Expert Perspectives
Expert Perspectives

Sexual Orientation OCD - Part 3: HOCD Sub-Types

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 three of an ongoing series.

There are many variations and sub-types of Sexual Orientation OCD (HOCD).

When I initially wrote the part one and part two of my article on Sexual Orientation OCD (aka “Homosexual OCD”, aka “HOCD”, aka “Gay OCD”), it was intended solely to reflect this rather common form of the disorder as I saw it presented in several of my clients.  I 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.

I’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 I have seen this OCD manifestation present and the different Cognitive Behavioral Therapy (CBT) strategies that appear to work.  I 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 I 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.

All-Or-Nothing HOCD

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 handwasher 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.

Relationship HOCD

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.

Self-Hating HOCD

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.

Spectrum HOCD

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 imaginal 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 I 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.