Exhibitionists are characterized by recurrent compulsive urges to expose their genitals to another person, usually an adult (DSM-IV code 302.4; ICD-10 code F65.2).(34) Exhibitionists have strong sexual urges to expose themselves that become so intense that they find themselves sexually aroused and making concerted efforts to expose themselves to particular individuals. Although a few exhibitionists expose themselves to males, this is infrequent; exhibitionism is generally perpetrated by males against females.

As part of the sequence of behaviours leading to exposure, exhibitionists begin by seeking settings where women are present, preferably settings that will not lead to their being identified and/or arrested. Once the female and setting are identified, the exhibitionist begins fantasizing, not about exposing himself, but about having some type of sexual interaction with the victim. His intent is not to frighten the victim, although many victims are frightened as they are unclear as to the motives of the exhibitionist. Many exhibitionists report altered states of consciousness, feeling as if they are transcendentally carrying out exposing themselves to the victim. As a victim approaches, the exhibitionist may attract the attention of the victim by stepping out from behind the cover of bushes and exposing his penis. Other variations include taking away books or newspapers from in front of his penis or, in some cases, suddenly appearing totally nude in front of the victim. Once the woman sees the exhibitionist's penis, the exhibitionist begins an extensive set of cognitive distortions that redefine the experience for him. For example, if the female appears to be frightened, the exhibitionist may interpret the startled look on her face as evidence that she is overwhelmed by her own sexual feelings which have surfaced as the result of seeing him and his penis. If the victim retreats and then looks back to assure herself that she is not being followed, the exhibitionist fantasizes that her sexual interest in him is so strong that she wants a second look. If the victim laughs at the inappropriateness of the man's actions, the exhibitionist will fantasize that, far from laughing at him, she is enjoying the sensual pleasure of seeing his penis. Almost irrespective of the victim's response, the perpetrator interprets her behaviour to mean an acceptance of him and a clear sexual interest in him. Some exhibitionists masturbate during the course of exposing themselves, while others wait until after exposing, masturbating later to fantasies of sexual intercourse with the victim as a partner.

One variation of typical exhibitionist behaviour is committed by individuals who completely disrobe and show themselves to females without attempts to masturbate during or after the experience. Aggressive angry feelings towards others appear to lead to this behaviour. According to the self-report of these exhibitionists, from their vantage point this is not a sexual experience even though they behaviourally appear nude before the individual.

Frequently, exhibitionists expose themselves many times daily to a series of women until their fear of apprehension, or guilt about the inappropriateness of their behaviour, leads them to stop. Then they may cease exposing themselves for weeks and/or months, later initiating a new series of exposures.

Exhibitionism is comorbid with a number of other paraphilias (Tâble 3), especially public masturbation. However, because DSM-IV criteria do not recognize the occurrence of public masturbation as distinguished from exhibitionism, clinicians must diagnose public masturbation as a paraphilia not otherwise specified. (3)

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