Treatment for HOCD

Obsessive-compulsive disorder is treated with a form of psychotherapy called cognitive behavioral therapy. It is a present-focused therapy that addresses how you are responding to your thoughts and feelings and how these responses can be modified to improve your mental health. Treatment for HOCD is no different from treatment for other forms of OCD. You identify the obsession, identify the compulsions, stop the compulsions, and starve the obsession. To achieve this, you attack the OCD from three angles: 

• Exposure,
• Recognition of distorted thinking, and
• Mindfulness

ERP for HOCD

Exposure with Response Prevention (ERP) is a way of overcoming fears by gradually confronting things that cause the fear state while (and this is key) resisting the compulsive response. It’s not enough to look at weights at the gym. You have to pick them up and resist gravity’s objection.

Working with an OCD specialist, you will want to identify what it is about your HOCD that really compels you to ritualize. For some, it’s a straightforward discomfort with gay imagery (or imagery of another orientation than your own, recall my note above) and for that, you might do exposure to gay-themed pictures and videos of gradually increasing intensity while resisting the urge to convince yourself that you are straight. It’s extremely important that these exposures are done without any covert testing or analysis. In other words, looking at triggering pictures while reassuring yourself that you are not attracted to them is sending the signal to the brain that it should remain afraid of unwanted attractions instead of simply observe them.  

For others, the fear is more abstract, having less to do with unwanted sexual imagery and more to do with a loss of identity or a fear of emotionally scarring your loved ones by “coming out” to everyone’s dismay. For this, exposure to sexual material is less relevant because you may not be fighting a fear or disgust with gay sexual imagery, but instead are grappling with a fear of being an imposter. Exposures for this type of HOCD may focus more on being in environments where the thoughts are likely to be active and resisting checking or reassurance-seeking behaviors. You may also use imaginal exposure, such as writing narratives about your fears possibly coming true and the consequences therein. Many HOCD sufferers benefit from a combination of these two forms of exposure.

In both cases, it will also mean identifying what you are avoiding and gradually reintroducing yourself to those things. This doesn’t mean having you have to engage in unwanted sexual behaviors to overcome your fear. You presumably weren’t avoiding that before HOCD started. You just weren’t doing it. But you may have started to avoid other valued behaviors, such as reading a magazine if there happens to be an article about a gay celebrity in it, or listening to a piece of music performed by a gay person, or having conversations with someone you think may be gay. So, a lot of ERP is really about gradually returning to a life of behaviors totally unrelated to sexual orientation that got thrown off course by the HOCD.

Dealing with the HOCD Thoughts

Recognizing when a pattern of thought is leading you toward compulsive behavior and then challenging that way of thinking can be helpful. This may be addressed in therapy with something called cognitive restructuring, a way of identifying mistaken assumptions and responding to intrusive thoughts without doing compulsions. A good example of distorted thinking is the tendency in all forms of OCD to look at things in black-and-white terms. For example, equating the presence of one gay-themed thought with the self-identification of “being gay.”

There is also a powerful tendency toward disqualifying the positive, in this case of a life history of being one orientation in the face of fear over being another. In other words, though you may have always pursued members of the opposite sex, your obsessive thoughts about being gay seem to make that seem irrelevant – or worse, like a desperate attempt to deny the truth! Another common distortion in HOCD is equating the presence of any gay thoughts or feelings with being less “you” (i.e. less masculine or feminine).

Though it is important to identify and challenge distorted thinking in all forms of OCD, you want to be very careful not to use logic as your main weapon against the disorder. You can’t fight OCD illogic for very long with logic. You have to fight it with better illogic in the form of exposure. In other words, by leaning in to your fears and getting better at embracing uncertainty, rather than trying to convince yourself your fears are untrue and reinforcing the idea that the content of your obsession is a threat.

Mindfulness Skills and HOCD

Accepting thoughts, feelings, and physical sensations as they are is all mindfulness really means. It is noticing and accepting without judgment. Hey, look at that, another thought. All right then. But in HOCD, accepting thoughts, feelings, and sensations may feel like accepting a death sentence. If I accept a thought like, “Maybe I would love kissing that guy” then what’s to stop me from making out with my best buddy? Well, nothing really, except that you are basically only going to do it if and when you both want to. You cannot control the thoughts and feelings and random physical sensations that happen to occur in you. No one can. You just choose what to do with them. Consider what are likely a number of highly disturbing thoughts you have that you simply disregard as irrelevant because they don’t relate to your obsessive theme.

Mindfulness for HOCD often means allowing yourself to incorporate unwanted sexual thoughts, feelings, and sensations into the larger picture of whatever you are experiencing in that moment. So, rather than attend to wishing that you could have a conversation with a same-sex friend without “gay thoughts,” actively embrace the experience of having both the conversation and the thoughts simultaneously. The experience you are having involves both of those things. When you focus your attention only on the unwanted thoughts, their origins, and when you imagine they will leave, then you are depriving yourself of the other experience, a nice conversation with a friend. If, on the other hand, you can allow yourself to stop “minding” that the thoughts are there and commit to having whatever experience you are having, you not only get to enjoy more of your life, but you send a powerful message to your OCD mind that these thoughts are not particularly important and not worthy of intruding so aggressively.

Working with Uncertainty in HOCD

In the end, because certainty does not truly exist, we only ever have two choices in life. One choice is to take the risk and stand up to your OCD. Get treatment from an OCD specialist, do the exposure with response prevention, practice mindfulness, and possibly spend the rest of your life happily engaged in whatever you pursue. It may end up well, it may not. You may live the life of one sexual orientation and right at the very end decide it was all a sham. That would be really disappointing I imagine.

But compare it to the alternative. The alternative is you don’t treat the OCD and you spend the rest of your life devoted to the futile pursuit of certainty, ruminating over the subject of sexual orientation all day every day, avoiding anything that might make you happy, because happy things trigger the unwanted thoughts. You isolate yourself from the people who care about you. You avoid sex and all sexual expression in an attempt to cleanse yourself of any possibility of an unwanted sexual thought or feeling. And then at the end of your life, you decide this was all a sham. You’re who you always assumed you were and you just have OCD. But you threw your life away for no reason other than the avoidance of fear. And now it’s too late to start over. Which scenario is ultimately more disappointing?

Navigating Unwanted Sexual Sensations in HOCD

Few subjects get more attention and cause more distress for the HOCD sufferer than the subject of the so-called “groinal response.” This is, of course, not a clinical term, so let’s start with a definition. A groinal response in the context of the OCD experience is:

• Any physical reaction in the genital area (movement, tingling, swelling, etc.) after exposure to an OCD trigger, whether real or imagined, pleasurable or discomforting

The disorder has a way of distorting how we interpret our experiences, making it sometimes difficult to tell, “Was that a groinal response from my OCD or was that a genuine sensation of arousal because I’m gay?” Mental checking and mental review are compulsions aimed at getting certainty about this distinction. Through repeatedly analyzing the experience, the focus of the HOCD evolves from “how do I know if I’m gay?” to the even more abstract “what kind of sensation was that and what does it mean?” This leads to even further confusion. A sensation is a sensation and whether we define it as wanted or unwanted is all about the narrative we have about this experience. Efforts to be certain whether it was “just a sensation” or “evidence of attraction” always fall flat because it contributes to a story about sensation instead of the experience itself. The same is true of thoughts. Though we notably identify obsessions as unwanted thoughts and distinguish them from other kinds of thoughts, the truth is that thoughts themselves are simply words or images appearing in the mind. It is the judgment and analysis that gets us into trouble with OCD.

Why do groinal responses happen?

Any sensation anywhere in the body is going to have a variety of potential sources, the most common of which are:

• No apparent reason, stuff happens.
• Chemical changes naturally occurring in the body, sometimes affected by stress or diet, in which blood flow is increased or decreased in different areas.
• Fear itself. Fear is expressed in the body by a number of symptoms, including increased heart rate, sweating, shortness of breath, and for many, changes in blood flow to the groin.
• Happiness. Like it or not, when we feel happy, our bodies become activated, which sometimes results in sensations in the groin. This can be particularly triggering for an HOCD sufferer feeling the love of a meaningful friendship or someone with pedophile obsessions (a.k.a. POCD) experiencing the joy of parenthood.
• The presence of all sexual thoughts, whether preferred or not, trigger groinal responses by their very nature of being sexual thoughts.
• Focused attention on specific body parts resulting in increased perceptual sensitivity and either an actual physical response or the perception of a physical response.

The phenomenon of groinal response in HOCD is easily re-created in other parts of the body. If I ask you to divert your attention to the pinky finger on your right hand, you will immediately trigger the firing of nerve endings in that area. Now, focus only on the knuckle of that finger… now on one crease in that knuckle. Whenever your attention shifts away naturally, try to bring it back to the crease in the knuckle of your right pinky finger. Now tell yourself it feels weird. Does it feel weird? Tingling? Itching? Something is setting it apart from the rest of your body. The attention causes the magnification of thoughts about sensations. This leads to the perception of sensation and sensations themselves. Furthermore, thoughts and feelings about these perceived and real sensations intensify the experience, creating a vicious cycle of thinking, sensing, fearing, thinking, and sensing some more.

The HOCD sufferer is very likely to have groinal responses around the same sex for the precise reason that they are checking and telling themselves not to. Just as trying NOT to think of a purple unicorn just made you think of a purple unicorn, trying NOT to experience sensation often generates sensation in this very sensitive part of the body. Conversely, trying to generate groinal responses to the preferred attraction will often fail to produce results. By trying to create the experience, you are generating a somewhat synthetic version of what you were hoping for. Instead of the spontaneous arousal you assume you should be having, you get your brain’s attempt at arousal. It’s much like trying to tickle yourself. Because you are aware that you are doing it, it only sort of feels like tickling and doesn’t make you laugh. In the end, obsessions are more than intrusive thoughts. They are intrusive experiences.  

HOCD and Testing Compulsions

Testing is a form of reassurance seeking that involves initially exposing oneself to triggers and then analyzing the reaction to those triggers with the intention of getting certainty about the meaning of those reactions. This often comes disguised as exposure with response prevention (ERP) but is actually an OCD trap. Truly, it is exposure without response prevention and not OCD treatment. Many people have written to me describing having watched same-sex pornography to see if they had the “right” reaction to it. Many also describe compulsively looking at their historically preferred erotic pictures or videos and then analyzing whether they liked it enough or as much as the triggering material. This often involves checking the body for signs of sexual arousal and then analyzing the significance of the findings. Because the experiment is fundamentally flawed, the “evidence” of your reactions to the experiment is completely useless. Nonetheless, OCD takes the experiences from compulsive testing and uses them to strengthen your obsession. But “evidence” collected during the course of a compulsion is no more evidence than a confession derived by torture is a reliable source of the truth.

HOCD and the Fear of Being in Denial

The word “denial” is at the root of all forms of OCD. It is popularized culturally to relate to issues of sexual orientation, but every person with any form of obsessive-compulsive disorder experiences the fear of “denial” whenever they choose to do exposure instead of rituals. The compulsive hand washer who chooses to allow themselves to touch a dollar bill and then eat a French fry is sitting with the terror that they may be in denial of the cold hard fact that a molecule of someone’s feces may have made its way from the dollar, to the fry, to their mouth. The Harm OCD sufferer, who lives in a war-torn mind of horrific images of violence against loved ones, holds a baby in their arms and tries to breathe evenly while covertly contemplating whether or not they are simply in denial of their closeted sociopathic “true” nature. Still, nowhere does this word “denial” get tossed around more than in the context of HOCD, the obsessive-compulsive fear of being or becoming a sexual orientation not your own. So, what is denial?

Denial is actively choosing to behave in a way that directly opposes your values or beliefs without acknowledging it. 

Denial is not:

• Choosing to disregard thoughts, feelings, and sensations associated with another sexual orientation
• Pursuing relationships of meaning and value despite thoughts and feelings whose content seems incompatible with this pursuit
• Committing to relationships you are invested in despite the presence of doubtful thoughts about sexual orientation
• Accepting the presence (without guilt, disgust, or fear) of sexual fantasies outside of your historically preferred orientation
• Letting go of seeking reassurance about your orientation
• Accepting uncertainty regarding your sexual orientation and the label that goes with it

HOCD Meets ROCD

One common concern among HOCD sufferers is that if they choose to accept uncertainty and stop doing rituals, they may discover that they are gay and that discovery will result in a revelation to their partner that they have been lying about their orientation. The obsession is therefore not only about sexual orientation, but about the authenticity and safety of the sufferer’s relationship with another person (as in Relationship OCD/ROCD). The fear thrives on an image of a tearful husband or wife feeling deceived, tricked, led on a long and ultimately meaningless journey to middle age alone, the victim of a fraud perpetrated by the a fool who couldn’t come to terms with their orientation. In other words, “I can’t just be with this person I love if there is any doubt as to the meaning of these gay thoughts, so I must get certainty to protect my loved one from a future betrayal.” To the contrary, cognitive behavioral treatment for HOCD when there is a significant other involved must include exposure to the idea of denial and the way in which it could destroy the other person. So, in addition to imaginal scripting exposures in which the sufferer could write out the feared consequences of persisting in gay denial in a relationship, the sufferer might also do exposures to strengthening their relationship. By investing more fully and more completely in their love for their significant other, they are getting both exposure to the fear of destroying a loved one and, as an interesting side effect, a better, more meaningful relationship. In short, invest in your relationships in such a way that if they fail, it will be the most devastating. That is romance.

Typical exposures for HOCD fears may involve looking at triggering materials, listening to triggering music, and being around triggering people (all without doing compulsions of course!). But for the specific fear of being denial, life itself is the trigger and exposure means committing to that life. This may mean following through on your plan to propose to your partner, letting yourself really be moved by a love story of a different orientation than your own, or allowing a thought to be enjoyable if it’s enjoyable even if it doesn’t fit your identity in that moment. Consider this – we may define denial as running from the truth. If this is the case, then it is far worse to be in denial of your OCD (and not committing seriously to treating it with CBT) than it is to be in denial of whatever your OCD is talking about. While the consequences of your fears coming true are quite unknowable, to deny yourself OCD treatment has clear and predictable consequences.