Voyeurism is achievement of sexual arousal in an adult by observing people who are naked, disrobing, or engaging in sexual activity. When observations are of unsuspecting people, this sexual behavior often leads to problems with the law and relationships. Voyeuristic disorder involves acting on voyeuristic urges or fantasies with a nonconsenting person or experiencing significant distress or functional impairment because of such urges and impulses, in a person who is at least 18 years of age.
Voyeurism is a form of paraphilia, but most people who have voyeuristic interests do not meet the clinical criteria for a paraphilic disorder, which require that the person's behavior, fantasies, or intense urges result in clinically significant distress or impaired functioning or cause harm to others (which in voyeurism includes acting on the urges with a nonconsenting person). The condition must also have been present for ≥ 6 months.
A desire to watch others in sexual situations is common and not in itself abnormal. Voyeurism usually begins during adolescence or early adulthood. Adolescent voyeurism is generally viewed more leniently; few teenagers are arrested. When voyeurism is pathologic, voyeurs spend considerable time seeking out viewing opportunities, often to the exclusion of fulfilling important responsibilities in their life. Orgasm is usually achieved by masturbating during or after the voyeuristic activity. Voyeurs do not seek sexual contact with the people being observed.
In many cultures, voyeurs have ample legal opportunities to watch sexual activity (eg, digital or print pornography). However, voyeuristic behaviors are the most common of sexual behaviors that may result in a brush with the law.
Privately viewing sexually explicit pictures and videos now widely available on the internet is not considered voyeurism because it lacks the element of secret observation, which is the hallmark of voyeurism. However, with the miniaturization of surveillance cameras and the ubiquity of cell phone cameras, video voyeurism involving nonconsenting persons disrobing or engaged in sexual activity is increasingly common and is generally considered a crime in most countries.
Most people with voyeuristic behaviors do not seek medical help; thus, the prevalence of voyeuristic disorder in the general population is uncertain. In a population-based study, approximately 12% of males and 4% of females reported at least one episode of voyeuristic behavior (1). Various studies show the ratio of male to female voyeurs to be 2:1 to 3:1 (1, 2). Most of the data are from studies of incarcerated sex offenders, not from community samples. People with voyeuristic disorder studied in carceral settings may have comorbid hypersexuality, exhibitionistic disorder, depression, conduct disorder, or antisocial personality disorder.
General references
1. Långström N, Seto MC: Exhibitionistic and voyeuristic behavior in a Swedish national population survey. Arch Sex Behav 35(4):427-435, 2006. doi: 10.1007/s10508-006-9042-6
2. Thomas A G, Stone B, Bennett P, et al: Sex differences in voyeuristic and exhibitionistic interests: Exploring the mediating roles of sociosexuality and sexual compulsivity from an evolutionary perspective. Arch Sex Behav 50(5): –2162, 2021. doi:10.1007/s10508-021-01991-0
Diagnosis of Voyeuristic Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) criteria
Diagnosis of voyeuristic disorder requires the following (1):
Patients experience recurrent and intense arousal from observing an unsuspecting person who is naked, undressing, or engaging in sexual activity; arousal is expressed in fantasies, intense urges, or behaviors.
Patients have acted on their sexual urges with a nonconsenting person, or these fantasies, intense sexual urges, or behaviors cause clinically significant distress or impaired functioning at work, in social situations, or in other important areas of life.
The condition has been present for ≥ 6 months.
Voyeuristic disorder is not diagnosed in patients < 18 years.
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC.
Treatment of Voyeuristic Disorder
Psychotherapy and support groups
Selective serotonin reuptake inhibitors (SSRIs)—employed with limited success in those who present voluntarily for treatment
Sometimes antiandrogen medications
When laws are broken and sex offender status is conferred, treatment usually begins with therapy, support groups, and SSRIs.
If these therapies are ineffective, which is commonly the case, and if the disorder is severe, medications that reduce testosterone levels and thus reduce libido should be considered. These medications are referred to as antiandrogens, although the most commonly used medications inhibit the release of testosterone, they do not block its effects. Limited data suggest they reduce clinically significant sexual behaviors that likely lead to arrest (1).
Medications include
Both classes of medications decrease pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) and thus reduce testosterone production. Full informed consent and appropriate monitoring of liver enzymes and serum testosterone levels are required.
Treatment reference
1. Turner D, Briken P: Treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending with luteinizing hormone-releasing hormone agonists: An updated systematic review. J Sex Med 5(1):77-93, 2018. doi: 10.1016/j.jsxm.2017.11.013
Key Points
Most people with voyeuristic behaviors do not meet the clinical criteria for a voyeuristic disorder.
Voyeuristic behaviors are the most common sexual behaviors likely to involve law enforcement.
Diagnose voyeuristic disorder only in adults over 18 years of age if the condition has been present for ≥ 6 months and if patients have acted on their sexual urges with a nonconsenting person or if their fantasies, intense urges, or behavior causes clinically significant distress or impairs functioning.
Most people with voyeuristic behaviors do not seek medical help; treat patients who have been incarcerated for a sexual offense with psychotherapy and SSRIs first, and if additional treatment is needed and if informed consent is obtained, treat with antiandrogen medications.
