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H-OCD is Real and Misunderstood: Understanding the Many Forms of OCD
This is Part 1 in a four-part series on sexual orientation-themed OCD.
Obsessive-compulsive disorder (OCD) is a serious condition that afflicts approximately 2% of the population. Obsessions are intrusive thoughts, impulses, or images that cause distress and anxiety. Compulsions are behaviors intended to decrease the distress and anxiety caused by the obsessions, although relief is only temporary. Obsessions return, resulting in more compulsions as the OCD cycle repeats itself.
Obsessions and compulsions come in many different forms, therefore each individual's OCD may be different. It is possible for two people with OCD to have no overlapping symptoms at all. Because of the wide variety of symptoms, many studies have been conducted to classify OCD into discrete subtypes or symptom dimensions. These include contamination/cleaning, doubt about harming/checking, unacceptable/taboo thoughts, symmetry/arranging, and hoarding symptoms.
Much research has been conducted on doubt /checking and contamination/cleaning dimensions, but one area that has seen less attention is in the area of sexual obsessions—a large part of the unacceptable/taboo thoughts dimension. Sexual obsessions can take many different forms. For example, sexual obsessions may include fears of being attracted to children, fears of engaging in inappropriate sexual activity, or intrusive sexual images. Unwanted sexual thoughts are common, and most people are able to dismiss an occasional bothersome thought. However, people with OCD cannot rid themselves of unwanted thoughts, and when the content is sexual in nature, the obsessions can be especially upsetting. Over 10 percent of patients seeking treatment for OCD have some type of sexual obsession as their main concern.
About Sexual Orientation Obsessions
Sexual orientation obsessions in OCD (SO-OCD, also called H-OCD) are a specific type of sexual obsession. These symptoms continue to cause a great deal of concern and confusion among OCD sufferers and the professional community alike. SO-OCD is sometimes called HOCD—a name coined by the online community for "homosexual OCD." So perplexing is SO-OCD, that many OCD online forums forbid its discussion. People with SO-OCD typically feel ashamed of the thoughts, and encountering non-acceptance in forums of fellow OCD suffers makes those with SO-OCD feel even more alienated.
SO-OCD is not a separate or new diagnosis, so people with this type of OCD should not be treated differently than anyone else seeking help. Rather it is a constellation of OCD symptoms seen clinically that involves extreme anxiety surrounding sexual orientation. SO-OCD includes worries about experiencing an unwanted change in sexual orientation, fears that others may think one is gay, or fear that one has hidden same-sex desires. About ten percent of OCD patients who seek professional help have unwanted sexual orientation obsessions at some point during the course of their disorder, making SO-OCD somewhat common.
People with SO-OCD seem to have difficulties beyond those experienced by people with other types of OCD. They spend more time obsessing and have more life interference from the obsessions. They experience greater distress from the obsessions, and spend more time avoiding things that trigger their obsessions. It does seem that people with sexual obsessions spend more time in treatment than people with other types of OCD, but it is not clear if this is the case for SO-OCD specifically. There has been surprisingly little research about this form of OCD.
Sexual Orientation Obsessions Misunderstood
The lack of research about SO-OCD reflects the often misunderstood nature of sexual orientation obsessions. It is important to understand that sexual orientation obsessions in OCD are very different than thoughts and fears an individual might experience as the result of a same-sex or bisexual orientation. Lesbian, gay, and bisexual (LBG) people who have negative feelings about their own sexuality are said to have internalized homophobia or internalized heterosexism (IH), but most people with SO-OCD are in fact heterosexual, so this conceptualization is generally not applicable to SO-OCD sufferers. A person with internalized homophobia/heterosexism usually has some positive feelings about homosexuality and will enjoy same-sex fantasies, whereas the person with SO-OCD dreads the thoughts and finds them intrusive. Furthermore, it should not be assumed that people with SO-OCD are homophobic, as people with SO-OCD have a wide range of feelings about homosexuality.
It can be hard to make sense out of how people with SO-OCD can have anxiety about their own sexual orientation when they are fairly certain that they are not gay and typically have a clear history of heterosexual relationships. However, people with other sorts of OCD worry about all manner of implausible events, such as "What if touching this toilet gives me HIV?" or "What if I left the stove on and my house is burning down?" or "What if that speed bump I ran over was really a small child?" In the case of SO-OCD, the process is the same but only the content of the worry is different. The person wonders, "What if the fact that I noticed that buff guy in the gym means I'm gay?" or "What if crossing my legs this way makes people think I'm gay?" or "What if I become gay and have to leave my spouse and kids?" or "What if I have been unconsciously gay all along and I just don't know it yet?"
To complicate matters, it is possible for LBG individuals to have unwanted OCD-related sexual orientation obsessions as well. It might seem odd that an LBG person would worry about becoming straight, given that heterosexuality is considered the desired norm in our society. However, OCD is all about possibilities. In my own practice, I treated a gay male who obsessed about how a potential heterosexual relationship might affect his other LGB relationships and change his very personality. These types of worries may occur for reasons unrelated to OCD, but what distinguishes these from normal concerns is an unwarranted focus on the possibility of unwanted events happening when the person's actual circumstances do not make them especially likely.
Find Part 2 here: Sexual Orientation Obsessions: New Research & Suicide.
References
Williams, M. T. & Wetterneck, C. T. (2019). Sexual Obsessions in Obsessive-Compulsive Disorder: A Step-By-Step Definitive Guide for Understanding, Diagnosis, and Treatment. Oxford University Press. ISBN: 9780190624798.
Gordon, W.M. (2002). Sexual obsessions and OCD. Sexual and Relationship Therapy, 17(4), 343-354.
Grant, J. E., Pinto, A., Gunnip, M., Mancebo, M. C., Eisen, J. L., & Rasmussen, S. A. (2006). Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Comprehensive Psychiatry, 47, 325-329.
Szymanski, D. M., Kashubeck-West, S., & Meyer, J. (2008). Internalized heterosexism: Measurement, psychosocial correlates, and research directions. The Counseling Psychologist, 36(4), 525-574.
Williams, M. T. (2008). Homosexuality anxiety: A misunderstood form of OCD. In L.V. Sebeki (Ed.), Leading-Edge Health Education Issues. Nova Science Publishers.
Williams, M. T., & Farris, S. G. (2011). Sexual Orientation Obsessions in Obsessive-Compulsive Disorder: Prevalence and Correlates. Psychiatry Research, 187, 156-159.
