484 CHAPTER 11
among men, in this section we use the masculine pronouns (e.g., him) when discuss-
ing patients with these disorders. (In the section on understanding paraphilias, we
will examine possible reasons for this extreme gender difference.)
Mental health researchers believe that, based on the number of Web sites and on-
line chat rooms, the prevalence of paraphilic disorders is higher than had been previ-
ously thought, but the actual prevalence is unknown. Most research on paraphilias
has been conducted with men whose disorders involve nonconsenting individuals
(such as child molesters, rapists, and exhibitionists) and who have come to the atten-
tion of mental health clinicians and researchers through the criminal justice system
or at the urging of family members. We examine that type of paraphilias fi rst.Paraphilias Involving Nonconsenting Individuals
The common feature of the paraphilic disorders discussed in this section is that the
person with the disorder has sexual fantasies, urges, or behaviors that involve non-
consenting individuals—children in the case of pedophilia. Specifi cally, if the patient
has recurrent fantasies or urges involving a nonconsenting person but does not act
on them, a diagnosis of the paraphilic disorder is given only if the fantasies and urges
cause signifi cant distress or interpersonal diffi culties. In contrast, if the man did act
on those recurrent fantasies and urges with a nonconsenting individual, the diagnosis
would be made, even if the patient did not experience distress or other interpersonal
diffi culties. For instance, someone who “fl ashes” others, who molests children, or
who sadistically sexually assaults victims would be diagnosed with a paraphilic dis-
order if the duration criterion (at least 6 months) for the behavior were met.
Thus, men who engage in some criminal sexual behaviors could qualify for the
diagnosis of a paraphilia, which creates confusion about what constitutes criminal
behavior versus mental illness. However, psychiatrists who helped to create the di-
agnostic criteria for paraphilias in DSM-IV-TR point out that they never intended
to allow paraphilias to be diagnosed solely on the basis of sexual behaviors, because
doing so “blurs the distinction between mental disorder and ordinary criminality”
(First & Frances, 2008, p. 1240). This problem is likely to be addressed in the next
edition of the DSM, DSM-V.Exhibitionism: Physically Exposing Oneself
The paraphilia exhibitionismis characterized by sexual fantasies, urges, or behav-
iors that hinge on a person’s exposing his genitals to a stranger, usually as a surprise
(see Table 11.3). Moreover, to be considered a disorder, the man must either experi-
ence distress or relationship problems as a result of the fantasies and urges or have
actually exposed himself. People who expose themselves for money (such as nude
dancers or artists’ models) are not considered exhibitionists because they do so for
compensation, not for sexual arousal (McAnulty, Adams, & Dillon, 2001).
A man with exhibitionism typically gets an erection and may masturbate while
exposing himself. Men with this disorder commonly report that they don’t intend
to frighten or shock strangers, but hope that strangers will enjoy or be aroused by
seeing their genitals (Lang et al., 1987; Langevin et al., 1979). Men with exhibition-
ism may rehearse beforehand; they may achieve orgasm during the exhibitionistic
episode or later, when they think about it. One study found that, over the course of
his life, the typical man with this disorder had “fl ashed” an average of 514 people
(Abel et al., 1987). (However, some very active men skew the average; the median
number of people fl ashed is 34.) Case 11.2 examines one man’s experience.CASE 11.2 • FROM THE OUTSIDE: Exhibitionism
Tom was a 39-year-old married businessman who was referred for... assessment because of
persistent dependence on phone sex, video pornography, and compulsive masturbation de-
spite relapse prevention sex offender group therapy and individual psychodynamic psycho-
therapy. Tom had been arrested for exhibitionism 2 years before as well and was on probation.
In an attempt to control his urges to expose himself, he had made a behavioral contract withExhibitionism
A paraphilic disorder in which sexual
fantasies, urges, or behaviors hinge on
exposing one’s genitals to a stranger, usually
as a surprise.