Sexual obsessions

# Overview
Sexual obsessions are obsessions with sex, and in the context of Obsessive-compulsive disorder (OCD) these are extremely common (Foa et al, 1995). Sexual obsessions can become extremely debilitating, making the sufferer ashamed of the symptoms and reluctant to seek help. Preoccupation with sexual matters, however, does not only occur as a symptom of OCD and may be enjoyable in other contexts (i.e. sexual fantasy). This article focuses on unwanted sexual obsessions.

# Understanding OCD and Sexual Obsessions
Obsessive-compulsive disorder involves obsessions -- unwanted thoughts or images that are upsetting or interfere with an individual's life, followed by compulsions -- actions that temporarily relieve the anxiety caused by the obsessions (APA 2000). Obsessions are involuntary, repetitive, and unwelcome. Attempts to suppress or neutralise obsessions do not work and in fact make the obsessions more severe.  OCD is considered an anxiety disorder.
Typical obsessive themes center on contamination, illness, worries about disaster, and orderliness. However, people with OCD also obsess about violence, religious questions, and/or sexual experiences. Up to a quarter of people with OCD may experience sexual obsessions (Grant et al, 2006).
Repetitive sexual thoughts are seen in many disorders in addition to OCD. For example, sexual thoughts are common to people with paraphilias, post-traumatic stress disorder, sexual dysfunction, sexual addiction and as part of the normal fantasy life of the general population. The recurrent sexual thoughts and feelings in these situations are sometimes referred to as sexual obsessions. However their content, form, and meaning vary depending on the disorder (Gordon 2002).

# The Sexual Focus
Since sex carries so much emotional, moral, and religious importance, it easily becomes a magnet for obsessions in people predisposed to OCD. Common themes include homosexuality, unfaithfulness, deviant behaviors, pedophilia, AIDS, intrusive thoughts concerning the unfaithfulness or suitability of ones partner, and profane thoughts combining religion and sex. People with sexual obsessions may have legitimate concerns about their attractiveness, potency, or partner, which can serve as an unconscious catalyst for the obsessions.

# Examples of Sexual Obsessions
Sexual obsessions take many forms. For example, a father might obsess about sexually abusing his daughter. He might wonder if these thoughts mean that he is a pedophile and worry that he could act them out, despite the fact that he has never sexually abused anyone and feels disgusted by the idea. A woman who has happily dated men all of her life might suddenly start to worry that her lukewarm feelings toward her boyfriend mean that she is a lesbian. She might then start to look at every woman wondering if, in fact, she is attracted to someone of the same sex. Another example is a man who worries that he may accidentally impregnate a woman by shaking her hand because he was not careful enough in washing his hands after touching his genitals (Williams 2007). A patient may also experience fears that their obsession has already been carried out.
In the midst of the thoughts, the sexual obsessions may seem real. Occasionally individuals with OCD believe that their obsession is true, and in such a case they would be said to have "poor insight." But the vast majority of people with OCD recognize at some point that their fears are extreme and unrealistic. The problem is that even though they know the obsession is false, it feels real. These individuals can't understand why they are unable to dismiss the obsession from the mind. The obsession may temporarily go away in the face of a logical argument or reassurance from others, but may spike when caught off guard by a sexual trigger (Gordon 2002).
Sexual obsessions can be particularly troubling to the individual with OCD, as something important and cherished becomes twisted into its nightmarish opposite, and one will always fixate on the worst-case-scenario. People with sexual obsessions are particularly likely to have co-occurring aggressive and religious obsessions, clinical depression, and higher rates of impulse control disorders (Grant et al, 2006).

# The Role of Self-Doubt
Obsessions are often viewed by the patient as a series of "What if"s. They may wonder, "What if I am really a homosexual?" "What if I really want to seduce my student?" "What if I got AIDS from visiting a prostitute while sleepwalking?" The chance of an obsession coming true is remote but often the concern can never be completely disproved (i.e. "What if I really was aroused by that picture of a child?") Arguing with a person with OCD is usually futile. Objective feedback contradicting the obsession is dismissed because it lacks one-hundred percent certainty. For someone with OCD, no possibility is ever remote enough to permanently banish the fear. Attempts to prove the unprovable leads to circles of doubt, reassurance seeking, and checking compulsions (Gordon 2002).
Sexual obsessions can occur with or without compulsions. A compulsion can be a behavioral act or a mental ritual. Examples of mental rituals include silent prayers, repeating special phrases (i.e. "I truly love my wife,") and mental arguments with oneself about the validity of the obsession. Compulsions are performed as an attempt to counteract the obsession. Compulsions temporarily reduce anxiety, but ultimately they make the OCD more severe. This type of checking can be extremely destructive to the person with sexual obsessions as they use the very existence of the compulsive behavior as a sign that they are in fact sexually deviant.
Another form of OCD that can take hold of a person is a fear that they do not love their partner sufficiently (ROCD).  As with sexual obsessions, and quite often in response to them, a person may feel the need to end a perfectly good relationship based on their inability to feel how they want to.  Instead of finding good in their partner, they are constantly focused on their shortcomings.  They often overexaggerate these "flaws" and use them to prove the relationship is fundamentally bad.  Even when they know they love someone, they constantly check and reassure themselves that it is the right feeling.  When they attempt to end the relationship, a surge of anxiety takes hold of them because, although free from the obsessive thoughts, they may realize that they prematurely ended a good relationship.  The fact that they are unable to concentrate on anything but their partner's flaws causes the sufferer great anxiety, and often leads to a strained relationship.

# Avoidance
In the same way that those who have OCD fears of contamination avoid anything that will 'contaminate' them (i.e., doorknobs, puddles, shaking hands), those who are suffering from such sexual obsessions may feel an overpowering need to avoid all contact with anything that can cause them to have anxiety, or 'spike'. Such avoidance may be:
Not looking at (for instance) another member of the same sex in the face,   
avoiding locker rooms, showers, and beaches, etc.  It can also mean avoiding sexual situations with members of the opposite sex, for fear of what a particular circumstance (not being aroused enough, intrusive thoughts, etc.) might mean. A sufferer may also avoid hugging children, including their own, a compulsion which may cause severe damage to the well-being of the child. It may cause social problems as the sufferer avoids being with gay, or straight, friends, or people with children. The social isolation feeds the anxiety, and therefore the OCD.

# Sexual Fantasy
It cannot be overemphasized that the sexual obsessions in OCD are the opposite of the usual sexual daydream or fantasy. Normal sexual fantasies are enjoyable and generally harmless. They may consist of wishes or memories of past sexual experiences. However, the sexual ideation in OCD is unpleasant and distressing. The individual with OCD does not want the thought to become real. The idea of acting out the obsession fills the OCD victim with dread (Gordon 2002). The sexual ideation in such situations is termed "ego-dystonic" or ego-alien, meaning that the behavior and/or attitudes are seen by the individual as inconsistent with his or her fundamental beliefs and personality.
Sexual obsessions in OCD rarely produce sexual arousal because anxiety and arousal cannot occupy the same space. As a result, OCD usually decreases sex drive. However, the sufferer's constant focus on not becoming aroused or checking that they do not become aroused may lead to 'groinal response'. Many OCD sufferers take this groinal response as actual arousal, when in reality it is not. OCD sexual obsessions often result in guilt, shame, and may interfere with social functioning or work.

# Treatment
People with sexual obsessions can devote an excessive amount of time and energy attempting to understand the obsessions. They usually decide they are having these problems because they are defective in some way, and they are often too ashamed to seek help.
Because sexual obsessions are not as well-described in the research literature, many therapists may fail to properly diagnose OCD in a client with primary sexual obsessions. Mental health professionals unfamiliar with OCD may even attribute the symptoms to an unconscious wish, sexual identity crisis, or hidden paraphilia. Such a misdiagnosis only panics an already distressed individual. Conceptualizing a problem such as homosexuality fears as a struggle with "coming out of the closet" can cause the patient to become even more upset and confused (Gordon 2002). Fortunately, sexual obsessions respond to the same type of effective treatments available for other forms of OCD -- cognitive-behavioral therapy and serotonergic antidepressant medications (SSRIs). People with sexual obsessions may, however, need a longer and more aggressive course of treatment (Granta et al, 2006).

## Medication for Sexual Obsessions
Many people with sexual obsessions are alarmed that they seem to lose their sex drive. People with OCD may see this as evidence that they no longer have normal sexual attractions and are in fact deviant in some way. Some may wonder if medication is the answer to the problem. Medication is a double-edged sword. Drugs specifically for erectile dysfunction (i.e. Viagra, Cialis) are not the answer for people with untreated OCD. The sexual organs are working properly, but it is the anxiety disorder that interferes with normal libido.
Medications specifically for OCD (typically SSRI medications) will help alleviate the anxiety but will also cause some sexual dysfunction in about a third of patients (Bystritsky 2004). For many the relief from the anxiety is enough to overcome the sexual problems caused by the medication. For others, the medication itself makes sex truly impossible. This may be a temporary problem, but if it persists a competent psychiatrist can often adjust the medications to overcome this side-effect.

# Related Links
- Understanding Homosexuality Obsessions
- NeuroticPlanet OCD Online Forum
- I Think it Moved