Review

Sexuality and
obsessive-compulsive disorder: the hidden affair

Eva Real1, Ángel Montejo2, Pino Alonso1 & José Manuel Menchón*1

Practice points
„„ High percentages of sexual dissatisfaction have been reported in both women and men with
obsessive-compulsive disorder (OCD).

„„ The excessive need to control their thoughts, high disgust sensitivity or the concealing of obsessional beliefs
may hamper the person’s capacity for intimacy and interfere with sexual functioning.

„„ Sexual obsessions are a common clinical feature in OCD, but are often misdiagnosed in both children and adults.

„„ Compulsive sexual behavior, either sexual paraphilias or nonparaphilic sexual behavior, share some clinical
features with OCD spectrum disorders.

„„ Pharmacological treatment of OCD (mainly serotonin reuptake inhibitors) is associated with sexual
dysfunction itself.

„„ Sexual problems have a deep effect on patient quality of life. If the dysfunction is attributed to pharmacological
treatment it can make the management of OCD difficult, as it is one of the worst tolerated side effects and may
challenge patient compliance.

Summary Obsessive-compulsive disorder (OCD) is a chronic condition estimated  to

affect 1–3% of the population, with older adolescents particularly prone to developing
the disorder. It is characterized by the presence of obsessions (repetitive thoughts, images
or urges that may lead to distress or anxiety) and/or compulsions (repetitive behaviors or
thoughts performed in response to obsessions or according to rigorous rules). It is considered
one of the most disabling anxiety disorders, and many aspects of quality of life are negatively
affected by the disease. One of the less studied areas within OCD functionality is sexual health
and behavior. Sexual problems in people suffering from OCD are multifactorial and can
be explored by different (but not necessarily excluding) points of view. This article reviews
and discusses clinical and therapeutic implications of the following issues: sexual health in
OCD, sexual obsessions, compulsive sexual behavior (paraphilic and nonparaphilic sexual
phenomena) and sexual dysfunction associated with pharmacological treatment of OCD.

1
OCD Clinical & Research Unit, Department of Psychiatry, Bellvitge Hospital, L’Hospitalet de Llobregat, Neuroscience Group – Institut
d’Investigació Biomèdica de Bellvitge, Centro de Investigación en Red de Salud Mental-Instituto de Salud Carlos III, Barcelona, Spain
2
Department of Psychiatry, Hospital Universitario de Salamanca, IBSAL University of Salamanca, Salamanca, Spain
*Author for correspondence: Tel.: +34 932 607 662; Fax: +34 932 607 658; jmenchon@bellvitgehospital.cat part of

10.2217/NPY.12.72 © 2013 Future Medicine Ltd Neuropsychiatry (2013) 3(1), 23–31 ISSN 1758-2008 23
Review  Real, Montejo, Alonso & Menchón
Sexual health in obsessive-compulsive
disorder
Sexuality is a relevant aspect of functionality
that has received little attention in the case of
obsessive-compulsive disorder (OCD) patients.
It is a very complex phenomenon in which many
factors may converge to disrupt sexual function-
ing. There are many aspects that contribute to
sexual dysfunction, and it should not only be
attributed to pharmacological treatment or to
an effect of the disorder itself [1] .
Several classical studies report high per-
centages of sexual dissatisfaction and sexual
dysfunction in OCD (54–73%) [2–4] . Despite
some methodological limitations (small sample
sizes, absence of control groups, gender-specific
studies and retrospective data collection) there
is quiet consensus that women and men suffer-
ing from OCD are often sexually dissatisfied
and avoidant in their sexual relationships. Dif-
ficulties in interpersonal relationships are often
associated with OCD [5] . Although the specific
ways in which these difficulties lead to sexual
or sentimental dissatisfaction are unkown,
there seem to be some common aspects espe-
cially affected. Significant marital problems and
distress have been reported for OCD patients
[6] . Many patients do not have a partner (47%
according to Freund and Steketee) [3] or have
not had sexual intercourse for years [7] . Besides
social skill deficits, other reasons have been pro-
posed to be involved in trouble establishing and
maintaining relationships for OCD patients.
For example, the excessive need to control their
thoughts and to take control [8] , high disgust
sensitivity [9] or the concealing of obsessional
beliefs that may hamper the person’s capacity for
intimacy (either because they fear that reveal-
ing obsessions will increase the probability of
their occurence, or that it will lead to shame and
embarrassment) [10] . Moreover, fears of contami-
nation can jam sexual functioning [2] . In recent
work by Abbey et al., research is addressed to
three specific points of romantic functioning:
intimacy, relationship satisfaction and self-dis-
closure [11] . They concluded that the severity of
obsessions (measured by the Obsessive-Compul-
sive Inventory-Revised) [12] were related to nega-
tive associations in all forms of intimacy. They
also found a relationship between the Obses-
sive-Compulsive Inventory-Revised washing
scale and worry about becoming contaminated
through intercourse and oral–genital sex. How-
ever, other studies did not find this relationship
24 Neuropsychiatry (2013) 3(1)
with OCD severity and clinical dimensions.
Vulink et al. assessed subjective appreciation of
sexuality and sexual functioning in 87 female
OCD patients and 27 healthy subjects, control-
ling for the influence of medication and OCD
subtypes [13] . Compared with controls, patients
more frequently reported low or absent sexual
desire (62 vs 26%), moderate to severe sexual
disgust (26 vs 4%), decreased or no pleasure
with sexual thoughts (40 vs 19%), absent or very
low level of sexual arousal (29 vs 0%), difficul-
ties in reaching orgasm (33 vs 7%), dissatisfy-
ing orgasm (20 vs 4%), little or absent vaginal
lubrication (25 vs 4%) and lack of pleasure in
sexual activities (10 vs 0%). Although patients
with OCD reported fear of sexual intercourse
more frequently and hardly enjoyed it, they
had similar frequencies of sexual intercourse to
normal controls. Moreover, no significant dif-
ferences were found for the role of medication,
the severity of OCD or the different symptom
subtypes (the dysfunction was not limited to
patients with contamination obsessions).
Another interesting point to discuss is the
onset of sexual dysfunction within the course
of the disorder. Although patients explain sexual
problems in the medical consultation after initia-
tion of pharmacological treatment, some authors
have reported high rates of sexual dysfunction
prior to the appearance of OCD (20% accord-
ing to Freund and Steketee) [3] . Kendurkar and
Kaur compared sexual dysfunction in drug-
free outpatients suffering from three different
mental disorders: OCD, major depressive dis-
order (MDD) and generalized anxiety disorder
(GAD), as well as in controls [14] . They found
levels of sexual dysfunction in 76% of MDD
patients, 64% of GAD patients, 50% of OCD
patients and 30% of healthy controls. Severity
of illness did not correlate with the severity of
sexual problems, and orgasmic dysfunction was
the most frequently reported complaint in OCD
(but comparable with that found in women with
GAD and MDD). In another study compar-
ing sexual problems in OCD and social anxi-
ety disorder, patients with OCD also reported
more difficulties in reaching orgasm and less fre-
quent effective erections [15] . The authors ascribe
these findings to the need of OCD individuals
to keep their own thoughts under control [8] ,
when orgasm requires the capability to abandon
self-control.
Although there is consensus on the fact that
a number of OCD patients suffer from sexual
future science group

difficulties and dysfunction, the majority of
studies on the topic have methodological flaws,
such as the absence of a placebo group, a base-
line assessment (prior to the onset of pharmaco­
logical treatment) or the failure to use validated
rating scales to assess sexual functioning. These
factors limit the evidence about the rates of
dysfunction within the disorder.
Sexual obsessions
Sexual obsessions are a common clinical fea-
ture in OCD that has received little attention
in research. Reasons such as embarrassment in
discussing sexual content or because this kind
of obsession is sometimes denied seem to hin-
der the assessment of this specific issue. Sexual
obsessions include several types of unwanted,
unacceptable cognitive intrusions with ego-
dystonic sexual content that can range from
thoughts about family or children, concerns
about sexual orientation, thoughts of sex with
animals or fears about engaging in sexually
aggressive behavior. Sexually intrusive thoughts
are also highly prevalent in the normal popula-
tion (93% according to Julien et al.) [16] . For
some authors, clinical obsessions have their
origin in these normal unwanted thoughts
[17,18] . What distinguishes the unwanted cogni-
tive intrusion of the nonclinical person from
the clinical obsession of OCD is the meaning
or appraisal associated with the intrusion. The
thought–action fusion is a cognitive bias that
can maximize the significance of an intrusion,
involving an interpretation of the unwanted
thought as morally or realistically equivalent
to its behavioral manifestation [19] . Moreover,
Wetterneck et al. recently reported that indi-
viduals endorsing negative beliefs about sexual
desire experienced sexually intrusive thoughts
more frequently (and they were perceived
as more distressing) [20] . Negative, undesir-
able beliefs included the feeling of threat by
sexual desire (lust and guilt), and according
to the authors these could be mediated by
cognitive factors such as an inflated sense of
responsibility, the need to control thoughts and
thought–action fusion.
Prevalence of sexual obsessions in OCD range
from 20 to 30% according to different stud-
ies [21] . They have also been found in chidren
(4% reported by Swedo et al.) [22] , and some
cases have been reported to be associated with
previous sexual molestation [23] . Grant et al.
found current sexual obsessions among 13.3%
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Sexuality & obsessive-compulsive disorder: the hidden affair  Review
of patients, with 24.9% reporting lifetime symp-
toms [24] . They also found that patients with
current sexual obsessions were more likely to
report aggressive and religious obsessions (as
reported by other authors [25,26] ). Moreover,
they also found that patients with sexual obses-
sions reported an earlier age of onset of OCD
(15.1 ± 5.6 years) compared with subjects with-
out them (19.0 ± 10.3 years). Previous literature,
although limited, had examined clinical cor-
relates of sexual obsessions. For example, they
were thought to be more common in men with
OCD [27] or in subjects with tic disorders [28] .
They were also associated with poorer treatment
response and with poorer insight [29,30] , as well as
with impaired sexual satisfaction [3] . However,
these associations have not been found in later
studies. In the sample of 293 patients in Grant’s
study, subjects with and without sexual obses-
sions did not differ in terms of clinical sever-
ity, insight, gender, response rates (to cognitive
behavioral therapy or to pharmacotherapy), or
sexual functioning or satisfaction [24] . In addi-
tion to the reasons stated above (the patients’
reluctance to refer sexual content), the fact that
some of the previous studies had grouped sexual
obsessions with religious or aggressive obsessions
may explain the discrepancies observed between
studies.
Within sexual obsessions, sexual orienta-
tion concerns have received specific attention
by some authors. They include fears of becom-
ing homosexual, fears that others might think
one is homosexual or recurrent doubts about
whether one is homo- or hetero-sexual [31] . The
assessment of this issue is especially complex
because this symptom can be misunderstood
by clinicians and by patients as a sexual iden-
tity conflict, leading to potential flaws in treat-
ment. Unwanted homosexual thoughts are also
present in the general population [32] but OCD
patients, once more, need to control these intru-
sive thoughts (as they are perceived as highly
meaningful) and feel greater distress about
them. Williams and Farris assessed clinical and
socio­demographic correlates of individuals with
specific sexual orientation obsessions in a sam-
ple of 409 OCD patients [33] . They found that
11.9% of patients endorsed lifetime symptoms,
and were twice as likely to be male rather than
female, with moderate OCD severity. More-
over, three Yale–Brown Obsessive-Compulsive
Scale items (time, interference and distress)
were found to be significantly and positively
www.futuremedicine.com 25
Review  Real, Montejo, Alonso & Menchón
correlated with sexual orientation obsessions.
These findings suggest that these patients may
feel increased distress and be more impaired.
Compulsive sexual behavior: paraphilic
& nonparaphilic sexual addictions
Excessive nonparaphilic (and paraphilic) sexual
behavior has been related to the OCD spec-
trum in the last two decades. Excessive sexual
behavior has received several names (hyper-
philia, satyriasis, sexual addiction, sexual
impulsivity and hyperactive sexual desire dis-
order) [34,35] , with Coleman et al. the first to
propose the term ‘compulsive sexual behavior’
to explain this phenomenology [36] . Its main
features are repetitive thoughts and rumina-
tions associated with anticipatory anxiety or
tension that are followed by ‘sexual compul-
sions’, initially resisted but later conducted to
reduce anxiety or distress (similar to the relief
perceived by OCD patients after concluding
their compulsions). As opposed to paraphilias,
excessive nonparaphilic behavior is considered
an exaggerated repetitive behavior comprising
culturally accepted normophilic sexual perfor-
mances. The term impulsive-compulsive sexual
behavior is used by Mick and Hollander to refer
to all the representations of this behavior (that
exclude paraphilias) [37] that Coleman classified
previously in seven subtypes [36] : compulsive
autoeroticism (repetitive masturbation that
usually leads to genital injuries); compulsive
use of the internet or telephone (for anonymous
sexual outlets such as pornography); compul-
sive multiple love relationships (obsession and
compulsion toward finding the intense feeling
of a new relationship); compulsive sexuality in
a relationship (unending needs for sex, expres-
sions of love and attention that briefly relieve
anxiety); compulsive use of erotica (obsessive
and compulsive need to seek sexual stimula-
tion through erotica, associated hoarding and
hiding erotic materials); compulsive cruising
and multiple partners (insatiable demand for
multiple partners, considered as ‘things’ to be
used, as part of a strategy for reducing anxiety
and maintenance of self-esteem); and compul-
sive fixation on an unattainable partner (despite
lack of reciprocal response).
On the other hand, paraphilias are charac-
terized by deviant, socially unconventional
sexual behavior (exhibitionism, voyeurism, and
actions involving objects, children or other non­
consenting persons) and are associated with high
26 Neuropsychiatry (2013) 3(1)
rates of sexual hyperactivity (72–80% accord-
ing to Kafka and Hennen) [38] . The association
between OCD and paraphilias come from few
case reports, and to date it is not known whether
the prevalence of these deviant sexual behaviors
is higher or not in OCD. Some authors report
cases of paraphilias and comorbid OCD improv-
ing with selective serotonin reuptake inhibitor
(SSRI) treatment [39–41] . However, others report
a higher amelioration of OCD symptoms with
these medications compared with a mild or
null effect on comorbid sexual behavior [42,43] .
The OCD hypothesis has been proposed as a
model to explain these deviant behaviors, but
important inconsistencies arise to differentiate
them. The most relevant is that pure obses-
sions in OCD are egodystonic, while repetitive
sexual thoughts and actions in paraphilias (as
well as compulsive sexual behavior) are usually
egosyntonic. This means that sexual obsession
in OCD is always unacceptable and never gives
pleasure to the individual. However, feelings in
paraphilias and compulsive sexual behavior are
often positive and can act as triggers for engag-
ing in sexual behavior, contrary to OCD patients
who rarely engage in actions reflecting their
obsessional thoughts (Table 1) [44] .
Although some aspects such as the comor-
bidity of excessive sexual behavior with OCD
and their similar response to SSRIs has been
proposed by some authors to bring these disor-
ders closer together [37] , most authors support
the conceptualization of excessive sexual behav-
ior as an addictive behavior [37,44] . Similarities
between these disorders include a craving state
prior to behavioral performance, escalation of
sexual activity, impaired control over behav-
ioral engagement, withdrawal symptoms such
as anxiety, guilt and rumination, related to a
reduction of sexual activities, and continued
behavioral engagement despite adverse conse-
quences [45] . Moreover, comorbidities between
excessive nonparaphilic sexual behavior and
other addictions are significantly greater than
with OCD; 64–71% in the case of addictions
versus 15% with OCD [46,47] .
Many medications, mainly high doses of
SSRIs such as citalopram, fluoxetine and ser-
traline, have been reported to be effective in
the treatment of paraphilic and nonparaphilic
excessive sexual behavior [48–50] . However, other
agents have also been cited in case reports as
helpful in treating these disorders (atypical anti-
psychotics, lithium, methylphenidate, tricyclic
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 Sexuality & obsessive-compulsive disorder: the hidden affair  Review

Table 1. Characteristics and examples of sexual obsessions, paraphilias and issues related to romantic love.
Sexual obsessions
Characteristics
Cognitive, unwanted thoughts
Unacceptable, repetitive intrusions
Unpleasant, do not represent
fantasies or wishes
Egodystonic
High anxiety and negative ‘affect’
Moderate response to SSRIs
Examples
Fears of becoming homosexual
Fears of engaging in sexual activity
with children or animals
Fears of engaging in aggressive/
harmful sexual behavior
Incestuous thoughts/images
SSRI: Selective serotonin reuptake inhibitor.
Paraphilias Romantic love
Deviant, unconventional sexual behavior Sentimental dissatisfaction due to several reasons
(especially difficulties in interpersonal relationships)
Egosyntonic (usually perceived as Hampered sexuality
exciting and positive)
Associated with sexual hyperactivity SSRIs may cause sexual dysfunction
(72–80%)
Poor response to SSRIs –
– –
– –
Exhibitionism Sentimental dissatisfaction due to the need to take control,
concealing of obsessions from the partner (shame and
embarrassment) and social skill deficits
Voyeurism Hampered sexuality due to difficulties in reaching orgasm,
low/absent sexual desire, less frequent effective erections,
high sexual disgust sensitivity and worry of being
contaminated by corporal secretions (in patients with
contamination obsessions)
Transvestism –
Sexual actions involving children, –
nonconsenting persons and objects

antidepressants, nefazodone and topiramate)
[51–56] . The optimum therapeutic interventions
use both pharmaco­logical and psycho­logical treat-
ment, with cognitive-­behavioral therapy the most
recommended for excessive sexual behavior [57] .
Sexual dysfunction associated with
­pharmacological treatment in OCD
Although there is a lack of studies assessing sex-
ual dysfunction associated with pharmaco­logical
treatment in OCD, a lot of data describing the
effects of antidepressants on sexual health are
available. SSRIs and clomipramine are con-
sidered the most efficacious agents at relieving
OCD symptoms. SSRIs have been reported to be
particularly prone to causing sexual side effects,
but data are highly variable, ranging from small
percentages to more than 80% of cases [58] .
According to the review by Soomro et al., the
relative risk for sexual dysfunction for the dif-
ferent SSRIs (compared with placebo) range
from 5.74 to 18.64 [59] . Sexual problems have
also been found to occur in healthy volunteers
after administration of SSRIs [60] . The majority
of reports have been focused on SSRIs and it has
been suggested that SSRIs lead to more sexual
dysfunction than tricyclic antidepressants [61] .
However, the reasons for the increased reporting
of SSRI-related sexual effects (compared with
other types of antidepressants) are not clear,
and many reasons could be involved (e.g., the
much wider use of the newer antidepressants,
more recent systematic ways of obtaining data
on sexual dysfunction and greater interest in the
patient’s quality of life) [62] .
Given the complex nature of the sexual dys-
function phenomena, the estimation of the inci-
dence and prevalence of it varies greatly between
studies. Some of the reasons suggested in the
reviews by Balon [62] and Montgomery et al. [63]
are the under-reporting of sexual problems by
patients, the existence of methodological flaws
due to the failure to use validated rating scales
and the difficulties in establishing a normal pop-
ulation baseline. The incidence of global SSRI-
associated sexual dysfunction would probably
lie between 30 and 50%, but low percentages
up to more than 80% have been reported. The
differ­ences for various SSRIs have also been
studied, with great variations according to some
authors [64–66] .
SSRIs and clomipramine increase synaptic
availability of serotonin. Stimulation of post-
synaptic serotonin receptors are suspected to

future science group www.futuremedicine.com 27

Review  Real, Montejo, Alonso & Menchón
be responsible for some of the adverse effects of
these drugs, although various neurotransmitter
systems seem to be involved [67] . All aspects of
sexual function can be interfered with by SSRIs,
mainly loss of libido and delayed orgasm (and
also erectile dysfunction and delayed ejacula-
tion) [58] . The assessment of sexual functioning
in OCD patients is necessary for several reasons.
First, there is evidence that OCD drug response
is better at higher doses, compared with the stan-
dard doses used in depression [68] . Moreover, it
has been estimated that 40–60% of patients
do not respond completely [69] and maximum
doses of SSRIs and augmentation strategies
are commonly used, leading to higher rates of
side effects. Augmentation strategies involve
antipsychotic agents. Although there are dif-
ferences between antipsychotic drugs, some of
them have also been reported to induce sexual
side effects [70] . In these cases, the pathogenesis
of sexual dysfunction seems to be related to
increased prolactin levels, although it may not
be the only mechanism involved [71] . Sexual dys-
function induced by pharmacological treatment
can lead to several problems in the management
of psychiatric disorders. It is one of the worst-
tolerated side effects, especially if the patient is
a man [72] . In addition, older adolescents seem to
be particularly prone to developing the disorder
[73] and the onset of sexual problems can compli-
cate normal initialization of sexual behavior or
hamper the functioning of a previously sexually
active adolescent. The results of previous studies
in the Spanish population showed that 40% of
men and 20% of women with sexual dysfunc-
tion had considered discontinuing treatment for
this reason [70] .
Box 1. Management of pharmacological-associated sexual dysfunction.
ƒƒ Switch to a drug with lower incidence of sexual dysfunction: switching
to antidepressants mirtazapine, bupropion or agomelatine may diminish
drug-induced dysfunction (however, these drugs do not have an indication
for obsessive-compulsive disorder); for antipsychotics, it is better to choose
aripiprazole, quetiapine or olanzapine, rather than risperidone, amisulpride or
paliperidone
ƒƒ Wait for spontaneous remission of the dysfunction or for tolerance to develop
ƒƒ Reduce doses of the antidepressant or antipsychotic (with continuous and rigorous
assessment of clinical symptoms)
ƒƒ Introduce drug holidays; the antidepressant can be discontinued for a brief period
(e.g., 1–2 days), with sexual activity scheduled at the end of the period
ƒƒ Add ‘antidotes’ or augmenting agents (i.e., tadalafil and sildenafil have been found
to improve erectile function and overall sexual satisfaction in men with selective
serotonin reuptake inhibitor-associated erectile dysfunction and may improve
antidepressant-induced female orgasmic disorder) [82,83]
28 Neuropsychiatry (2013) 3(1)
The assessment of sexual function should be
performed using specific and validated question-
naires for obtaining quantified evaluation values.
Examples of validated instruments include the
Changes in Sexual Functioning Questionnaire
[74] , the Arizona Sexual Experience Scale [75,76] ,
the Psychotropic-Related Sexual Dysfunction
Questionnaire [76,77] , the International Index
of Erectile Function [78] , the Derogatis Inter-
view for Sexual Functioning [79] and the Female
S­exual Function Index [80] .
Listed in Box 1 are strategies recommended
by specialized clinicians for the management of
pharmacological-associated sexual dysfunction;
for review see Balon [62 ] and Basson et al. [81] .
Conclusion & future perspective
Sexuality in OCD is a field that has been scarcely
studied despite the possibility of a significant
relationship between some OCD features and
sexual functioning. Some of the cognitive biases
featured in OCD may affect sexual satisfac-
tion and functioning. Furthermore, particular
symptoms, such as contamination obsessions or
high disgust sensitivity, may also impair sexual
performance. Even fewer studies have been car-
ried out on the impact of the presence of sexual
obsessions.
The effect of drug treatment on the sexual
functioning of OCD subjects may be another
focus of concern. Patients with OCD are usually
treated with SSRIs at higher doses and for longer
periods than in other disorders and, therefore, it
increases the likelihood of suffering from sexual
dysfunction.
Sexuality is a domain to be taken into account
in the assessment of OCD given that, on the
one hand, sexual dysfunction due to the dis-
order may be frequent although not reported
by the subject and, on the other hand, sexual
dysfunction due to drugs may affect adherence
to a treatment that is usually maintained for a
long time.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert t­estimony, grants or patents received or
pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.
future science group

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