The image most widely associated with OCD, or obsessive-compulsive disorder, is the person who compulsively washes his hands or avoids touching others because he is afraid of germs. What is less well-known is the person who avoids touching others because he is worried it might be sexually inappropriate. But this can also be a symptom of OCD.
In fact “sexual obsessions,” as they are called, are little understood component of OCD not uncommon in teenagers and even children, notes Jerry Bubrick, an expert on OCD and a clinical psychologist at the Child Mind Institute. And they are particularly isolating for the kids who have them because they are ashamed to be having sexual thoughts they find troubling.
Kinds of sexual obsessions
Sexual obsessions can take many different forms. One of the most common is related to homosexuality. A girl who is heterosexual might become obsessed with the idea that she is gay. She might have every reason to believe she’s straight — she has always had crushes on male movie stars, she might even have a boyfriend — but she starts to wonder: What if I’m gay? What if I’m attracted to that girl — does that mean I’m gay? Kids with this obsession might try to “test” themselves by looking at pictures of pop stars and trying to evaluate whether they find them to be attractive or not.
Or a child might worry that he has done or will do something sexual without consent. This can be something as small as worrying that he has offended a peer by inadvertently brushing against her in a crowded hallway. Or he might be plagued with worrying that he might commit rape. He might have zero desire to actually commit rape, but the possibility that he might is terrifying to him. He might walk with his hands in his pockets and keep a larger distance than is normal from people, to lower the risk that he might do something inappropriate.
People with sexual obsessions might also worry that they have taboo sexual desires such as pedophilia or incest. Just as in the other examples, they don’t actually experience these desires, but they are disturbed by the possibility that they might. These kids might avoid being alone with family members, or avoid being alone with children, at all costs.
Distress and diagnosis
Sexual obsessions are like any other OCD obsession in that they are unwanted and intrusive thoughts that are deeply distressing to the person experiencing them. Kids might be unable to focus in class or socialize normally because of the relentless nature of their thoughts. But with sexual thoughts there is an added element of shame. “I think kids are way more freaked out about this obsession than others, especially because it goes against their grain,” says Dr. Bubrick. The obsessions make kids doubt that they are good people, or question basic aspects of their identity, like their sexual orientation.
For these children it can also be hard to get help. “Sexual obsessions are typically misunderstood in the field,” notes Dr. Bubrick. “People mistakenly think they aren’t part of OCD because of their sexual nature.”
Clinicians who aren’t aware that sexual obsessions can be part of OCD might misunderstand the symptoms, thinking they are actual desires and not a source of extreme anxiety. This confusion may be compounded by the fact that the children experiencing the symptoms may also be worrying that they reveal actual desires.
“Like other obsessions, the difference is when kids have them they cause a lot of anxiety and distress and avoidance of the situations that cause the thoughts,” explains Dr. Bubrick. “Pedophiles actively seek out situations to be alone with children and like those experiences, whereas someone with OCD who has those obsessions will feel extreme guilt and shame. They’ll avoid those situations and feel horrible about themselves just for having the thought.”
Related: OCD: It’s Like a Bully in Your Brain
Compulsively seeking reassurance is often a symptom of OCD, and something many children struggling with sexual obsessions will do. A common example of this might be anxiously seeking reassurance from family members. Repeated questions like, “This doesn’t mean I’m gay, right?” might be a parent’s first clue that something is wrong.
Kids might also do a lot of self-reassurance. They might try to be hyper vigilant about noticing when they are feeling aroused. They might try to “test” themselves when looking at pictures to “prove” whether or not their obsession reflects an actual desire. Others might go in the opposite direction and strenuously avoid looking at pictures or going to places where people might be physically exposed, like the beach.
The compulsions can vary from child to child. “Sometimes they’re very vocal about the obsessions and sometimes they’re very quiet and we don’t know about them until we ask,” says Dr. Bubrick.
Treatment for sexual obsessions
The treatment for OCD is something called exposure and response prevention. ERP works by exposing kids to the things that cause them anxiety gradually and in a safe environment. During the exposure the child will learn to tolerate the anxiety that he is feeling and, over time, he will discover that his anxiety has actually diminished and that he is ready to take on more challenging exposures.
To make sure treatment isn’t too difficult, the clinician will begin by helping the child map out his symptoms, ranking the things that cause him anxiety from minor stress to major impairment. Then they will tackle the symptoms one by one.
For a child who is anxious about touching other people, they might start by having him touch someone on the arm to get her attention. Then they might move on to shaking hands with another person and then eventually hugging someone.
For a child who has an obsession that he might be gay, the clinician might ask him to look at pictures of movie stars in a magazine, read a story with a gay character and rank the top ten hottest male movie stars. If the child is having some social anxiety because he is worried that he does things that people might interpret as being gay, he might go to the LGBTQ section of the bookstore and look at the books.
For a child who is afraid that she is attracted to her father, exposures might include looking at pictures of her father, listening to a tape of her father speaking and being in a room with her father — all without feeling any anxiety.
“You can imagine in the context of a child or an adolescent how much disruption these obsessions can cause,” says Dr. Bubrick. “Walking down hallways, being in large crowds, sleepovers, after-school activities, spending time with family — these can all be hard.” For the kids and families struggling with them, the obsessions can feel hopeless. But with the right treatment, kids can learn how to deal with their symptoms, and then they can get back to just being kids.