Expert Perspectives
Expert Perspectives

Sexual Orientation OCD - Part 4: Challenges to Treatment of HOCD

By Jon Hershfield, MA

Jon Hershfield, MA, of the OCD Center of Los Angeles discusses common challenges seen in the treatment of Sexual Orientation OCD, also known as HOCD or Gay OCD.  Part four of a four-part series.

Sexual Orientation OCD – also known as HOCD or Gay OCD – is best treated with Cognitive Behavioral Therapy.

In my previous blog on Sexual Orientation OCD (aka HOCD), I 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 I 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, I anticipate lots of angry emails from your psychoanalyst).  I think 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.  I am assuming these people exist because I have seen them on television, but then I 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 sexual orientation OCD, 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.

Feeling Gay

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.  As 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 to me.

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 a therapist specializing in Cognitive Behavioral Therapy, some beliefs will always seem inherently distorted to me.  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 seek when responding to them.