer. From the self-reports, Freund learned that making obscene phone calls is a
relatively common co-paraphilia in exhibitionists, as are compulsive visits to prostitutes, both
representing impersonal, and therefore preferred, routes to sexual gratification. The men
overwhelmingly reported that they preferred the target woman to be a complete stranger and
that they usually spent considerable time and effort searching out an appropriate target, a
woman who would somehow confirm that the exhibitionist was sexually desirable. The men
denied deliberately seeking a reaction of fear, disgust, or anger (which is nonetheless what they
usually received), but they did admit that negative reactions were far better than a show of
indifference. Freund was aware that self-reports were not necessarily true reports and were
often deliberately self-serving in forensic populations (designed to lighten their sentence). He
also believed that the men were often not conscious of their own motivations nor of the
reactions they set out to evoke as a result of genital exposure [3].
The literature reports divergent results of questionnaires asking questions similar to those
pioneered by Freund et al. [23] of men with a history of exhibitionism. My aim in this paper is
to rely on a self-report that was not a response to a questionnaire but, a synthesis of bi-weekly
therapy sessions conducted over the course of 20 years with a patient who had several
psychological problems in addition to exhibitionism. Consent was not obtainable because
the patient has been deceased for over 10 years. All identifying details have been altered.

The Case

The man in question (I’ll call him Charles) was 20 years old when he first came for treatment
and he became, over the years, one of my favorite patients because he was highly intelligent,
 Psychiatric Quarterly

witty, often amusing and always engaging. He was usually very attuned to his feelings and
their source, and managed, in this and other ways, to maintain my undivided attention. I
always looked forward to his visits because he was full of surprises, often challenging and
irascible, very often coming to therapy sessions drunk. There were times during the 20 years
when he disappeared for a time and then returned. At the end of therapy, he moved to another
province, married, but kept occasionally in touch. As far as I could tell, the marriage was solid,
the exhibitionistic behavior had stopped but he continued to drink to excess. His death was a
result of liver failure.
Charles came from a well-to-do family who lost their money when Charles was in his teens.
He attributed the change in circumstance to his father being an ineffectual man who allowed
himself to be domineered by his wife. Both parents reportedly had problems with alcohol.
Charles actively disliked his mother whom he remembered as being cruel to him and his sisters
when they were children. His main affectional bond was with his two older sisters.
Charles misbehaved in primary school and did not do well academically so was sent, at age
12, to an all boys’ boarding school. He hated his time there and was terrorized by boys who
were bigger and stronger than he was. Some of the abuse that he suffered at the hands of his
peers was sexual in nature and involved physical force, a topic he referred to tangentially, and
only when he was drunk. He may well have experienced what Jungian therapist, Joy
Schaverian, has called ‘boarding school syndrome’ [24], a result of parents sending boys to
boarding school before they are ready to leave home. Schaverian believes that this results in
later problems with intimacy. A case history from Malaysia of an adult exhibitionist very
closely describes what I believe happened to Charles as a boy in boarding school: “…..forced
to perform oral sex to his seniors in his first month of boarding school life at the age of 13
years old, which ended up with physical abuse when he struggled during the process” [25].
In his late teens, Charles began to expose himself to women in parks when out walking or
in his car when driving. These episodes rapidly led to a compulsive habit of needing to expose
himself whenever he was feeling stressed. He did not have an erection during the exposure and
he did not masturbate during it, but the act, nevertheless, brought him relief. Fantasizing about
it afterwards did lead to masturbation and orgasm. In his fantasies, the target women were
impressed by the sight of his genitals and sexually aroused.
Charles was apprehended and served time in jail after which his family sent him away to
another country because of the social disgrace. Charles continued to compulsively expose
himself; the chances of getting caught increased the excitement and made it increasingly
difficult to resist doing it again and again, especially when he was drunk. He also sometimes
made indecent phone calls to women he knew, disguising his voice. He became a regular
customer at massage parlors. As well, he had occasional girlfriends with whom he had sex, but
the relationships were short-lived and never satisfying. He was often impotent, which he
attributed to alcohol use. He developed caring relationships with some of these women and
was hurt and often very much distressed when the relationships ended. Such endings tended to
trigger exposure events.
Many have written about the non-sexual gratifications of genital exposure. With Charles, the
compulsion to expose came after disappointments in relationships or at work; the excitement of
exposing himself relieved the stress. An aspect of the comfort that exposure provided was
reassurance that, even if friendships or work were disappointing, he was still adept at an activity
that other men did not know how to perform (exposing himself in public, evoking a strong
response, getting away with it). Many have theorized that the act of exhibiting a phallus is an act
of power, showing off the size and strength of something that women do not have, establishing
Psychiatric Quarterly

the fact that this very masculine organ can astound by its size and strength. Charles claimed he
never saw it that way. Throughout the 20 years I knew him, he appeared insensitive to the terror
he was inflicting on women. He often said, much like the men that Freund questioned, that he
could not see why the sight of his penis would not cause pleasure to women, much like the sight
of a woman’s bare breasts caused pleasure to him. His victim preferences were young adult
women who were strangers. He rarely talked to the women he exposed himself to, never
touched them, never followed them. He was apprehended on multiple occasions by police, and
the possibility of being caught appeared to augment the pleasure.
Risk-taking played a large part in Charles’ life, quite apart from his exhibitionistic
behaviors. He took very large risks at work, gambled incautiously, won and lost large amounts
of money, took interpersonal risks with his employers and colleagues - missing work, coming
to work intoxicated), and also with his sisters (showing up unexpectedly, forgetting family
occasions). He took risks with me in the sense that he periodically called me at home in the
middle of the night when drunk; he also came to my office drunk, he shouted at me, he missed
appointments and sometimes stayed away for months at a time. He took emotional risks with
the women for whom he felt affection, prematurely telling them how he felt about them before
he knew whether his affection was reciprocated.
Aside from his compulsive genital exposures and risk taking, Charles was also addicted to
opiates and admitted himself several times to drug rehabilitation centers. Despite his serious
problems, he was relatively successful at work and eventually terminated his treatment because
he had amassed enough money to follow a childhood sweetheart to another province, where he
convinced her to marry him. He wrote occasionally and I was under the impression that he no
longer exposed himself, but that he continued to take risks at work and to drink heavily. His
marriage, surprisingly to me, lasted until his death.

Discussion

Prevalence of Exhibitionism

Given that acts of exhibitionism are rarely brought to the attention of authorities and that self-
report is likely to underestimate the numbers of such behaviors, it is difficult to estimate the
prevalence of this disorder in the general population. Clarke et al. [26] conclude from their
research with victims that the behavior is frequent and that individual perpetrators each
accumulate a large number of victims. According to women’s reports, lifetime victimization
rates range from 33 to 52%.
The best estimate is that the prevalence of exhibitionistic disorder ranges from 2 to 4%
among males, with far lower rates among females [6]. Långstrōm and Seto [27] analyzed a
random sample of Swedish 18–60 year old men and women and found that 3.1% of 1279 men
and 1171 women who responded to a self-administered questionnaire reported at least one
incident of having been sexually aroused by exposing their genitals to a stranger. This was true
for 4.1% of men and 2.1% of women. In this study, the risk factors, besides male gender, were
a history of psychological problems, poor life satisfaction, significant drug and alcohol use,
and sexual hyperactivity. This last included multiple sexual partners, greater than usual self-
reported sexual arousability, a high frequency of masturbation and pornography use, a greater
than usual likelihood of having had a same-sex sexual partner and of exhibiting atypical sexual
behavior (e.g. sadomasochistic or cross-dressing behavior). In a recent sample from Brazil of
 Psychiatric Quarterly

persons who use drugs (three quarters of whom were men), the prevalence of all paraphilic
behaviors or thoughts was 47% [28]. No comparisons can be made between these two studies
because the populations and recruitment and ascertainment methods were totally different, as
were the end points. The study from Brazil introduces an important consideration – the
investigators found a strong association between paraphilic thoughts and behaviours and the
history of physical and emotional neglect during childhood [28].
Summarizing what is known about the prevalence of exhibitionistic disorder: the percent-
age usually cited, 2–4% in men, may be a low estimate because most exhibitionistic acts go
unreported and, even when reported, engagement in treatment (from which statistics are
drawn) is infrequent. The offending men are not usually caught and they relatively rarely
seek treatment voluntarily.

Risk Factors from the Literature

History of Child Abuse

A history of sexual abuse in childhood has long been considered a risk factor for paraphilia
[29–31], although the literature suggests that the potential link between abuse and abusing is
dependent on many moderating variables [32].
The nature of the reported abuse varies considerably, but what is universal is the relative
power of the abuser and the powerlessness and subjugation of the victim. It has been
hypothesized that feeling powerless is a worse trauma for boys than for girls because it goes
against the prevailing masculine norm. Teen age boys characteristically equate submission
with deficiency; they want, above all else, to be seen as strong and dominant [29, 33].
Davis and Knight [34, 35] have described a specific role for early male caretaker abuse in
the history of adult male sexual offenders. Male on male sexual abuse by peers during
adolescence, as was the case for Charles, is anecdotally thought to be common, but is rarely
mentioned in the academic literature [36, 37] perhaps because the victims rarely report it.
According to a study by Sperry and Gilbert [38], less than a fourth of victims of peer abuse
disclose the event. For Charles, the abuse he suffered in boarding school may well have served
as a major determinant of his exhibitionistic behavior.
Briefly, the literature suggests that sexual abuse in childhood and adolescence plays a large
part in adult exhibitionism.

Substance Abuse

As in the case of Charles, who consumed both alcohol and codeine, many exhibitionists abuse
substances. It may be that substance abuse and exposure are linked, in that, tempted to expose
oneself, taking an intoxicating substance may bolster the confidence required to proceed with the
act. Or it may be the other way around. Overindulgence in drugs and alcohol may come first and
be sufficiently disinhibiting to overcome sober reflection and facilitate exposure [39, 40]. In many
cases, substance abuse is prevalent in the offender’s birth family [41], as was the case for Charles.
One quarter to half of sex offenders (a category that partially overlaps with the term paraphilia)
appeared, according to a recent review, to be intoxicated at the time of their offense [42].
In summary, substance abuse, as other disinhibitory factors (for instance, rage, fear, hunger,
fever, sleeplessness, social isolation, brain compromise) can be a risk factor for exhibitionism
and has been found to almost double the chance of reoffending [43].
Psychiatric Quarterly

Parental Attachment Problems

The majority (approximately 60%) of sex offenders report poor relationships with their parents.
They either see parents as rejecting or else absent during early childhood [44]. Insecure
attachment has been reported to lead to low self-confidence, poor social skills, and lack of
empathy for others. It can also lead to difficulties with relationships and subsequent loneliness.
Recent research has shown that recidivism rates for sex offenders may be related, at least in part,
to intimacy deficits and the inability to establish healthy, committed relationships [45].
To summarize, parental attachment is an important concept that needs to be further explored
in exhibitionism and other paraphilias.

Sexual Dysfunction and Small Penis Syndrome

Among a group of male college students in Portugal, those who self-reported sexual aggression
against women also reported more sexual inhibition, erectile and orgasmic difficulties than did
their peers. They also believed themselves to be less desirable and less competent than their fellow
students [46]. Sexual inhibition has also been reported by exhibitionists in France [47]. Over 20%
of sex offenders are said to experience sexual dysfunction, although it is difficult to estimate
whether this is a substantially greater number than is found in the general population and whether
the category of sex offender is likely to accurately represent most exhibitionists [48].
Metz and Sawyer [49] illustrate how treatment for erectile dyfunction, inhibited sex desire,
excessive sex desire, premature ejaculation, inhibited orgasm, and other sexual difficulties can
reduce paraphilic fantasies and behavior. They theorize that sexual dysfunction, or the fear of
sexual dysfunction, may be what maintains the need for paraphilic fantasies and acts.
Worries about not only performance but also about the size and shape of the phallus is a common
concern among men [50]. In the East, it can manifest itself as koro, fear that the penis is shrinking
[51]. In the West, it shows up in requests for penile enlargement surgery [52]. Penis size in all
cultures is symbolic of masculinity, a concept which includes elements of power, economic success,
and social prominence [53]. Exhibiting one’s penis to women may, thus, serve similar functions as
going to the doctor for augmentation or to the herbalist for koro treatment. The individual exposes
himself in order to obtain a startle reaction from the victim which, in his fantasy, confirms his ample
endowment, and, by extension, his sexual potency and his overall powerfulness [54, 55].
There are also exhibitionists, and it is impossible to say how many, who may consciously
fantasize about women becoming sexually excited at the sight of their penis but who, in the
moment of exposure are preversely aroused by the shock, disgust and fear that they elicit.
Piemont [56] describes three such cases. Stoller [57] theorized that the act of provoking fear
reverses early childhood experiences of being terrorized.
A recap of the main points in this section is that paraphilias result from a range of complex
interrelated factors. These factors range from distal causal contributors such as genetic
predisposition and early life experience to more proximal triggers such as loneliness, emo-
tional dysregulation or disinhibition, to attempts at compensation for deficiencies such as
sexual dysfunction and low self-esteem.

Effect on Women

As has been noted, many exhibitionists believe that women will be sexually aroused by the
sight of their penis in the same way they themselves are aroused at the sight of a woman’s bare
 Psychiatric Quarterly

breasts. Charles said this to me many times during the years I knew him. This is in stark
contrast to reports of women’s reactions to the experience of a male stranger showing off his
genitals. Sixteen percent of women in 2014 admitted having encountered an exhibitionist in
the preceding year [58] and most rate the experience as both unsettling and threatening [26].
Almost half the respondents in a recent online survey of 1075 women were 15 years or
younger at the time of the genital exposure incident [59]. In more than half the cases, the
perpetrator was described as masturbating or, in ¾ of cases touching his penis. In approxi-
mately one third of the cases, the perpetrator spoke to the victim and, in 20%, the girl/woman
was invited to engage in sexual activity. The reported emotional reactions on the part of the
women were combinations of surprise, disgust, and fear [59].
Summing up, although by far the majority of reported incidents of encountering exhibi-
tionists are described as non-violent, the experience is distasteful and disquieting for the
victims.

Non-Sexual Motives for Genital Exposure

In themselves, paraphilic thoughts and behaviors cannot be thought of as a deviation from

normal. Fifty percent of university men and 40% of women reported engaging in at least one
behavior that can be classified as paraphilic [60]. It is the recurrence and compulsivity of such
behaviors that constitute a paraphilic disorder. The origins and motives of these disorders are
probably overdetermined [61] and differ from person to person. Many of the presumed
motives have been conceptualized as unconscious, with the act of exposure serving both
sexual and non-sexual functions [62].
The non-sexual functions have been theorized as representing an expression of anger
against women [63], and an assertion of autonomy and power [64]. Tuch [64] maintains that,
in most instances, the exhibitionist exposes a flaccid rather than erect penis, and experiences no
sense of sexual arousal. To Tuch, who has treated a large number of exhibitionists, vulnerable-
appearing women are deliberately targeted in a hostile act intended to evoke terror and shock.
To others, exhibitionism is seen as a way of increasing self-esteem by showing off a symbol of
manliness, or a way of dealing with stress by distraction via risk taking, or a way of dealing
with loneliness by substituting genital exposure for intimacy [45].
It can also be viewed as a compensation for perceived deficiency, an attempt to settle early
childhood conflicts and cope with biographical burdens, a way of countering shame and
humiliation, essentially transforming childhood trauma into adult triumph [57]. Snaith [8] sees
it as a way of filling emptiness by receiving attention and (imagined) admiration. The woman’s
actual reactions (shock, alarm) may be what the exhibitionist seeks not because of hostility
toward women but because the startle reaction can be attributed, in the exhibitionist’s fantasy,
to the impressive sight of his penis [65].
Silverstein [66] has emphasized the motive of countershame. Countershame is defined as a
counterphobia - a repetitive compulsive attempt at mastering, avenging and overcoming
humiliating experiences from the past – re-enacting a scenario where the young boy’s sense
of masculinity was mocked or disparaged. The act may, thus, temporarily induce feelings of
pride and power that indirectly lead to sexual arousal. The risk-taking can also heighten
excitement even when it leads to arrest [67]. A paper by Raley [68] provides an excellent
illustrative example of countershame in an adolescent exhibitionist.
In brief, although exhibitionism and other paraphilias are considered as problems of sexual
deviance, they may also be problems of hostility, autonomy, loneliness, and shame.
Psychiatric Quarterly

Effects of Technology

Contemporary exhibitionist behavior cannot be fully understood without considering the

effects of smartphones and social networking websites (not available during the time of
Charles’ therapy). Almost 6% of participants in a survey of 959 respondents (26% male,
average age 21) reported engaging in either technological or face-to-face exhibitionistic
behavior [69]. The question asked in the survey did not distinguish between exhibitory acts
with lovers versus those with strangers. Most sexting (sexting is defined as “creating, sharing,
and forwarding sexually suggestive, nude, or nearly-nude images” through cell phones, the
Internet, and other electronic devices) occurs between lovers [69, 70].
The relative anonymity provided by technology decreases inhibition. Oswald et al., [71]
recruited 1087 men to complete an online survey on the topic of sending out photos of their
genitals, or “dic pics.” The most frequently admitted motive for sending such photos was the
hope of reciprocation. Men tend to think (erroneously [72]) that women are as interested in
visual sexual images as men are. When they do not receive the response they hope for from
one woman, they send their photos to more, hoping that at least one will be sexually excited by
what she sees and will respond in kind [73].
To sum up, technology has made exposing oneself to strangers much easier but, for
someone with an exhibitionistic disorder, this may not be as satisfying as real life exposure
because they cannot witness the receiver’s reaction first hand and the element of risk may not
be as great.

Treatment

As mentioned, my therapy with Charles, for the most part, did not directly address his
exhibitionistic behavior but, rather, his risk-taking, substance abuse, and interpersonal prob-
lems. I realized early in therapy that any attempts at presenting him with an exposure victim’s
perspective in order to increase awareness and empathy toward the feelings of women was a
strategy not apt to work. What seemed to work for Charles was the evidence of my empathy
toward him. During the course of therapy, he was arrested several times for drunk driving and
was voluntarily hospitalized on three occasions for substance use problems. He appreciated the
fact that I visited him in jail and in hospital. I did not prescribe any pharmaceutical agents for
him; any gains he made while in treatment can probably be ascribed to the increasing strength
of our relationship. He knew that I found him to be a worthwhile human being, that I was
available in emergencies and that I would not give up on him. I believe that this is what
allowed him to start to feel better about himself.
Shursen et al. [45] and Marshall and Marshall [74] have reported that rates of recidivism in
paraphilic conditions are related to intimacy deficits and the lack of ability to establish healthy,
committed intimate relationships. These researchers advocate the inclusion of an intimacy skills
module into cognitive behavioral therapies for sexual offenders and these are the very skills that
Charles slowly learned in therapy. Shursen et al. [45] also discuss contemporary behavioral
models of treatment - Relapse Prevention Model [75], Offense Cycle Model [76]. Attachment
Theory Model [77]. Group therapy that targets social skills is another recommendation [78].
The pharmacologic treatment of paraphilias consists of selective serotonin reuptake inhib-
itors (SSRIs), which have demonstrated some effectiveness in reducing impulsivity, and
testosterone lowering medications (medroxyprogesterone, leuprolide), which reduce sexual
drive. These can be used alone or in combination with psychological therapies. The World
 Psychiatric Quarterly

Federation of Biological Psychiatry guidelines [79] propose a protocol based on risk, starting
with psychotherapy alone for low risk individuals and progressing to a combination of
psychotherapy plus a gonadotropin releasing hormone with an antiandrogen and/or an SSRI
for offenders at risk for violent behavior. Surgical castration, a treatment of last resort, is no
longer recommended in most parts of the world [80, 81]. The Cochrane review of pharmaco-
logical agents for paraphilias from 2015 did not include trials of agents in current use [82].
In summary, what is advocated as optimal treatment for paraphilia is an individual approach
that takes into account the heterogeneous causes and circumstances of individuals with these
conditions [83] This includes addressing sexual dysfunction, co-morbid psychopathology, as
well as personal circumstances [49]. In other words, treatment for exhibitionism is best tailored
to the needs of the individual on a case-by-case basis. The relative effectiveness of treatments
has, thus far, proven impossible to meaningfully compare [84].

Therapeutic Alliance, Transference, Countertransference

In my own clinical experience treating men like Charles, a strong therapeutic alliance is the
key to success. Marshall et al. [85] and Ponder [86] have reported that therapist empathy and
warmth predict positive behavioral change. Transference matters [87] and may provoke
difficult emotions in the therapist when patients attempt to create feelings such as isolation
and ineptness in the therapist, feelings that they project because they cannot bear them within
themselves. Modeling how such emotions can be borne is an important task for the therapist.
In the case description above, I wrote that Charles “was one of my favorite patients, highly
intelligent, witty, often amusing and always engaging…..managed to maintain my undivided
attention.” Being an exhibitionist, it could be argued that he was showing off his best features
in the same way that he showed off his penis. I also wrote, “he was full of surprises. He called
me at home in the middle of the night when drunk; he shouted at me, he missed appointments
and sometimes stayed away for months at a time,” attempting to evoke in me shock, fear, and
anger, responses similar to those he evoked in his woman victims. But Charles, while often
annoying and always challenging, did not engender fright or disgust but, rather, concern and a
desire to help. Interpreting his behavior in therapy as analogous to his exhibitionistic behavior
would have been an error. What I did interpret was that he could well afford to take risks with
me because he knew that I would not get unduly angry with him and that I would not abandon
him. That seemed to make sense to him.
To sum up, therapists have wide license in interpreting transference reactions, but it is
always advisable to interpret them in ways that enhance therapeutic alliance.

Danger

As with other diagnoses, the patient’s safety and the safety of those with whom the patient
interacts is of paramount importance. The latest version of the Diagnostic and Statistical
Manual (DSM-5) distinguishes between exhibitionistic disorder and exhibitionist behavior.
While a large percentage of the population may exhibit exhibitionistic behavior, repetitive acts
that cause mental distress to the person or to others is a disorder [5, 60].
Individuals suffering from this disorder do not usually, but may, commit more serious
sexual offences than merely genital exposure. In one follow-up study of 210 cases over 8–
25 years [88], 26% of individuals with this diagnosis were convicted at least once for a contact
sexual offense. This eventuality was associated with a history of childhood conduct disorders,
Psychiatric Quarterly

theft, hypersexuality, homosexuality, or evidence of having pursued or touched the victim

during the original arrest.
In a study of 5990 twins from the general Finnish population [89], the investigators found that
that associations between exhibitionism and sexually coercive behavior were moderate to strong.
This means that not all exhibitionists are harmless, so that the fear exhibitionistic acts evoke in
women are, in some cases, well founded. A practitioner cannot always spot the possibility of
danger in advance but needs to be aware of it and take steps to prevent it from occurring.
The danger to the perpetrator is that psychiatric co-morbidity is increased in this disorder [90].
In fact, one quarter of a sample of 106 individuals with an exhibitionistic disorder were found in
one study to show symptoms of a mental illness and one quarter had a history of substance abuse
[91]. More than 84% of the sample in the study had been charged with other nonsexual crimes
[91]. Individuals who had had multiple exposure incidents and a history of physical assault
charges were the ones most likely to be subsequently charged with rape or molestation (16.9%).
Summarizing this section, exhibitionism can, in a minority of cases, serve as a forerunner to
more serious sexual crimes and/or may signal more serious psychiatric disease. It is a
therapist’s responsibility to be alert to signs of these dangers.

Conclusions

Studies of exhibitionism have come from forensic samples of sexual offenders, or from self-
referrals to psychoanalysts’ offices, or from online self-reports, or from questionnaires distrib-
uted to university students. It is, therefore, not surprising that the individuals studied have
presented with very different risk factors, recidivism rates, and stated motives. Because of the
heterogeneity, it is impossible to make summary statements that apply to all exhibitionists.
Taking the literature as a whole, exhibitionistic fantasies and acts appear to be very common in
the general population but the disorder, as defined by DSM-V, has a lifetime prevalence in
males of 2–4%, with a peak in late adolescence. Insecure attachment, sexual abuse in
childhood, substance abuse, and sexual dysfunction are risk factors with which most re-
searchers concur. Motives may be unconscious, although the effect on women victims is
almost always alarm and disgust. Smartphones and social networking websites have made
exhibitionistic acts easier, but the effect of technology on prevalence rates of the disorder is
unknown. Effective treatment depends on a strong therapeutic alliance and has taken the form
of a variety of psychological and sometimes psychopharmacological interventions. Outcomes
of different treatments have not been compared. Exhibitionists are usually, but not always,
harmless. It is recommended that therapists, no matter the approach used, establish a strong
therapeutic alliance, which appears to be a major contributor to recovery.

Authors’ Contributions I am the sole author.

Compliance with Ethical Standards

Conflicts of Interest/Competing Interests There are no competing interests.

Consent to Publish The case described is from long ago and the patient is deceased. All potentially identifiable
facts have been altered. The Research Ethics Committee of my hospital does not require committee approval for
case studies as long as the persons involved are not identifiable.
 Psychiatric Quarterly

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Mary V. Seeman MD is Professor Emerita in the Department of Psychiatry at the University of Toronto,
Canada.