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.”

Reassurance seeking

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.

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A mom writes to ask how to help her 10-year-old daughter, who is worrying a lot about “bad thoughts.”

Sometimes these thoughts are bad because they are mean: A family friend is “fat” or “wrinkly.” Sometimes they are sexual: She imagines a classmate naked. Or violent: She thinks she wants to kill her mother. They have one thing in common: she feels a need to confess all these thoughts to her mom, who wonders what’s going on.

It’s a scenario we hear a lot: A child is suddenly desperate to confess disturbing thoughts. A 9-year-old noticed his teacher’s cleavage, and feels guilty about it. As his dad writes: “The more he tries to control the thoughts, the more they come.” He worries out loud that there might be something wrong with him, and asks for reassurance that he’s okay. Over and over.

Kids can get very upset about these thoughts, though of course not all of them feel compelled to share them with their parents. But when they do, the constant confession and requests for reassurance can be stressful for parents, too.

Why do kids worry about “bad thoughts” and feel the need to confess them? And what can you do as a parent to help them?

What does this thought say about me?

Jerry Bubrick, a clinical psychologist at the Child Mind Institute, reminds us that we all have random thoughts that we think, as these kids do, are bad. We may think, Wow, that was unkind, or weird, or inappropriate! And then we dismiss them. We don’t express them, or act on them, and we quickly forget about them.

In contrast, Dr. Bubrick says, kids can get upset when these ordinarily fleeting thoughts get “stuck” and they are unable to dismiss them and move on. Instead of recognizing bad thoughts as meaningless, the kids hold themselves responsible for them.

“These kids are placing value on themselves based on the thoughts they’re having,” Dr. Bubrick explains. So they think, There must be something wrong with me in having that thought.  Or, I must be a horrible person if I’m having that thought.”

Dr. Bubrick calls it “over-responsibility of thought”—kids literally holding themselves responsible for their thoughts, instead of letting them go.  “And that’s why kids feel compelled to confess. They’re asking parents for reassurance, for a parent to say, ‘Yeah, that’s okay. Don’t worry about it,’ ” he adds. “That calms that fear: Okay, I’m not a bad person.”

Why do some thoughts get stuck?

Thoughts are often driven by emotional states, Dr. Bubrick notes. For example, “when I’m happy I’m more likely to have happy thoughts, and when I’m scared I’m more likely to have scary thoughts. When I’m hungry I’m more likely to have thoughts about food.” When we get frustrated or angry, we can all relate to imagining bad things happening to the person who’s standing in our way.

But most of us don’t become alarmed or self-critical based on our thoughts alone—what matters are the actions we take. Becoming fixated on “stuck” thoughts can be a symptom of anxiety, whether it’s just an anxious personality or a full-blown anxiety disorder.

What kids consider “bad” depends on the culture and what they’ve been taught. In religious families, for instance, kids worry about “bad thoughts” they think might offend God. Sexual thoughts are not infrequently disturbing to boys, especially before puberty makes talk of sexuality common among their teenage peers. Worries about wanting to murder people are surprisingly common in young children. Rachel Busman, a clinical psychologist at the Child Mind Institute, treated one 10-year-old girl who felt she needed to sit on her hands because she had thoughts about strangling someone.

Kids who feel compelled to confess and ask for reassurance are usually less than 12, Dr. Bubrick notes. “Older kids tend not to tell parents what they’re thinking, I would imagine, because the thoughts are darker or scarier. They’re more sexualized, or they’re more violent.”

How can we help kids handle ‘bad thoughts’?

The goal is simple: to help kids recognize that their thoughts are just thoughts.

“Just because you have a thought—whether it’s a good or a bad thought—doesn’t make it true,” Dr. Bubrick explains. “A bad thought doesn’t make you a bad person—It just means you’re having that thought. ”

That’s the message clinicians use when they treat kids with anxiety disorders using cognitive behavioral therapy. Kids are taught to identify their obsessive thoughts as separate from themselves—as a “bully in the brain,” as Dr. Bubrick puts it. “When thoughts get stuck in our mind, they kind of bully us into thinking they’re more important than they are,” adds Dr. Busman.

“Seeking reassurance is a way to relieve the distress or anxiety,” she says. “And it works, for the moment.” But the only way to stop the cycle of getting stuck on intrusive thoughts and asking for reassurance is to learn to tolerate the distress without confessing, and see that the anxiety will fade.

If bad thoughts really become a problem for a child—if they continue, if they cause great anguish or interfere with the child’s functioning, it may be a sign of an underlying anxiety disorder that deserves professional help.

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In families with religious beliefs, a child expressing faith and strong moral principles is usually a welcome development. But sometimes a child’s faith may become an obsession, and instead of consolation the child experiences extreme anxiety that he is violating religious norms and desperation to correct his perceived mistakes. This is what happens when children develop obsessive-compulsive disorder and it manifests itself in their religion.

Not all people with OCD will develop religious obsessions or compulsions, but it is a theme that is fairly common. Other common themes include obsessing over cleanliness, symmetry and “bad thoughts” including sexual obsessions.

Sometimes it can look like a person’s faith is causing his symptoms, but religion is more like an unfortunate bystander along for the ride. If you think about a person with OCD who worries about germs and washes his hands compulsively, it’s clear that the germs aren’t causing his behavior; the OCD is responsible for it. Religious OCD works the same way.

“It could happen to any religion, but it’s not about religion, it’s about OCD,” explains Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute. “We don’t treat people with religious OCD like they’re religious zealots, we treat the condition.”

What is religious OCD?

Religious OCD is also sometimes called “scrupulosity.” We don’t use the word scruple often anymore, but it means a moral misgiving or a pang of conscience. The Latin word it comes from literally means a sharp stone or pebble, and Cicero used it figuratively to describe feeling uneasy or anxious, as a person would if he had a pebble in his shoe.

In the case of religious OCD, or scrupulosity, instead of a pebble in the shoe a person is troubled with religious worries, but she finds them just as persistent and disturbing.

For example, someone with scrupulosity might worry that she didn’t say a prayer correctly — maybe some of the words were out of order, or she didn’t say it with the proper reverence. She might fear some religious consequence from this, so she says the prayer again — and possibly a third and fourth time — as a correction. She might worry that she doesn’t do enough good deeds, or worry that she only does good deeds for selfish reasons. She might worry about having blasphemous thoughts and offending God.

Did I do that for God or the devil?

Dr. Bubrick describes treating a 12-year-old boy named Matt who had religious OCD. Matt’s family was religious, but not very religious. Matt’s scrupulosity was debilitating.

“He worried about literally everything he did: ‘Did I do that because God wanted me to or did I do that for the devil?’ ” Dr. Bubrick says. “Opening doors, sitting down, standing up, doing his homework. Every single action he worried whether it was for the right reason or the wrong reason.”

Agonizing over everything he did was exhausting, so Matt started avoiding doing things because, he reasoned, it was safer. One of the things he stopped doing was eating, and he lost so much weight he actually needed to be hospitalized.

Matt also had compulsions, or things that he did to try to alleviate his anxiety. He had a particular prayer that he would say, he would carry a bible around with him during the day, and he slept with a bible under his pillow and one on each side of his head at night. He asked his grandparents repeatedly for reassurance when he was feeling worried.

Getting help for scrupulosity

Treatment for OCD always begins with helping young people and their families understand how their symptoms are caused by OCD. The obsessions and compulsions that people experience are powerful — in Matt’s case, powerful enough to put him in the hospital — but understanding how the disorder works starts to give people some of that power back.

People with OCD perform compulsions to fend off or neutralize the anxiety they are feeling, which is caused by things like unwanted thoughts, images or impulses. These are known as obsessions. But people with OCD do not always realize that a mental health disorder is behind these thoughts and behaviors. In the case of scrupulosity, they might mistake praying compulsively as an appropriate response to a blasphemous thought. They don’t realize that their OCD is behind the thought.

Helping people understand what’s coming from OCD and what’s coming from religion is essential. “If you want to pray because it brings you peace and you feel connected, that’s wonderful. But if you are praying because you fear if you don’t then you’ll be punished, then maybe that’s more OCD,” explains Dr. Bubrick.

Exposure with response prevention

The treatment for OCD is something called exposure with response prevention, or ERP. It works by exposing people to the things that cause them anxiety gradually and in a safe environment.

The child doing the exposure learns to tolerate the anxiety that he is feeling and, over time, discovers his anxiety has actually diminished. Then he is ready to take on more challenging exposures.

To make sure the exposures aren’t too difficult, at the beginning of treatment the child will work with his clinician to rank the things that cause him anxiety, from minor stress to major worry. Then they will tackle the symptoms one by one, together.

In the case of Matt, a lot of his exposures involved his anxiety about the devil. “We would do things like listen to music that had the word ‘devil’ in it because as soon as he would hear the word devil in a song he’d turn it off,” says Dr. Bubrick. They also listened to music with the word “hell” in it, ate devil dogs, and made Matt a jersey to wear with the number 666. These were big steps forward for a boy who had been effectively immobilized by his anxiety, but the steps were taken gradually and with great care. “We were breaking the association between God and fear,” explains Dr. Bubrick.

Reconsidering reassurance

One other very important part of treatment is teaching other people in a child’s life how to respond to her OCD. A big part of the disorder is asking other people for reassurance. This can take different forms, including:

  • Asking questions, like “Did I just commit a sin?” and needing a definitive answer
  • Wanting people to participate in rituals, like compulsive praying
  • Demanding that others avoid her anxiety triggers, like not saying certain words or doing certain activities in her presence

Getting reassurance makes the child feel better in the moment, so families provide it because they think they are helping. But reassurance-seeking is just another compulsion, and when people give reassurance they are participating in the compulsion and inadvertently feeding the OCD.

That’s because receiving reassurance once is never enough for a person with OCD. The requests will come again and again in an endless cycle that doesn’t address the root of a person’s anxiety, and actually makes the anxiety stronger. It also makes people with OCD feel dependent on those around them to feel (temporarily) better. Psychologists call this reassurance process “accommodation.”

As part of treatment Dr. Bubrick explains to family members how to recognize OCD symptoms, and how to avoid accommodation and instead encourage children to use the skills they are learning in therapy to deal with their anxious feelings in a more healthy and productive way.

Including religious leaders

In the case of scrupulosity, it often makes sense for religious leaders to be made aware of the OCD, too. That’s because they are often asked for reassurance and naturally believe that it is their role to provide guidance and answer questions.

Dr. Bubrick gives an example of treating a child who was worried about offending God so he would seek a lot of reassurance from his rabbi.

“I talked to his rabbi and explained to him the difference between OCD and scrupulosity versus being religious. The rabbi understood it very easily because he had been asked for reassurance thousands of times. So I taught him to do the same kind of support that I would teach the family.”

That includes denying kids the definitive answers to religious questions that they are often seeking. As Dr. Bubrick puts it, “You can’t answer every question. At some point you just have to have faith.”

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