Exhibitionistic disorder

Essential (Required) Features:

• A sustained, focused and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—that involves exposing one’s genitals to an unsuspecting person in public places, usually without inviting or intending closer contact.
• The individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them.

Additional Clinical Features:

• Exhibitionistic Disorder should not be diagnosed among children and should be diagnosed only with utmost caution among adolescents. Sexual experimentation is typical during adolescence and exhibitionistic acts may occur impulsively or opportunistically rather than representing a recurrent pattern of sexual arousal.
• The diagnosis of Exhibitionistic Disorder is generally not adequately supported when the evidence indicating a sustained, focused and intense pattern of sexual arousal consists solely of a single or very limited number of instances of exhibitionistic behaviour, as there may be other explanations for specific occurrences (e.g., intoxication, opportunity). In the absence of the individual’s report of their sexual thoughts, fantasies, or urges indicating a sustained, focused and intense pattern of exhibitionistic sexual arousal, examples of other forms of evidence that may support the presence of an exhibitionistic arousal pattern include a preference for specific types of pornography; preference over other forms of sexual behaviour; or planning and repeatedly seeking out opportunities to engage in exhibitionistic behaviour.

Boundary with Normality (Threshold):

• By definition, Exhibitionistic Disorder specifically excludes consensual exhibitionistic behaviours that occur with the consent of the individuals involved. Moreover, in some cultures there are socially sanctioned forms of public nudity, which do not constitute Exhibitionistic Disorder.

Course Features:

• Individuals with Exhibitionistic Disorder often report the onset of exhibitionistic sexual interest during adolescence.
• Exhibitionistic Disorder is relatively stable after young adulthood, but sexual thoughts, fantasies, urges, and behaviours may change over time such that an individual who was previously assigned a diagnosis of Exhibitionistic Disorder no longer meets the diagnostic requirements.

Developmental Presentations:

• Advancing age may be associated with decreasing paraphilic sexual arousal and decreasing behavioural manifestations of Exhibitionistic Disorder due to increased impulse control and decreased sexual drive.

Culture-Related Features:

• Laws defining what is considered exhibitionistic behaviour may vary across cultures, including by gender. In addition, cultures vary regarding acceptance of the practice of nudity and its appropriateness in specific contexts (e.g., pornography, saunas, nudist settings). In these contexts, certain behaviours may not be considered exhibitionistic by the cultural group.

Sex- and/or Gender-Related Features:

• Exhibitionistic Disorder is much more common among men.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Compulsive Sexual Behaviour Disorder: Both Exhibitionistic Disorder and Compulsive Sexual Behaviour Disorder may involve repetitive sexual impulses, urges or behaviours that result in marked distress or impairment. Exhibitionistic Disorder is characterized by sexual impulses, urges, or behaviours that are manifestations of a sustained, focused and intense pattern of sexual arousal that involves exposing one’s genitals to an unsuspecting person in public places. In contrast, Compulsive Sexual Behaviour Disorder is characterized by a persistent pattern of failure to control sexual impulses, urges, or behaviours, regardless of the focus of sexual arousal. If an individual with Exhibitionistic Disorder is able to exercise some degree of control over the behavioural expressions of the arousal pattern, an additional diagnosis of Compulsive Sexual Behavioural Disorder is generally not warranted.
• Boundary with Disorders Due to Substance Use: Episodes of impulsive or disinhibited sexual behaviour, including exhibitionistic behaviour, may occur during substance intoxication. Such episodes may not be a manifestation of a sustained, focused, and intense sexual arousal pattern. At the same time, some individuals with Exhibitionistic Disorder may use substances with the intention of engaging in exhibitionistic behaviour that does reflect an underlying paraphilic arousal pattern. A diagnosis of Exhibitionistic Disorder may be assigned together with a Disorder Due to Substance Use if the diagnostic requirements for both disorders are met.
• Boundary with other mental disorders: The occurrence or a history of behaviours involving exposing oneself to non-consenting individuals is not sufficient to establish a diagnosis of Exhibitionistic Disorder. Rather, these behaviours must reflect a sustained, focused, and intense pattern of sexual arousal. When this is not the case, other causes of the behaviour need to be considered. For example, exhibitionistic behaviours that do not reflect an underlying, persistent pattern of sexual arousal may occur in the context of some mental disorders, such as Bipolar Type I Disorder during Manic or Mixed Episodes or Dementia.
• Boundary with sexual crimes that do not involve a Paraphilic Disorder: Sexual crimes involving exhibitionistic behaviour may consist of actions or behaviours that are not associated with a sustained underlying paraphilic arousal pattern. Rather, these behaviours may be transient and occur impulsively or opportunistically. The diagnosis of Exhibitionistic Disorder requires that these behaviours be a manifestation of a sustained, focused, and intense pattern of sexual arousal.