I found a great article about Hocd on the ocd center of los angels website This article helped me understand what I was going through and I wanted to put it on my blog to help educate people on the subject. If anyone else is going througn thishopefully the can find this article and get one step closer to feeling better
~Many people mistakenly think of Obsessive Compulsive Disorder (OCD) solely as a condition in which people wash their hands excessively or check door locks repeatedly. There are actually many sub-types of OCD. In this ongoing series, the OCD Center of Los Angeles discusses Gay OCD, also known as HOCD or Sexual Orientation OCD.
So, Am I Gay or What?
Having gay thoughts is not the same as being gay
I sat down to write this blog on Gay OCD while my wife and I had started to watch a movie (It’s been suggested I work too much). It’s either irony or personalization, but the opening scene of the movie involves a man kissing his lover… another man. This is the second film in two weeks that I’ve rented which involve men and their male lovers, something I was not aware of when I selected the films.
Or was I?
Gay OCD is sometimes referred to as HOCD, an abbreviation for Homosexual Obsessive Compulsive Disorder. This is an unfortunate abbreviation because it misses the true nature of this manifestation of OCD.
First, it is not exclusive to heterosexuals. Over the years, therapists here at OCD Center of Los Angeles have treated many homosexuals (male and female) who are plagued by obsessive fears of being “straight”, and who suffer equally when OCD attacks their sexual identity. Furthermore, the fears that clients with this condition report have little to do with actually becoming gay (or straight). At its core, Sexual Orientation OCD is the fear of not knowing for sure, paired with the fear of never being able to have a healthy, loving relationship with a partner to whom one feels genuinely attracted.
Similarly, someone with contamination fears may on the surface appear to be overly concerned with dirt, but this fear is indicative of an overwhelming fear of never feeling clean again. “If I don’t wash my hands, I will feel this way forever and nothing will be right in the world”. For every cry of “does this mean I’m gay?” there appears to be a louder cry of “does this mean I can’t be heterosexual anymore?”
In my experience with these clients, it also appears to have little to do with homophobia or bigotry. On the contrary, these clients are often quite open- minded on issues related to sexual orientation. In fact, it is their own lack of bigotry that often ends up being a fear trigger. One notable exception is cultural bigotry in which part of their Sexual Orientation OCD is fueled by the broader societal beliefs of the sufferer’s culture of origin. For simplicity’s sake, I will refer to “gay” throughout the rest of this article to describe any sexual orientation that is not one’s own. For those who are homosexual but have obsessive fears of “straightness” please substitute the appropriate word.
One thing that has struck me as bizarrely consistent is that OCD sufferers who obsess about their sexual identity seem notably less “gay” than me. Allow me to illustrate:
•Picture a man who loves the arts, has no interest in sports, admires electronic music, doesn’t “pull chicks” at the bar and feels little discomfort in the presence of naked men in the gym locker room. Obviously gay, right? But then, that describes me, despite the fact that I am straight.
•So what is the opposite of me? A man who loves watching sweaty guys fight over a ball, admires music fronted by long-haired androgynous men singing about love, and showers at home to avoid naked guys… Well, this sounds pretty gay too.
So this is what happens when your OCD locks in on sexual orientation. Whoever you are, whatever you do, suddenly seems gay. Just as the selective abstraction found in Contamination OCD makes it appear that dirt is everywhere, so does this same distortion make gayness appear to be hunting you down.
When this form of the OCD is in full swing, sufferers tend to over-attend to any indication that their “sexual orientation of origin” may be compromised. Since anxiety, distraction, and a lack of being “in the moment” are likely to make sexual experiences less gratifying, this often becomes a major trigger. “If I don’t always want to have straight sex, I must be gay!” Interestingly, the idea that they might be asexual altogether doesn’t come up. It’s the fear of the dark side, not the neutral one. And the idea that their libido is actually compromised as a result of the anxiety and obsessions that they experience due to their OCD just sounds like an excuse, rather than a rational argument. You simply cannot win when you play OCD’s game – OCD cheats.
Many people who suffer from Sexual Orientation OCD get stuck on the notion that they may or may not find someone attractive and that this may or may not mean something important about them sexually. If they see a member of the same sex, they feel it is possible that the “seeing” was really intentional “looking” and that this intentional looking indicates a secret sexual desire. They will often then attend to and monitor their genitalia to check for arousal in an attempt to prove or disprove the theory. This often backfires since attention causes sensation. This, by the way, is true of other body parts as well. When you consider picking something up with your hands, the brain actually sends a priming impulse to the hand before you’ve even made a decision to move.
It is important to recognize the fundamental error in the line of thinking that pairs acknowledgment of attractiveness with sexual desire. Attraction is a word we use to describe the feeling of being pulled into something, like a magnet. We generally conceptualize this feeling of being pulled-in as evidence of our desire to be near someone or something. This idea is troubling for the OCD sufferer who feels a strong need for
certainty about the meaning of attraction, particularly when the false assumption is being made that all attraction is sexual attraction.
I often hear the question, “Am I attracted to this person?” from my clients. I’m never quite sure how to answer it because it is a loaded question. The words themselves only ask if the identified object is one they feel compelled to be near. Furthermore, the reason for the attraction could be any number of things, positive or negative. But the meaning my clients are hinting at is usually more along the lines of, “Do I desire to have sexual intercourse with this person?” The idea that I personally could even know what another person truly desires indicates an error in information processing. What is more striking is the fact that their OCD does not allow them to consider the possibility of being attracted to someone, while concurrently not wanting to engage in sexual behavior with that person.
Every person is capable of identifying others as “attractive”. This means that a person, regardless of gender, meets some set of criteria that is personally and culturally seen as attractive. For Westerners, this may have something to do with musculature, bone structure, and/or facial symmetry. But according to researchers, ancient Mayans apparently had a cultural preference for those who were cross-eyed and had flat foreheads. In other words, “attractive” is not a fixed concept, and has different meaning for different people.
When we look at an attractive landscape in nature, we desire to be near it. When we see an attractive person, this also compels us to linger. In some cases it may be envy that draws us in. Saying, for example, “I wish I had a body like that.” But in many cases, it’s just giving a thumbs-up to the universe. “Good one, Universe, you made an attractive person”. But for the person suffering with Gay OCD, this triggers abject horror.
I often get asked the question, “Do you think I’m gay?”. After the usual therapist-speak of “Does my opinion matter? Why do you want to know? And what would it mean to you if I thought you were?”, I suggest that my clients study the evidence with me. The test is not very thorough. It has one, simple question, with a few optional follow-ups:
“Do you like to have gay sex?”
That’s pretty much all we need to know in order to determine whether or not we should get busy with the work of treating their OCD.
I have seen clients with OCD who also happen to be gay. They obsess about the same things that other OCD sufferers struggle with, except quite notably that they don’t obsess about their sexual orientation. The only exceptions to this are gay clients who obsess about the possibility that they might actually be straight. And I have never had a homosexual client tell me they weren’t sure if they liked homosexual sex.
On the other hand, for straight individuals with Gay OCD, their biggest fear is often that they will seek therapy for unwanted thoughts about their sexual orientation, and that the therapist will tell them that these thoughts indicate that they must actually be gay. Unfortunately, this often happens when clients end up with ill-informed treatment providers who don’t understand what constitutes Obsessive Compulsive Disorder, and illuminates the importance of finding a therapist who thoroughly understands OCD and its appropriate treatment with Cognitive Behavioral Therapy (CBT).
To put it as simply as possible, gay thoughts are not unwanted by homosexuals. For homosexuals, gay thoughts are what psychologists call ego-syntonic thoughts. That’s just a fancy way of saying that their gay thoughts are in keeping with their true values and desires. Conversely, for heterosexuals, gay thoughts are ego-dystonic, which simply means that the thoughts are in opposition to their true values and beliefs. Furthermore, gay people like to have gay sex, while straight people with Sexual Orientation OCD are terrified of having gay sex.
Treatment of Gay OCD / HOCD
Gay OCD (also known as HOCD) can be successfully treated with Cognitive Behavioral Therapy and Mindfulness
As noted in our previous post, Gay OCD (also known as HOCD or Sexual Orientation OCD), is a condition in which an individual, straight or gay, obsessively doubts their sexual orientation. Research has consistently found that the most effective treatment for this and all types of Obsessive Compulsive Disorder (OCD) is Cognitive Behavioral Therapy (CBT), with a focus on Exposure and Response Prevention (ERP).
Over the past ten years, many OCD specialists have also begun to integrate concepts from Mindfulness-Based Cognitive Behavioral Therapy (MBCBT) into their treatment of OCD. In MBCBT, the goal is to change one’s perspective toward one’s thoughts, as well as the behavioral responses these thoughts lead to. Using mindfulness, it is possible to circumvent much of the OCD process and ultimately reverse it into remission.
Mindfulness is particularly helpful when treating the more obsessional variants of OCD, including HOCD. When combining MBCBT with the traditional tools of Cognitive Behavioral Therapy, the following treatment techniques are used to address the unwanted thoughts and behaviors seen in Sexual Orientation OCD.
Mindfulness for Gay OCD / HOCD
Thoughts are just thoughts. You have them because you have a brain. The rest is just details.
Practicing mindfulness means actively observing your own tendency to over-attend, over-value, and over-respond to thoughts. In Sexual Orientation OCD, the sufferer is over-attending to ego-dystonic thoughts related to sexual identity. For most people, if they have a thought about a meteor hitting them today, they quickly shrug it off with a “whatever happens, happens” approach. Anything is possible, and being wrong would mean certain death, but it hasn’t happened so far and life is too short not to go outside just because of the highly unlikely possibility of being struck by a meteor. But if an individual with Sexual Orientation OCD has a thought of secretly or suddenly being gay, they feel an overwhelming need to investigate, neutralize, and suppress that thought.
When you over-attend to any thought, you automatically give it increased value. It is no longer a thought that just popped up for no apparent reason; now it is an important thought you carefully monitored until it presented itself! And now that it has been over-valued, you desperately want to respond to it. Of course, any response in this situation will be an over-response, because the thought has no important value in the first place. These unnecessary responses are essentially compulsive efforts to neutralize or eliminate a thought that was meaningless and not worth more than a moment’s attention. Compulsive behavioral responses in Sexual Orientation OCD typically involve the following:
•Avoidance of sexual orientation-related triggers (i.e. gay people, gay films and TV shows, gay neighborhoods);
•Physical rituals designed to “prove” ones sexuality (i.e. checking ones genitals for signs of arousal, increased sexual activity in an effort to prove to one’s self that they are straight, compulsive masturbation to straight pornography);
•Mental rituals aimed at forcing unwanted gay thoughts away (over-analysis of gay thoughts, trying to force straight thoughts into consciousness, mentally reviewing past sexual encounters, etc.).
Cognitive Restructuring for Gay OCD / HOCD
Everyone has distorted thinking at times. And people with Sexual Orientation OCD have distorted thinking about their sexuality. In Cognitive Restructuring, the objective is to learn to identify distorted thinking, and challenge it with rational, objective, evidence-base thinking. Identifying distorted thinking means learning the language of OCD and knowing when to call yourself out on maladaptive cognitions.
This can be a slippery slope for the obsessive-compulsive who may feel inclined to use restructuring as a mental ritual. The trick is to be straight (no pun intended) and to the point. A triggering situation occurs, you think something about it, and then you have one shot to modify that thought for something more rational. It is important to remember that this is not a debate between you and the OCD. The OCD got its chance to call you gay. Then you get your chance to challenge the idea. Anything else is mental ritual.
It is important to understand that mental rituals are compulsions, and that they make your OCD worse. By spending mental energy trying to prove your sexual orientation, you are only contributing to the brain’s misconception that the thought was important, and that there is some reason to doubt your orientation. When simple cognitive restructuring is not doing the trick, it is always a wiser choice to return to mindfulness and to accept that many thoughts happen without those thoughts having to mean something important. Don’t get conned into an OCD contest you can never win.
Cognitive distortions in Sexual Orientation OCD typically include the following:
•All-or-nothing thinking – “If I have even a single gay thought, that must certainly mean that I am gay.”
•Catastrophizing – “Being gay would destroy my life.”
•Discounting and minimizing the positive – “Despite having had these thoughts many times, I’ve always been straight, but this time is different.”
•Comparison – “I’ll never be happy like that straight couple over there.”
This is, of course, just a sample of the trickery OCD uses with this issue. Identifying your OCD’s thought traps and mastering the language of CBT for OCD is what you should expect in the early part of treatment.
Exposure and Response Prevention for Gay OCD / HOCD
The greatest change, in fact the only change, occurs when we change our behavior. We would all like to feel better before actually taking the steps needed to get better. But that’s putting the cart before the horse, and is not realistic. We must first change behavior, and then learn patience while we wait for thoughts and feelings to catch up. Learning to ride a bike requires exposure to the fear of falling, paired with prevention of the instinctual response of jumping off the bike to prevent falling. Nobody with a fear of falling off a bike gets over that fear before getting on the bike.
Some OCD sufferers may be concerned that this means engaging in homosexual behavior to overcome their fear of being gay. This is missing the mark. The fear is not about having gay sex, but is instead about being stuck with thoughts that you think have the power to ruin your enjoyment of heterosexual sex and destroy your life. So “testing” yourself by engaging in sexual contact outside of your historically-true sexual orientation as a means to overcome this fear will generally backfire.
Instead, a more effective approach would be exposure to thoughts of homosexuality and the fear that you are not who you thought you were. Your OCD brain tells you that you must not think certain thoughts because they are dangerous to you. But your rational brain has the power to stand up to this bully and burn out the OCD circuits by intentionally exposing yourself to unwanted thoughts about your sexual orientation. This often takes a combination of visual, situational, and imaginal exposure.
•Visual exposure would typically involve looking at images or videos of things that trigger the unwanted thoughts while resisting mental rituals to explain or neutralize the thoughts. To be done effectively, this form of exposure would start with something mildly triggering, such as a picture of an attractive same-sex celebrity. Once this no longer elicits a fear response, the exposure would be heightened to repeatedly looking at pictures of a more sexual nature, and ultimately multiple viewings of explicit pornographic material.
•Situational exposure would typically involve visiting gay neighborhoods, bars, nightclubs, listening to “gay” music, spending time with gay acquaintances, etc.
•Imaginal exposure would typically involve writing out a short, but explicit story in which you describe yourself living a homosexual lifestyle, and the unwanted consequences that you envision would arise from this.
The objective of these exposures is to intentionally, but gradually, raise the anxiety caused by your unwanted thoughts, and to ultimately demonstrate to your brain that you can tolerate the presence of these thoughts. Conversely, compulsions teach the opposite – that you cannot tolerate discomfort. Exposure is the same mechanism employed any time you wish to gain strength. You lift a weight, something heavier than you normally would lift in your everyday life. Over time that weight becomes easier to lift. But the weight stays constant. What changes is your ability to accept the weight.
On the subject of consequences, it is important to remember that Sexual Orientation OCD causes suffering equal to that of other forms of OCD. Culturally, the idea of someone worrying about being gay might trigger a sense of amusement in someone not afflicted with this form of OCD. However, let’s not overlook what the person suffering from Sexual Orientation OCD is really afraid of:
•“My entire history as a lie.”
•“I will be rejected and abandoned by my family and friends.”
•“I will be subject to public ridicule.”
•“I will have to spend the rest of my life having sex that feels alien to who I am.”
•“I will have a lifetime of self-hatred and self-disgust.”
•“I will never truly connect to another person again.”
In short, dying alone in the dark. Ask the right questions, and every obsessive fear arrives here. But it’s important to point out that what the OCD sufferer fears is not accurate. While being part of any cultural minority has unique challenges, I have never heard any genuinely gay clients describe their own homosexuality in the above terms. Simply put, what the OCD is threatening is not true.
Sexual orientation is so wrapped up in identity that it’s an easy target for OCD. Obsessive Compulsive Disorder spends its free time researching new and exciting ways to lock you into fear. There really is no reason to ask why Sexual Orientation OCD happens. The answer is obvious – because it works.
CBT and MBCBT are aimed at reversing a learned fear cycle. HOCD says you must not have gay thoughts. But gay thoughts exist. People who say they’ve never had one are lying; not because they are secretly gay, but because it requires a gay thought to even know what the word means. So if something necessarily exists and you are trying to prevent it from existing, this is not going to work out well. If instead, you can accept the reality that a variety of sexual thoughts occur as a function of having a brain, then you can train yourself to treat those thoughts with whatever significance that you, not your OCD, deem appropriate.
When we initially published part one and part two of this series on Gay OCD (also known as HOCD), it was intended solely to reflect this rather common form of the disorder as we saw it presented in many of our clients. We had not anticipated such a significant online response, with so many additional questions and angles on the subject.
Sexual obsessions in general are under-reported because of shameful feelings associated with them. And yet there is probably a somewhat higher prevalence of sexual obsessions in OCD than any other obsession for this same reason – the thoughts are unwanted! This seems so very evident in Sexual Orientation OCD because the feared consequence appears so tangible. In other common OCD obsessions, such as “Harm OCD”, the idea that someone might be in denial of violent impulses is plenty terrifying. However, there is an understanding that being violent is unacceptable in and of itself. With Sexual Orientation OCD, the sufferer generally does not see anything wrong with being gay per se, as long as it is not themselves being gay. This causes a lot of confusion and a lot of resistance to seeking treatment.
We’d like to use this latest installment in what has become a series of discussions on Sexual Orientation OCD to be more specific about the different ways we have seen this OCD manifestation present and the different Cognitive Behavioral Therapy (CBT) strategies that appear to work. We have attempted to categorize them, but it’s important to remember that sufferers are likely to fall into a combination of several categories and not just one. Also bear in mind that we will continue to use “gay” or “homosexual” to be synonymous with alternative orientations for simplicity’s sake only. Homosexual and bisexual individuals with OCD can, and do, sometimes obsess about being straight.
This is perhaps both the most common and the least reported subtype of HOCD because it is easy to overlook the OCD characteristics. In short, All-Or-Nothing HOCD describes the experience of those who have always been of one orientation, have never experimented with other orientations, and who do not have gay fantasies, but who just randomly have a “gay” thought or feeling one day and it scares them. It is often reported as starting with a simple, “Did I find that person attractive?” and “What does it mean that I can’t be 100% certain that I did not find that person attractive?”
In All-Or-Nothing HOCD, the primary distorted belief is that straight people never have any gay thoughts, so any gay thoughts must be an indicator of latent homosexuality. In fact straight people do have gay thoughts, but generally prefer not to apply them to gay sexual behaviors. In actuality, it is not possible to know what the word “gay” even means on a literal level without having what can only be described as a “gay” thought.
So for the sufferer who sees gay thoughts as contaminating an otherwise purely straight mind, compulsions are going to be focused on making the gay thoughts go away through various proving rituals. This may take the form of compulsive masturbation to straight fantasies or avoidance of anything that might trigger the presence of a gay thought. It often involves avoiding people who the sufferer sees as even having the potential to be gay. Just as a hand washer tries to be certain there is not contaminant on their hands, this HOCD sufferer is aiming for total eradication of the unapproved gay thought.
Cognitive Behavioral Therapy (CBT) treatment strategies for All-Or-Nothing HOCD should involve gradual exposure to things that trigger gay thoughts while the sufferer practices resisting the urge to tell themselves they are not gay.
People are complicated. That means relationships are twice as complicated. Some people are lucky in love, some people are unlucky, some people are both, and some people really can’t tell because of their OCD. This form of HOCD occurs when an OCD sufferer uses potential gayness as an explanation for what they see as failed heterosexual relationships. Women with Relationship HOCD may identify themselves as “man-hating dykes”, while men may see themselves as “just not understanding women”, and may describe themselves as being “in denial” of their “true” sexual orientation.
Often in cases like these, the HOCD itself is a smokescreen for what is sometimes called Relationship OCD (aka ROCD) or Relationship Substantiation OCD. Those with ROCD tend to have obsessions that revolve around fears of not “really” loving or being sexually attracted to their spouse or partner, not being involved with the right person, or not being the right person for their partner. Those with Relationship HOCD can put off dealing with these issues if they conceptualize themselves as being incapable of having a healthy heterosexual relationship because, in their mind, they might actually be gay!
Because this form of HOCD emphasizes partnership, sufferers are likely to over-attend to how they relate to people of the same sex. A man may notice that he feels better understood, has more in common with, and enjoys his time with another man in ways that women do not satisfy him. The only thing missing is the sex, he thinks, and this triggers a lot of compulsive analysis about who he is “really” wired to love.
Similarly, a woman may become aware that other women share qualities their male partners seem to lack – for example, sensitivity, patience, and emotional availability. In those who don’t have HOCD, this same-sex identification is looked at as totally normal. “Of course my same-sex friends understand where I’m coming from. They know what the other sex is like! They get my interests and motivations!”. The word “gay” doesn’t enter into the equation.
CBT for Relationship HOCD is going to involve traditional Exposure and Response Prevention (ERP) for sexual orientation fears, but also exposure to behaviors that demonstrate vulnerability to a romantic partner, accepting uncertainty about the “quality” or “completeness” of heterosexual relationships, and other non-avoidance exposures.
This form of HOCD generally has more to do with depression than sex or sexual orientation. Typically (though not exclusively) this seems to occur in people who were severely mistreated, abused, or bullied. Just as this can occur in Social Anxiety Disorder, the “bully” takes up residence in the person’s mind and any perceived failure in life triggers an internal statement of “You’re gay.” It’s meant as an insult, more than a suggestion that one should set about finding themselves sexually.
The constant inner-abuse seen in this type of HOCD often leads to a deeper depression, which further distorts the intrusive thoughts, which in turn leads to even more depression. In some cases this may lead to a pseudo-gay fantasy state in which the sufferer imagines themselves living out what they see as the greatest disappointment to their parents. The line of thinking is that they are so unlovable as to be invisible to their desired orientation. In treating those with this type of HOCD, there may be more emphasis on cognitive restructuring and learning to identify “bully” thoughts as distorted glitches in the mind which are essentially irrelevant to sexuality. Because ERP requires significant motivation and commitment, it may also be clinically appropriate to focus on the depression first before engaging in exposures.
Experimental History HOCD
Despite the fact that same-sex exploration is common in children who are learning about the human body (i.e. playing “doctor”) and discovering how different things look and feel, people with OCD who obsess about their sexual orientation may use benign childhood experiences as “proof” of latent homosexuality. So despite a post-pubescent life of heterosexual behavior, the presence of unwanted homosexual thoughts triggers frightening doubts. The sufferer is likely to compulsively review childhood memories and the unknowable memories of thoughts and feelings that might have been had during any same-sex exploration. “What exactly did I do and why?”
It is also common for teenagers throughout the course of puberty to experience confusion related to gender, orientation, and other sexual issues. As the sexual brain develops, so too the does the sexual mind. For people with OCD during their teens, this can be very troubling. For those whose HOCD develops later, they may look back on this period in which their sexuality was developing and compulsively analyze anything that could be construed as inconsistent with their current sexual preference.
Another variation on this reflecting form of HOCD is compulsive analysis of any same-sex play that might have taken place in college or at some other point in life. A big part of treatment for those with this type of HOCD is identifying mental checking as a compulsion to be resisted, instead of as a way to figure out one’s sexuality. Curiosity is not orientation. Whatever happened, happened.
Real Man / Real Woman HOCD
People who suffer from this form of OCD place a lot of emphasis on masculinity and femininity and the cultural expectations that come with them. A male sufferer might notice an attractive male, and then chastise himself for being able to notice attractiveness in males. He assumes this is a sign of femininity, something a “real man” would have no ounce of (again see the all-or-nothing thinking). This can also present itself through a man’s affinity for the arts or other things he may have been culturally primed to see as non-masculine.
Cognitive Behavioral Therapy (CBT) for this form of HOCD may involve more exposure to material that the sufferer sees as “dainty” or weak, such as watching program with a flamboyant homosexual character or attending a ballet. This is sometimes more triggering than exposure to gay pornography.
Similarly, a heterosexual woman may notice another woman is beautiful and then distort this through the belief that “real women” only ever think about men. It also may involve avoidance of assertive behavior or any other cultural attribute traditionally associated with masculinity. Exposure for this sufferer may involve images and films involving “butch” lesbians or feminist literature.
Groinal Response HOCD
The functioning paradigm here is, “I must experience sexual arousal or groinal sensations only in very specific pre-approved circumstances.” These circumstances typically mean in the presence of an attractive, age-appropriate member of the opposite sex. But there are a few important considerations to note here:
•all sexual thoughts (wanted or unwanted) may cause sexual arousal;
•attending to one’s groin actually causes sensations to occur there;
•there are sensations going on in your groin all the time, but unless you go out of your way to pay attention to them, you just don’t notice them;
•groinal sensations often occur for no reason.
Men don’t get headaches just because they thought of something painful and they don’t get erections just because they are feeling sexual. In short, who knows what’s going on down there? Yet the HOCD sufferer is going to compulsively check and analyze sensations for evidence of homosexuality. Part of the confusion the OCD capitalizes on is the fact that groinal stimulation is generally considered a positive sensation. Fellatio or cunnilingus is going to feel good no matter what gender is delivering it, but the HOCD mind insists it only be delivered by a person to whom we are attracted in order to accept it. HOCD manipulates the mind into thinking that any positive groinal sensation at the “wrong” time must mean a general sexual preference to whatever is in the environment at that moment.
Cognitive Behavioral Therapy(CBT) for the treatment of this type of HOCD is going to involve identifying and challenging distorted beliefs about groinal responses and exposure to arousing material that falls outside of their traditional preferences.
Not everyone agrees, but many believe as Alfred Kinsey did, that sexuality exists on a scale with straight on one side, gay on the other, and people mostly somewhere in the middle. While it will no doubt be triggering for some readers to consider, many people who identify as heterosexual sometimes have homosexual thoughts, feelings, sensations and fantasies. Those without obsessive-compulsive tendencies allow themselves to enjoy this aspect of their reality. These are people who prefer sexual activity with the opposite sex, but also find same-sex fantasies (and even behaviors) to be somewhat intriguing and arousing. They are not bisexuals, who would likely say they are quite capable of sexual and romantic fulfillment with either sex, but are instead heterosexuals who simply are not dangling off either edge of the Kinsey scale.
For those people who experience themselves as somewhere within this spectrum of sexuality, but also have HOCD, this can be very upsetting. They will want to know for sure if they are bisexual or not, how far in one direction or another they “belong”, and what the “right” term is to describe themselves. “Am I 10% gay? 20%? If I don’t know for sure, then I will always feel that I am harboring a secret.” Without an appropriate label, they live in constant fear of an identity crisis.
Treatment for this type of HOCD relies heavily on Mindfulness Based CBT and resisting compulsive mental analysis. The exposure is not aimed at homosexuality, but at uncertainty. This can sometimes be done in the form of an imaginable exposure script in which the sufferer describes the negative consequences of never knowing what to label themselves.
(Really) Need-To-Know HOCD
These are people who identify as heterosexual but have been struggling with untreated (or mistreated) HOCD to such an extent that they have gone from mental checking, to physical checking, to actual experimental checking. This is somewhat rare and I would imagine some people might read this and say, “OK, let’s just call it gay then,” but that’s not what is happening here. People who suffer from OCD, regardless of the manifestation, are struggling against an intolerance for uncertainty. People without OCD largely tolerate uncertainty by not paying much attention to it.
For any reader who does not have OCD, try thinking really hard about the fact that you are not 100% certain what will happen when you die. Now imagine that all of the people you love will consider you hugely irresponsible for not attaining certainty on the issue. This is how an OCD sufferer often feels. Not only do they poorly estimate the risk posed by unwanted thoughts and feelings, but they have an exaggerated sense of responsibility for avoiding these risks.
Ultimately, for some HOCD sufferers, being gay may sound like a relief from not knowing for sure that they are straight. So they begin to build a case for gayness. This may involve seeking treatment from LGBT specialists, trying to train themselves to enjoy gay pornography and sometimes engaging in sexual experimentation. The goal is not necessarily to like gay sex, but to determine once and for all – “am I gay or straight?”.
Typically this backfires in one of two ways. Either the person finds the experience somewhat satisfactory but not preferential to straight sex, or they find the experience abhorrent and resent themselves for having done it. In either case, they are left with the same uncertainty they find intolerable, plus more ammunition for the OCD. Just as in the other forms of HOCD, the objective has to be tolerance for not-knowing rather than proof.
These are the various subtypes and angles on HOCD that we have treated thus far, but there are certainly others. In the next installment of this series, we will examine some additional nuances to HOCD and common impediments to effective treatment
In our previous blog on HOCD, we looked at some of the potential sub-types that appear in this condition. While they are all treated with various Cognitive Behavioral Therapy (CBT) strategies, crippling fear can lead people toward beliefs that impede therapy. Here are some thoughts about treatment issues we commonly hear from HOCD clients.
My Big Gay Secret Self
Many HOCD sufferers, regardless of sub-type, become preoccupied with the idea that other people might think that they somehow “appear” gay. As a result, some men with HOCD may over-attend to the way they dress, opting for baggy, neutral choices rather than fitting, stylish choices that they might associate with homosexuality. They may pay special attention to the way they speak or even the way they hold a drink, trying to eradicate any possibility that a person may mistake them for being gay. Women with HOCD may over-attend to the length of their hair, or whether their clothes are “feminine” enough. Both men and women with HOCD are likely to obsess about their body type and whether there is something inherently “gay” about it.
Some of this distorted thinking comes from limited or erroneous information they have collected about homosexuals, which leads them to compulsively avoid stereotypes that really have little to do with homosexuality. Still the HOCD persists with the notion that the sufferer has some clue of what gay “looks like” and then compels them to avoid that. For most, this appears not to be a fear of negative evaluation, but more a fear that this imagined person who may somehow identify them as gay will actually be seeing into their soul – that if another person calls them gay, this person is seeing their “true self” and this will confirm their worst fear… gay denial!
There is no gay denial.
There is no latent homosexuality, there is no hidden self. It’s something someone made up one day. It does not exist. There is no secret version of yourself waiting to be discovered (yes, we anticipate lots of angry emails from your psychoanalyst). It is important to recognize that people often choose to modify their behaviors to fit with what they think society expects of them. In some cases this results in people of one sexual preference choosing to live the lifestyle of another sexual preference as a way of avoiding what they see as the negative consequences of accepting themselves as they are. This could be done in order to avoid professional, cultural, religious, or other consequences. Of course, there may be a small percentage of the population that somehow is not conscious of what their preferences are, and appear surprised when they “come out” as gay. We are assuming these people exist because we have seen them on television, but then we see a lot of rare and bizarre things on television.
In all seriousness, there are people who claim not to have known their sexual preference until they met the right person. This concept is very disturbing to an HOCD sufferer. Yet it cannot be referred to as “coming out” since it is really more like “waking up.” And this real “coming out” doesn’t begin with fear, but with yearning.
Get Out of the Way
The most effective treatment for all forms of OCD is a type of Cognitive Behavioral Therapy (CBT) called “Exposure with Response Prevention” (ERP). The most common impediment to ERP treatment for HOCD is the continued practice of compulsive behavior throughout the exposure itself. Usually this comes in the form of self-reassurance. For example, many HOCD sufferers may attempt to overcome their fears by exposing to gay pornography, gay neighborhoods, or other things that are likely to trigger their discomfort. Among the most common self-ERP attempts I hear involves reading online “coming out” stories. All of these may be good ideas for ERP work, but they can easily backfire for the following reason: trying to prove you don’t like the porn, or that you don’t belong in the gay neighborhood, or that the person in the coming out story is nothing like you will never work.
ERP only works if the person resists doing this mental ritual, and instead accepts whatever thoughts and feelings the OCD may throw at them without protest. In more intensive ERP, you are not only accepting the thoughts, but actively agreeing with them, diving head first into the fear instead of tip-toeing around it. Any effort to analyze the exposure for evidence of your sexual orientation results in the brain confirming once again that your sexuality is up for debate. If instead, your behavior indicates to the brain that the presence of triggering material does not result in mental rituals, then your brain will begin to recalculate its position on the importance of knowing the certainty of your sexual orientation. In other words, if you stop doing mental compulsions aimed at finding certainty about your sexual orientation, your brain will learn that it is not necessary to have that certainty.
A common fear related to ERP treatment is the distorted idea that accepting the presence of gay thoughts in your mind somehow leads to a likelihood of acting out gay behaviors. This OCD logic has the sufferer in a double bind in which doing compulsions feels like a way to protect oneself from becoming gay, but at the same time actually fuels the obsession about one’s sexual orientation. When someone with HOCD stops doing the compulsions, they often see this as dangerously opening the door to unwanted gayness. This is not unique to HOCD, as it is an identical frame for the Harm OCD sufferer who worries that accepting harm thoughts will lead to violence, or the contamination OCD sufferer who worries that not washing will lead to contracting a terrible disease. It is important to remember, then, that ERP for OCD always feels like you are doing something wrong. This is because what you thought was right (compulsive behavior) is actually the source of the problem.
As the ERP work intensifies, the OCD fights for its own survival by leading the sufferer to fear that they are “feeling” gay. Feeling gay is an interesting phenomenon because it is oxymoronic. A truly gay person does not over-attend to gay feelings, but sees them as a normal part of their existence. It’s no more conscious than the feeling of me having brown hair. A gay person doesn’t sit around “feeling gay” any more than a straight person sits around feeling straight. It’s the OCD that makes someone over-attend to their feelings, and it’s that same over-attending that distorts these feelings into something to obsess about. An HOCD sufferer is likely to report feeling gay when they do exposure work and being terrified by this. But the fact that they report “feeling” gay actually means they don’t have any idea what it is like to actually be gay!
An additional challenge to ERP treatment often presents itself when a person starts to initially see the benefits of the treatment. At that point, the person habituates to things that would previously have triggered a significant spike in their anxiety. As this habituation takes place, the person’s thoughts and feelings become more congruent with those of non-HOCD sufferers. In other words, the individual becomes less upset by the presence of the unwanted thoughts and feelings they experience related to the issue of sexual orientation. At this juncture, some with HOCD then begin to obsess that they are not “bothered enough” by the trigger, and then use this as evidence of their homosexuality. This is sometimes referred to as (awkwardly enough) a “backdoor spike” because the OCD goes from identifying the fear as evidence of being gay, to now identifying the lack of fear as evidence of being gay.
What often goes unnoticed in HOCD and similar obsessions is that demonstrations of disgust and terror can also be compulsions, which are essentially behavioral strategies for avoiding or reducing discomfort. This does not mean they always feel good to do (often they do not). By actively causing oneself to be repulsed by gay thoughts, a sufferer can then avoid the discomfort that comes from thinking that the gay thoughts are acceptable and then inferring that this makes them gay. It’s enough to make anyone dizzy.
Whether the OCD is using fear or ambivalence as its threat, the goal of treatment needs to remain firmly focused on accepting whatever is going on inside as simply going on. Thoughts happen, feelings happen, sensations happen, and nowhere in this does anyone have certainty as to what it means. We guess and we tolerate whatever discomfort we imagine could come from being wrong. Life without OCD is lived in the present, making choices based on current preferences, not predictions, and choosing labels based on patterns in those preferences.
The Fear of Not Having HOCD
One of OCD’s more sinister sneak attacks is the threat that having HOCD is just a cover for not accepting that you’re gay. Of course, sufferers of all types of OCD obsess about not having OCD. The “scrupulosity” OCD sufferer may see OCD as a way of denying they are sinners, while a “contamination” OCD sufferer may debate whether they are just inherently lazy about cleanliness, while someone who obsesses that they might be a pedophile or a murderer will worry that identifying their problem as being OCD is just a way to avoid accusations of being a monster.
All of these people miss the larger point, which is that non-OCD sufferers do not obsess about having OCD. To be clear, virtually everyone has some obsessions and compulsions, but roughly 2-3% of the population has them to such an extent that it impairs functioning and is diagnosable as a disorder. So a non-OCD sufferer may be disturbed by an intrusive thought or may engage in a pointless ritual, but they do not get so completely trapped by this cycle that their quality of life is affected, and they are unlikely to be concerned with whether or not they have OCD.
HOCD sufferers often seek reassurance from their treatment providers that they do indeed have OCD. This is really the same reassurance-seeking compulsion that they engage in elsewhere when trying to gain certainty that they are not gay. Just as the HOCD sufferer must learn to tolerate uncertainty related to their orientation, they must also learn to tolerate uncertainty related to their diagnosis. If somehow they managed to be in such denial that they convinced an OCD specialist to diagnose them with a disorder they didn’t have, then they must have been obsessing over that denial to such an extent that they compulsively sought reassurance from a treatment provider who would tell them they weren’t gay. That sounds like OCD.
Gay Fantasy and OCD
Some people have gay sexual fantasies. Some people have OCD. Some people have both and none of this has to do with one’s sexual orientation.
Sexual fantasy in itself is a healthy thing. While there are ways in which it can be used compulsively or destructively, for the most part mindfully observing arousal thoughts is an activity we should all be able to enjoy as one of the perks of having a brain. Most, if not all, sexual fantasy involves taboo. It is this state of actually allowing ourselves to entertain and fully embrace and accept “wrong” thoughts that is so stimulating and freeing. It is good because it is oh so bad. For example, a heterosexual man may conjure up in his mind the fantasy of cheating on his wife. This man is not necessarily interested in cheating on his wife and in all likelihood he would run awkwardly away from an opportunity to actually do so. If he walked into a room and a beautiful stranger were laying there saying “take me,” he would probably not be comfortable. “This is a real person,” he thinks, “someone’s sister or daughter! Plus, are they disease free? When was the last time they showered? What will they think of me afterwards? What will I think of myself? Will my wife find out? Would this hurt my wife? Will I be able to live with the guilt?” He can accept the fantasy, but not the reality, because the fantasy appears wrong and the reality to him actually is wrong. The appearance is exciting, the reality is distressing.
For many heterosexuals, gay fantasies are not technically unwanted thoughts themselves. They are taboo, and while the reality might be unpleasant, the fantasy is undoubtedly stimulating. But a gay fantasy should not to be confused with an HOCD obsession, which is an intrusive, unwanted thought about the fear of being gay. For people with actual gay fantasies who also have HOCD, the obsession is not about the existence of the gay thoughts, but about the fear that enjoying their fantasy element means they are engaging in the reality of it.
This is very painful for heterosexual men who, to put it lightly, simply have a dick thing. They are attracted to women, choose women for their relationships, but simply happen to find masculinity, and penises in particular, to be conceptually activating. Maybe a penis is a narcissistic reminder of one’s own beauty, or maybe it represents control, power, submission, any number of things. Maybe it represents freedom from having to always perform as the archetypal strongman in control. Who knows. In any case, it is not important. What is important is to live in the present and allow yourself to value the things that are presently in your life. If that means today you love being with your wife, but tomorrow you will spontaneously choose to be with a man, then deal with tomorrow when tomorrow comes. Across all forms of OCD, the energy spent trying to sort out a thought in order to preempt it from creating a catastrophic future is nothing more than a mental compulsion.
Some may note that there appears to be slightly more acceptance of lesbian fantasizing in Western culture and media (note I said fantasizing, not necessarily practicing). This may be because our patriarchal society promotes the fantasy of men with multiple women to pleasure them, so thinking of them pleasuring each other creates the implication that a man would be happily welcomed to join them. It’s a chauvinist cultural flaw, but it exists nonetheless. But women with HOCD tend not to allow this patriarchal loophole to give themselves permission to enjoy gay fantasy. The OCD mind distorts the pleasurable thought into one being grotesque, sexless, and unlovable. So the challenge of living with HOCD is both easier and harder as a woman because this perceived acceptance for straight women having gay fantasies can equate to a greater fear that being gay is a tangible truth.
All this being said, it is normal and healthy for straight people to sometimes have gay thoughts. Whether or not these thoughts are enjoyed or hated is somewhat beside the point. As therapists specializing in Cognitive Behavioral Therapy, some beliefs will always seem inherently distorted to us. The belief that simply having a gay thought and liking it makes you a gay person is one of these beliefs. Remember, our lives are defined not by the content of our thoughts, but by the behaviors we choose when responding to them.