“I have an inpatient who worries that he might be a pedophile,” the psychiatrist said. “I think it’s OCD, but he has a young daughter and our social worker wonders if we should make a report to children’s services.“
This was when I first heard about “John,” as we’ll call him. A psychiatrist at a local hospital contacted me because he wanted to consult about their latest admission. The treatment team was divided on his diagnosis and what the next steps should be.
John was a devout Christian, tormented by unrelenting thoughts that he was really a child molester—a ticking bomb just waiting to go off and cause harm to his young daughter, her friends, and any children he might get his hands on. These terrifying thoughts became so upsetting that John fell into a deep depression, finally contemplating suicide as the only way to keep his daughter safe. That was when his family took him to the ER.
Because I study and treat some of the lesser-known manifestations of OCD, I am frequently in touch with patients, family members, and other mental health professionals who are trying to make sense out of thoughts that just don’t make sense. Why would a good person who loves his family agonize over such ugly thoughts if he didn’t have something to hide?
The Obsessive-Compulsive Cycle
This is the paradox of OCD. It takes the very thing a person cares the most about and turns it upside-down. Most people know of OCD as that illness that makes people wash their hands over and over, or they mistake OCD for that quirky personality trait that drives perfectionists to color-code their files and line up cans in the pantry. OCD is much broader and more debilitating than most realize. Symptoms typically fall under one of four categories: contamination/cleaning, doubt/checking, symmetry/ordering, and unacceptable/taboo thoughts. Within the category of unacceptable/taboo thoughts are the sexual obsessions and their related compulsions. People with this sort of OCD may worry that they will become gay, commit rape, or cheat on their partners, but of all the forms that OCD may take, I am convinced that worry about becoming a pedophile is the worst.
As the name implies, people with OCD have obsessions and compulsions. Obsessions are worries and fears that keep coming back. Compulsions are ritual-like behaviors the person with OCD does again and again to ensure the safety of themselves or others. When someone worries about getting ill from germs (obsession), they may wash repeatedly (compulsion). But what does a person do who worries about molesting a child? John did his best to avoid his daughter and other children, especially when no one else was around. He said repeated prayers and compulsively read the Bible. He kept asking his wife and pastor for reassurance that he was really a good person. He repeatedly conjured up mental images of children to make sure he wasn’t sexually aroused by them. These rituals made him feel better until the worries returned, and then he would start all over. The interval during which John felt better got shorter and shorter. The worries had become nearly constant and the compulsions were now taking up his whole day.
People with Pedophile OCD Are Not Pedophiles
“Whatever you do, don’t make a report until I have a chance to asses the patient,” I told the psychiatrist. I knew that if John had OCD, it was very likely that his form of the disorder would not be quickly understood by authorities, potentially resulting in a stressful quagmire of legal issues surrounding his ability to be a parent. That sort of added stress would be the very thing that might drive an already fragile person over the edge. It is true that John was in no shape to function in any capacity, much less as a father. He had been demoted at work due to his condition, as he was frequently distracted, or he would call in sick due to depression. However, people with pedophile OCD (or POCD, as it is sometimes called in the online OCD communities), are actually the least likely to harm a child. In fact, John cared so much about the well-being of his daughter that he was willing to kill himself to keep her safe.
After John was discharged, I conducted a comprehensive assessment of his symptoms. He had been diagnosed with OCD at age 12. He used to worry about religious and spiritual matters, like if he was going to heaven after he died, but as he got older his worries shifted into other areas. He once feared that he might be attracted to his sister, then that he might be gay, and most recently that he might be a pedophile.
Treatment for Pedophile OCD
It’s important to understand that John was never attracted to children (nor men, nor his sister). OCD is a malfunction in the brain that causes catastrophic worries about things that are very unlikely to occur. Although largely genetic, OCD can be treated behaviorally. I treated John with a specialized form of cognitive-behavioral therapy (CBT) called Exposure and Ritual Prevention (Ex/RP). We used the 17-session protocol developed by Dr. Edna Foa and other clinical researchers at the University of Pennsylvania, where I had treated some of the most severe cases before relocating to the Center for Mental Health Disparities at the University of Louisville. Research has shown that other types of therapy, like traditional “talk therapy” or psychoanalysis, are not helpful for OCD.
The first thing I did was to teach John how to identify and distinguish between obsessions and compulsions. He was instructed to uncritically accept all obsessions, but to resist all compulsions. Compulsions are the driving engine for OCD, so by halting them, the disorder starts to weaken its grip. We also conducted behavioral exposures, focused on doing the things John had been avoiding. Initial exposures were as simple as having John look at pictures of children without ritualizing. It was a slow start, and John cried throughout our first three sessions. He would sometimes call my cell phone in a panic when something triggered his worries, but over time his ability to tolerate anxiety increased. As we moved to up the hierarchy to bigger things, John began spending time with children and taking his daughter to swimming lessons. By the end of the treatment program, he was feeling tremendously better. Although there is no 100% cure for OCD, John became convinced he was not a pedophile.
One Patient’s Act of Bravery
I am always amazed by how quickly this treatment can help people get their lives back, which is one of the reasons I love working with people who have OCD. John was able to resume his normal life after just 17 sessions. In fact, he remains so grateful and excited about his recovery that he was willing to share his experience on a local TV show, The Power to Change. I was in the studio audience when the episode was recorded, and several of my close colleagues were expert guests on the show. One of the reasons the public knows so little about POCD is because people are afraid and ashamed by it. By putting his story out there for others to hear, I believe John’s act of bravery will make an incredible difference in the lives of many.
Bruce, S. L., Ching, T., & Williams, M. T. (2018). Pedophilia-themed obsessive compulsive disorder: Assessment, differential diagnosis, and treatment with exposure and response prevention. Archives of Sexual Behavior, 47(2), 389-402. doi: 10.1007/s10508-017-1031-4
Gordon, W.M. (2002). Sexual obsessions and OCD. Sexual and Relationship Therapy, 17(4), 343-354.
O’Neil, S.E., Cather, C., Fishel, A.F., & Martin Kafka, M. (2005). “Not Knowing If I Was a Pedophile . . . ” - Diagnostic Questions and Treatment Strategies in a Case of OCD. Harvard Review of Psychiatry, 13, 186-196.
Purdon, C. (2004). Cognitive-Behavioral Treatment of Repugnant Obsessions. Journal of Clinical Psychology/In Session, 60: 1169-1180.