193 - 6D30 Exhibitionistic disorder

6D30 Exhibitionistic disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Paraphilic disorders frequently co-occur with a number of other mental disorders, including mood disorders, anxiety and fear-related disorders, and disorders due to substance use. It is also common for an individual to meet the diagnostic requirements for more than one paraphilic disorder. Paraphilic disorders may be associated with arrest and incarceration, or impairment in functioning (e.g. at work, in interpersonal relationships), but these are not diagnostic requirements. Paraphilic disorders should not be diagnosed among children, and should be diagnosed only with the utmost caution among adolescents. Sexual experimentation is typical during adolescence, and sexual acts may occur impulsively or opportunistically rather than representing a recurrent pattern of sexual arousal. General cultural considerations for paraphilic disorders • Behavioural norms, thresholds of abnormality, and attitudes and interpretations regarding paraphilic disorders vary across cultures. Accurate assessment requires information about the etiology, function and consequences of the symptoms across cultural groups. Exhibitionistic disorder Essential (required) features • A sustained, focused and intense pattern of sexual arousal – as manifested in 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, is required for diagnosis. • 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 the 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 6D30 Paraphilic disorders | Exhibitionistic disorder

573 Paraphilic disorders 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. Paraphilic disorders | Exhibitionistic disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders 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 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 these behaviours to be a manifestation of a sustained, focused and intense pattern of sexual arousal. Paraphilic disorders | Exhibitionistic disorder