Expert Perspectives
Expert Perspectives

Sexual Orientation OCD - Part 2: CBT for HOCD

By Jon Hershfield, MA

Jon Hershfield of the OCD Center of Los Angeles discusses treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD, using Cognitive Behavioral Therapy (CBT) and Mindfulness.  Part two of an ongoing series.

Treatment of Sexual Orientation OCD

Sexual Orientation OCD can be successfully treated with Cognitive Behavioral Therapy and Mindfulness.

As noted in our previous post, 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 Sexual Orientation OCD.  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 – 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 – Thoughts about thoughts that don’t help.

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 – 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.  Your OCD 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.