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Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures", and can include "heterosexual or homosexual content" with persons of any age. As with other intrusive, unpleasant thoughts or images, most people have some disquieting sexual thoughts at times, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity. Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing. The person with OCD understands that their notions do not correspond with the external world; however, they feel that they must act as though their notions were correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, but such an individual might find their consequent behavior irrational on a more intellectual level. In severe OCD, obsessions can shift into delusions when resistance to the obsession is abandoned and insight into its senselessness is lost. (Insel and Akiskal (1986))

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