Obsessive compulsive disorder (OCD) is one of the most serious causes of disability and impaired quality of life in those who struggle with mental illness—and although common, the related sexual OCD is typically underappreciated in clinical practice.

Pozza A, Veale D, Marazziti D, et al. Sexual dysfunction and satisfaction in obsessive compulsive disorder: protocol for a systematic review and meta-analysis. Syst Rev. 2020 Jan 9;9(1):8.

 

 

In the community

 

An early study showed that 10% of women with OCD reported anorgasmia and 22% exhibited problems with the sexual arousal phase, while 25% of men with OCD had lower sexual arousal and 12% experienced premature ejaculation. Overall, 39% of women with OCD experienced sexual dissatisfaction.

Thakurta RG, Singh OP, Dhar P, et al. Prevalence and nature of sexual dysfunctions in OCD in a tertiary medical college. Eastern Journal of Psychiatry. 2014 Dec;17(2).

 

In a more recent study from the same researchers, sexual dysfunction occurred in 53.33% of a sample of women with OCD, with orgasmic dysfunction affecting 20.51% of the sample and problems with desire affecting 15.38%.

Pozza A, Veale D, Marazziti D, et al. Sexual dysfunction and satisfaction in obsessive compulsive disorder: protocol for a systematic review and meta-analysis. Syst Rev. 2020 Jan 9;9(1):8.

 

 

What it's like to live with the condition

 

Compulsions in sexual OCD, write authors in the Annals of Neuroscience, could include neutralizing behaviors, such as checking body situations that may activate obsessions by clenching muscles, or maintaining distance from another person to avoid touching.

Chaudhary S, Singh AP, Varshney A. Psychodynamic perspective of sexual obsessions in obsessive-compulsive disorder. Ann Neurosci. 2022 Apr;29(2-3):159–165.

Other neutralizing behaviors could involve mental actions (eg, praying). 

 

Content may include thoughts about sex with family members, engaging in child abuse, fears or thoughts related to sexual orientation, inappropriate sexual activity (with animals, children, or inanimate objects), and aggressive sexual behaviors.

 

Symptoms to watch for

 

Anxiety results in increased sympathetic tone and can distract from erotic stimuli, thus resulting in impaired sexual arousal, desire, and orgasm. Consequently, a person with OCD can fall into a vicious cycle of anxiety, dysfunction, and performance anxiety.

Koolwal A, Agarwal S, Manohar S, et al. Obsessive-compulsive disorder and sexuality: a narrative review. J Psychosexual Health. 2020;2(1):37–43.

 

 

During intercourse, intrusive thoughts about sexual performance/adequacy may distract a person from pleasurable sensations that arise before ejaculation and orgasm. Some experts suggest that hypervigilance linked to anxiety results in attention spent on threatening stimuli during intercourse.

Koolwal A, Agarwal S, Manohar S, et al. Obsessive-compulsive disorder and sexuality: a narrative review. J Psychosexual Health. 2020;2(1):37–43.

 

“Increased noradrenergic activity over the frontal cortex has been suggested to reinforce the cortico-striato-thalamo-cortical circuit, associated with worriness,” wrote authors in the Journal of Psychosexual Health. “All this, overall, results in the person getting distracted from the sexual cues and fantasies and focusing on intrusive thoughts, like getting concerned about the erection.”

Koolwal A, Agarwal S, Manohar S, et al. Obsessive-compulsive disorder and sexuality: a narrative review. J Psychosexual Health. 2020;2(1):37–43.

 

Obsessions over contamination with disease, sexual/religious/moral concerns, and the possibility of causing harm can also impair sexual life and functioning in those with OCD.

 

How you can help your patients

 

In total, 60% of patients with OCD respond either partially or not at all to OCD treatments such as SSRIs and cognitive-behavioral therapy (CBT).

Rachid F. Transcranial direct current stimulation for the treatment of obsessive-compulsive disorder? A qualitative review of safety and efficacy. Psychiatry Res. 2019;271:259–264.

In patients with resistant OCD, SNRI inhibitors, augmentative atypical antipsychotics, and glutamate-modulating agents have been tried to some effect.

 

As with other forms of OCD, exposure and ritual prevention (EX/RP) therapy may be useful in patients with sexual OCD.

Williams MT, Crozier M, Powers M. Treatment of sexual-orientation obsessions in obsessive-compulsive disorder using exposure and ritual prevention. Clin Case Stud. 2011 Feb;10(1):53–66.

With EX/RP, a form of CBT, patients are exposed to their feared stimulus, while eliminating the associated compulsion. This process teaches the patient that the feared outcome is unlikely to occur—even when an associated ritual is not performed. Patients with sexual OCD may need more time in therapy than patients with other forms of OCD.

 

Patients who do not respond to EX/RP or CBT might also benefit from art therapy, music, and exercise.