Paraphilia without symptoms of primary psychiatric disorder: a case report.

BACKGROUND: Paraphilias are recurrent and arousing fantasies, thoughts, and behaviors that cause distress to sufferers and surrounding people. This case report details the challenge of managing multiple paraphilias with compulsive sexual behavior. CASE PRESENTATION: A 48-year-old Malay man presented with compulsive sexual behavior, encompassing voyeuristic, frotteurism, and exhibitionistic behavior, increasing progressively over the years, with accompanying overvalued ideas of erotomania. Despite the high level of dysfunction occupationally and socially, there were no apparent psychotic, manic, or depressive symptoms. An organic workup was unremarkable, and he was diagnosed with multiple paraphilias. Treatment with selective serotonin reuptake inhibitors was commenced, and psychologically he was managed with techniques specific to compulsive sexual behavior. CONCLUSION: Though rare in the literature, both paraphilic disorders and compulsive sexual behaviors are very distressing to sufferers and their families alike, and thorough biopsychological investigations are essential to ensure reversible causes are not overlooked.

Portrait of an Exhibitionist.

Exhibitionism has been viewed through many lenses, from the perspectives of sexual deviance, forensic psychiatry, psychopathology, psychological dynamics, feminism, behaviorism, 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.

Estimated prevalence and impact of the experience of becoming a victim of exhibitionism and frotteurism in Korea: A general population based study.

Exhibitionism and frotteurism are often considered just nuisance crimes but may cause serious distress to the victims. Previous studies of victim experience have focused on specific groups, such as healthcare professionals or university students. To estimate the prevalence of victimisation by exhibitionism and frotteurism among young general population adults in Korea and to describe the impact of such experiences, trained researchers randomly recruited young adults for face to face interviews at transport hubs and on university campuses. In addition, we posted the questionnaire as a Google survey to a limited number of local websites. Data were analysed descriptively. Of 900 people directly approached, 747 (83%) agreed participation, as did 423 online. These two samples were similar demographically, so combined for analyses. Two hundred and thirty-five (20%) reported experiencing exhibitionism and 130 (11%) frotteurism. Exposure victims were older (means 23.2:21.1 years) and more likely to be women than frotteur victims. All but two exposure and nine frotteur perpetrators were said to be men. Reporting to police was rare (17 exposure, 2 frotteur); most exposure victims (73%) but under half of frotteur victims told family or friends. All but 15% of each group had bad feelings about the experience, varying by experience type. Ten percent of exposure and 20% of frotteur victims described distress lasting months; more reported enduring behaviour changes, like avoiding subways. Although our sample is unlikely to be wholly representative of the general population, our research examines a broader range of people than previous studies. Most victims of these "nuisance crimes" were distressed by them, and, hitherto less well recognised, at least a fifth of such victims may have long-term distress. Further research could establish the extent to which support outside the family or friends' group or treatment would be indicated.

CIO inventory: A new tool for measuring personality traits common to psychopathy and narcissism and their interaction with gender.

A lack of empathy, interpersonal dominance, aggression and the exploitation of others are the key features of both narcissism and psychopathic disorders. With the aim to better capture the shared facets of these traits, this study developed a new tool named the Capability to Influence Others (CIO) Inventory, which is based on the pleasantness evaluation of ten items-verbs presented in the infinitive form. The inventory, characterized by very quick submission, was administered to 67 males and 100 females and was correlated with the concurrent Narcissistic Personality Inventory (NPI) and Levenson Self-Report Psychopathy Scale (LSRP). An exploratory factor analysis supported the presence of only one factor in both the male and female groups. Internal consistency of the CIO was very good for both men (Cronbach's alpha = 0.85; 95% CIs: 0.80-0.90) and women (Cronbach's alpha = 0.83; 95% CIs: 0.77-0.87). Further statistics showed a high correlation between the CIO and the LSRP-F1 (primary psychopathy) in both genders (r > 0.47). Clear gender differences were found in the correlation between the CIO and the NPI: the correlation was high (r = 0.58) in males and absent in females. The CIO may represent a quick and low demanding tool for a preliminary screening of individuals with high psychopathic/narcissistic traits from community samples, forensic institutions, high schools and company personnel.

An Integrative Analysis of the Narcissistic Personality Inventory and the Hypomanic Personality Scale: Implications for Construct Validity.

The primary goal of this study was to explicate the construct validity of the Narcissistic Personality Inventory (NPI) and the Hypomanic Personality Scale (HPS) by examining their relations both to each other and to measures of personality and psychopathology in a community sample ( N = 255). Structural evidence indicates that the NPI is defined by Leadership/Authority, Grandiose Exhibitionism, and Entitlement/Exploitativeness factors, whereas the HPS is characterized by specific dimensions reflecting Social Vitality, Mood Volatility, and Excitement. Our results establish that (a) factor-based subscales from these instruments display divergent patterns of relations that are obscured when relying exclusively on total scores and (b) some NPI and HPS subscales more clearly tap content specifically relevant to narcissism and mania, respectively, than others. In particular, our findings challenge the construct validity of the NPI Leadership/Authority and HPS Social Vitality subscales, which appear to assess overlapping assertiveness content that is largely adaptive in nature.

Narcissism is associated with weakened frontostriatal connectivity: a DTI study.

Narcissism is characterized by the search for affirmation and admiration from others. Might this motivation to find external sources of acclaim exist to compensate for neurostructural deficits that link the self with reward? Greater structural connectivity between brain areas that process self-relevant stimuli (i.e. the medial prefrontal cortex) and reward (i.e. the ventral striatum) is associated with fundamentally positive self-views. We predicted that narcissism would be associated with less integrity of this frontostriatal pathway. We used diffusion tensor imaging to assess the frontostriatal structural connectivity among 50 healthy undergraduates (32 females, 18 males) who also completed a measure of grandiose narcissism. White matter integrity in the frontostriatal pathway was negatively associated with narcissism. Our findings, while purely correlational, suggest that narcissism arises, in part, from a neural disconnect between the self and reward. The exhibitionism and immodesty of narcissists may then be a regulatory strategy to compensate for this neural deficit.

More Than a Nuisance: The Prevalence and Consequences of Frotteurism and Exhibitionism.

Despite indications that acts of frotteurism and exhibitionism are frequent occurrences, these sexual paraphilias have received little empirical attention. To address this gap in our knowledge about these paraphilias, 459 undergraduate students in a major metropolitan city completed a self-report measure designed to investigate the frequency and correlates of frotteurism and exhibitionism. Results indicate a high rate of victimization among female college students for both paraphilias. Furthermore, acts of frotteurism and exhibitionism most often occurred in places related to public transportation (e.g., subway trains or platforms) in this urban setting. In addition, victims reported a number of negative outcomes as a consequence of victimization, including feelings of violation, changes in behavior, and even long-term psychological distress. Older females were the most likely to be victimized. These findings are discussed as they pertain to the prevention and deterrence of paraphilic sexual acts.

Assessment of the paraphilias.

Paraphilias are recurrent, persistent, and intense sexual interests in atypical objects or activities. The most commonly encountered paraphilias in sexological or forensic settings are pedophilia, sexual sadism, exhibitionism, and voyeurism. Paraphilias are often comorbid with other sexual, mood, and personality disorders. Assessment and diagnosis require an integration of multiple sources of clinical information, given the limits and biases of self-report (through clinical interview or questionnaires). Clinicians ideally have access to more objective assessment methods, such as phallometric testing of sexual arousal. The accurate assessment and diagnosis of paraphilias is essential to effective treatment and management.

Philosophical issues in the paraphilias.

PURPOSE OF REVIEW: Controversies surrounded the development of paraphilias in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5. This review examines the philosophical issues that emerge from an analysis of those debates and current literature. RECENT FINDINGS: The resolution of controversies in the publication of the DSM 5 drew upon the available evidence, theories of mental disorder, and normative assumptions. The rise of the Internet presents difficult challenges in this field. SUMMARY: Numerous philosophical assumptions underlie the psychiatric understandings of paraphilias. The focus here is on the nosological issues such as boundary justification for the determinations of normative and nonnormative human sexuality; the importance of not collapsing the distinction between mental disorder and crime, and the relationship between fantasy and action; epistemological questions of perspectivity, reasons-giving, and relationship of communication to truth claims; and sex differences not only in the paraphilias but also in the social context in which sex is formed and given expression.

Female exhibitionism: identification, competition and camaraderie.

The ancient figure of Baubo plays a pivotal role in the Greek myth of Demeter and Persephone with an exhibitionistic act that brings Demeter out of her depression. The Baubo episode raises questions about the meaning of female exhibitionism, suggesting divergences from earlier psychoanalytic conceptualizations as either a perversion or a compensation for the lack of a penis. In line with contemporary thinking about primary femininity, such as that of Balsam or Elise, the authors propose a more inclusive understanding of female exhibitionism, which would encompass pleasure in the female body and its sexual and reproductive functions. They argue that female exhibitionism can reflect triangular or "oedipal" scenarios and the need to attract the male, identification with the mother, competition or camaraderie with other women, a sense of power in the female body and its capacities, as well as homoerotic impulses. The authors posit a dual early desire and identification with the mother that underlie and characterize female sexual development. The authors present clinical data from adolescent and adult cases of female exhibitionism which illustrate these Baubo-like aspects and discuss the technical issues that are involved in such cases.

Androgen deprivation treatment of sexual behavior.

Gonadotropin-releasing hormone agonists are underutilized in patients seeking diminution of problematic sexual drives. This chapter reviews the literature on surgical castration of sex offenders, anti-androgen use and the rationale for providing androgen deprivation therapy, rather than selective serotonin reuptake inhibitors or more conservative interventions, for patients with paraphilias and excessive sexual drive. Discussions of informed consent, side effects, contraindications and case examples are provided.

The story of Sam: continuities and discontinuities in development, transforming into and out of a perversion.

The aim of this paper is to suggest new ways of understanding development that offer new therapeutic possibilities. I use observational and interview data showing the development of one research subject over forty years to highlight that the concepts of continuity and discontinuity need to be considered together to grasp the full complexity of psychological development. In the subject an unanticipated transformation occurs at age 14, the emergence of a perversion, whichfades by age 28. I will show that the observations can be best understood by co-ordinating the influence of antecedents that exert a pull backward with the transformative potential arising from the pull forward into new structures, compromises, and organizations.

[The moderating effect of self-esteem on the relationship between public self-consciousness, social anxiety and exhibitionism in Japan and South Korea].

This study examined the moderating effect of self-esteem on the relationship between public self-consciousness and social anxiety, and on the relationship between public self-consciousness and exhibitionism in Japan and South Korea. The participants were 213 university students in Japan and 234 university students in Korea. The results of hierarchical multiple regression analyses showed that self-esteem was a moderator of the relationship between public self-consciousness and social anxiety and of the relationship between public self-consciousness and exhibitionism in Korea, but not in Japan. In Korea, public self-consciousness was related to social anxiety for people with low self-esteem, while for people with high self-esteem, public self-consciousness was related to exhibitionism.

Lesbian erotics at women's hockey: fans, flashing, and the Booby Orrs.

This article analyzes a public breast flashing event that occurred during the women's ice hockey tournament at the OutGames/Western Cup Lesbigay athletic event in 2007. Employing a postfoundational perspective, I first contextualize the ice hockey subculture of the team called the Booby Orrs, outlining some of our history, norms, and context. I then tell the particular story that leads to our fans flashing their breasts as we finally scored some goals. I end with my analysis of this event: how a public nude display of sexualized women's breasts in a lesbian-coded public space prompted a resistant sporting moment, at least contingently.

[Criminal recidivism among sexual offenders]. / Kriminelt recidiv blandt saedelighedskriminelle.

INTRODUCTION: No previous reports have been published on the rate, frequency and nature of long-term sexual recidivism for a large cohort of Danish sexual offenders who have been through a forensic psychiatric evaluation. MATERIAL AND METHODS: A retrospective follow-up study of all male sexual offenders evaluated between 1st January 1978 and 31st December 1992 at the Department of Forensic Psychiatry, Aarhus University Hospital, or at the Clinic of Forensic Psychiatry, Ministry of Justice, Copenhagen (n = 441). RESULTS: Of the followed cohort (n = 342) 30% were sentenced for a new sexual criminal offence (including severe sexual acts), 17% for severe sexual acts, 32% for nonsexual violence and 61% for general crime during follow-up (average 16.5 years). There was a low rate of repeated sexual recidivism (12%) and severe sexual recidivism (6%). Extra-familial child molesters and exhibitionists had the highest risk of sexual recidivism and repeated sexual offences. Rapists had the highest risk of severe sexual recidivism and re-offended more rapidly than the other offender subgroups. Intra-familial child molesters had a low recidivism rate. Young offenders had a higher recidivism risk than older offenders. Severely mentally ill or retarded had a statistically lower rate of sexual recidivism than less disturbed offenders. CONCLUSION: The sexual recidivism rate varies across sexual offender types. The management and prevention of sexual recidivism need to focus on treatment of sexual offenders with the highest risk of severe and repeated sexual offences.

Women showing off: notes on female exhibitionism.

The limitations of the phallocentric cast of earlier psychoanalytic formulations of "female exhibitionism" linger into the present. In part this connects to certain historical expectations for women's social behavior, and to the vicissitudes of Freud's insufficient knowledge of women in his libidinal psychosexual phasing used as a basis for analytic understanding. The contemporary fade of libido theory contributes to the neglect of such topics as they relate to the biological body. Yet ease and conflict regarding conscious and unconscious female body image representations related to that stepchild of theory-pregnancy and childbirth in particular-play a major role in female body display. Recognition of such body fantasies and female body meanings from early childhood into maturity tends to be marginalized within all of the psychoanalytic theories current today. The focus here on female exhibitionism suggests a normative spectrum for pleasurably active sex seeking and pleasurable procreative desire and fantasy that is present in a female's use of her body and which (of course, but secondarily) can become caught up in conflict. Two cases accenting analyses of female "showing off" behavior are included.

Exhibitionism: findings from a Midwestern police contact sample.

This study used a police sample to examine offense characteristics, recidivism rates, and other types of sexual offending among individuals suspected of exhibitionism. The sample consisted of 202 incidents of indecent exposure perpetrated by 106 identified individuals. Demographic information showed that one quarter of the sample had symptoms of a mental illness and one quarter had a history of substance abuse. More than 84% of the sample had other nonsexual criminal charges. Approximately 30% of the perpetrators were charged for more than one exposure incident. Masturbating during the offense, exposing to child victims, and speaking to the victim did not show any relationship to the occurrence of more sexually aggressive behaviors. However, individuals who had subsequent rape or molestation charges (16.9%) were more likely than those who did not to have had multiple exposure incidents and a history of physical assault charges.

Long-term follow-up of exhibitionists: psychological, phallometric, and offense characteristics.

Exhibitionism has historically been viewed as more of a nuisance than a serious criminal justice matter. Research has demonstrated that the number of exhibitionists who are detected re-offending is a significant under-representation of the number who actually re-offend. The objective of this study was to extend a previous study conducted on exhibitionists, while attempting to solve the limitations described in that study. Two hundred eight exhibitionists were assessed at a university teaching hospital between 1983 and 1996. Archival data were derived from police and medical files. Results indicated that, over a mean follow-up period of 13.24 years, 23.6, 31.3, and 38.9 percent of exhibitionists were charged with or convicted of sexual, violent, or criminal offenses, respectively. Undoubtedly, this is an under-representation of the true rate, as we have no way of knowing how many exhibitionists re-offended and did not get caught. Nevertheless, in the present investigation, sexual recidivists compared with non-recidivists were less educated, scored higher on the Michigan Alcohol Screening Test (MAST), the Psychopathy Checklist, Revised (PCL-R), and the Pedophile Index. Violent recidivists were also less educated and scored higher on the MAST, PCL-R, and the Pedophile Index, and had accumulated a greater number of prior violent or criminal charges and/or convictions. Criminal recidivists were less educated; scored higher on the MAST, Buss-Durkee Hostility Inventory (BDHI), PCL-R, and Pedophile Index; and had accumulated a greater number of prior sexual, violent, and criminal offenses. Finally, the hands-on sexual recidivists accumulated a greater number of prior violent and criminal charges and or convictions than did the hands-off sexual recidivists.