Article written by Carmela Rivadeneira, Ariel Minici and José Dahab.
Psychologists who work in clinic from cognitive behavioral therapy know perfectly well what OCD is and how to treat it, since there is an abundance of literature on the matter and, today, no one is unaware of the implications of this pathology. We also know that it has a high incidence in our offices and that there are various subtypes of OCD depending on the form that the obsessions and compulsions that the patient presents take.
Since the appearance of the DSM 5, OCD as a diagnostic entity no longer belongs to the group of anxiety disorders, but rather forms a separate category. In this entity the specific contents of the obsessions and compulsions vary between individuals, but certain dimensions of the symptoms are common, such as cleansing symptoms (contamination obsessions and cleaning compulsions), symmetry (obsessions of symmetry and repetition , counting and tidying compulsions), forbidden thoughts (aggressive, sexual, and religion-related obsessions and compulsions) and harm thoughts (fear of harming oneself or others and related checking compulsions).
It should be noted that in this article we will talk about homosexual OCD and not about sexual identity, in the same way that we will talk about pedophilia OCD and not pedophilia or pedophilia. Sexual intrusive thoughts cannot be equated with being homosexual and, of course, suffering from involuntary ideations is not the same as being a pedophile or pedophile. We will develop this conceptual differentiation in detail when addressing each of these subtypes of OCD.
Within OCD with forbidden sexual thoughts there are then these two subtypes:
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- pedophilia OCD
- homosexual OCD
Although these subtypes may constitute initial reasons for consultation, the truth is that they usually appear after an advanced phase of treatment, since the patient feels very ashamed to tell it and fears that the therapist will judge him negatively as “perverse” or “degenerate”. Most likely, many people who suffer from these subtypes of OCD do not even come to the consultation, living with these ideas and surely taking actions to neutralize them without great success. It is for this reason that, although there are estimates about the incidence of these pathologies, it is suspected that the epidemiological data underestimate the reality of the phenomenon. Its frequency in the office is also surely biased by the prejudices of both the patient and some therapists who are not familiar with the aforementioned forms of the condition.
In this article, we carry out a conceptualization of the aforementioned subtypes of OCD, emphasizing the distinctive features of its differential diagnosis, which will lead us to the specificities of its treatment. Ergo, the treatment of these two subtypes of OCD (pedophilia and homosexual) shows some important differences with respect to the other subtypes; In fact, there is a risk of making mistakes, some of which are very serious.
table of Contents
What is OCD?
First of all, let’s do a brief recapitulation of what obsessive-compulsive disorder is and how it works. It is a pathology that involves a disorder in thinking, in fact, it is the most affected and dysfunctional element of the condition. The patient with OCD lacks a cerebral inhibitory mechanism at the level of the orbitofrontal cortex, the anterior cingulate cortex and the striatum.
This biological finding, the result of research in recent years, was in part what led to the removal of OCD from the chapter of anxiety disorders since, although anxiety constitutes a part of the syndrome, in its topography and functionality it does not. It behaves like the rest of the anxiety disorders. It is for this reason that the patient with OCD You don’t choose to think the way you do. and that psychoeducation, although it helps to understand the disorder, will never be enough to modify it. Roughly speaking, the patient with OCD evaluates, analyzes and judges his own thoughts. Sometimes he also does it with sensations and emotions. By thinking something like “if I grab a knife I can stab my son,” he will feel terrified and avoid being near knives. Now, here we are at the typical description of obsessions (the idea) and compulsions (the action).
Based on research in recent decades, some authors such as Paul Sakolvskis provided a valuable idea regarding the automatic thoughts that are triggered as a result of obsessions: they are thoughts of value judgmentswhich, instead of orienting themselves to an external fact, do so towards their own mental content, not any mental content, but their own obsessions.
These are meta-thoughts, that is, thoughts that refer to other thoughts. Today more work is done with the modification of such metacognitions than with the obsessions themselves. Examples of these automatic thoughts are: “Why do I think about stabbing my son with a knife? What kind of father can think something like that? Am I a repressed murderer? Could it be that in my unconscious I have a repressed desire to kill my son? “Will I love my son?” It is precisely in the face of these metacognitions that the triggering of suffering and aversion in the person is most likely and, from there, direct to generating the compulsion that mitigates those sensations.
To be clearer, the obsession does not trigger the compulsion, but the meta-thoughts cause intense discomfort and from there the compulsion appears as an action that tries to neutralize that aversive emotionality.
We outline this model of OCD below.
Thus understanding the dynamics of the thinking of the subject with OCD, let us then move on to observe the two subtypes of sexual OCD.
Pedophilia and pedophile OCD
To begin, let us establish a discrimination between pedophilia and pedophilia OCD.
The DSM 5 has a chapter called “paraphilic disorders,” which describes a set of disorders whose common denominator lies in the presence of: “intense and persistent sexual interest distinct from sexual interest in genital stimulation or preliminary caresses within human relationships.” consented and with physically mature and phenotypically normal partners.” The chapter includes disorders such as voyeurism, sadism, fetishism and exhibitionism, among others.
Although, like any psychopathological criterion, it can be questioned and leaves some cases unresolved, it gives us a general idea of what it aims to demarcate; That is, sexual pleasure that is obtained in an unconventional way and/or with people who, due to their age or condition, cannot consent to it, but in all cases it refers to a sexual pleasure that is actually obtained or strongly desired. Thus, paraphilias involve obtaining sexual pleasure; That is, it is an impulse that leads to the approach towards the objects that satisfy it. The way in which the general criterion is formulated allows it to include both onanistic satisfaction accompanied by fantasies and real practices with (or against) other people although, of course, in its severe form paraphilias, the most problematic and pathological, are those in which the subject cannot refrain from consummating such practices, thus exposing himself to the repudiation of his culture and, most of the time, to condemnation for a criminal act.
Pedophilia is a paraphilia
It consists of the sexual excitement or pleasure that an adult or an older adolescent obtains when carrying out activities or having sexual fantasies with children under 13 years of age. Beyond the formal criterion, psychologically speaking, pedophilia is a multifactorial construct in the personality of the sufferer, and is made up of mental aspects, sexual education, violence, impulse control, etc. In this sense, two types of pedophilia are usually distinguished: a primary or essential one, deeply rooted in the subject, and another secondary one, which appears motivated by circumstantial factors.
Pedophilic behaviors are very heterogeneous: from almost imperceptible cases to those in which they reach levels that fall within the criminal realm. The sexual activity of a pedophile with a minor under 13 years of age is known as child sexual abuse or pederasty. Without going into the details of this diagnostic category, not all pedophiles are abusers, since many simply do not go beyond having sexual fantasies about children and in this way feel pleasure. The pedophile, on the other hand, needs to have sexual actions with a minor and in this way achieves pleasure, committing a criminal act.
How does pedophilia OCD present?
In most cases, it appears in adult males who have and have historically had sexual relations with other adults, and their sexual fantasies also refer to adults. Thus, they enjoy masturbating while imagining or watching adult pornography. but these people they fear that they like children, they fear that when being close to children they may commit an act of sexual abuse or aggression, they fear that at some point they develop an uncontrollable desire to have sexual relations with children and, in this way, they become child abusers. But who suffers from pedophilia OCD He does not have nor did he have sexual relations with children, nor fantasize or watch pornography related to minors; what it does have is terror for such a thing to happen, due to which he carries out avoidance behaviors and compulsions. That’s why he suffers from OCD. Let us then describe the problem in the language of the painting.
The patient is presented with the obsession/intrusive thought of being able to sexually assault a child, which triggers automatic thoughts/metacognitions about being an abuser or pedophile, which leads to intense emotional discomfort that results in attempts at neutralization, that is, , compulsions and avoidance behaviors. Thus, in general, avoid staying in places where there are children, such as squares, near schools, or family gatherings where there are minors.
Put schematically:
When making the differential diagnosis, pedophilia OCD is frequently confused with pedophilia, perhaps because both have their scope in fantasy. However, there is a different and crucial element when comparing them: pleasure. The pedophile feels pleasure looking at photos, fantasizing, imagining sexual actions with children, while the subject with OCD feels disgust, repulsion or aversive sensations when images of sexual actions with children appear in your mind. If we manage to make this minimal distinction, we will begin to understand that they are not even similar paintings and that, therefore, the way of approaching them will also be completely different.
Pedophilia OCD Treatment
As we are talking about a subtype of OCD, the first choice technique in this disorder is exposure and…