As previously described, sexual orientation obsessions in obsessive-compulsive disorder (SO-OCD) are included in the OCD symptom category of unacceptable/taboo thoughts and are very upsetting. In fact, these worries drive many suffers to consider suicide. At one time it was thought that people with these types of OCD symptoms did not have compulsions, and were thus considered "pure obsessional" or "pure-o." We now know that so-called pure obsessionals do, in fact, have compulsions, although these rituals may be covert.
What would you do if you thought you were becoming gay? Would you try to do something to stop it? Would you spend time trying to figure it out? People with OCD do compulsions, or rituals, in response to their worries, and these rituals can take up hours each day. No studies have examined exactly what type of compulsions are most common among people with SO-OCD, but recent work has found that those with similar worries tend to engage in reassurance-seeking, mental compulsions, and checking. Below I describe each of these in SO-OCD, with examples from real people.
Mental rituals can include many different, compulsions that take place in the mind. An example of a mental ritual would be a male who mentally reviews experiences with the opposite sex to convince himself that he enjoyed being with females, thus confirming his heterosexuality. One client I treated would try to visualize two men kissing, and if he felt a negative visceral reaction, he was (temporarily) satisfied that he was not turning gay. If he didn't feel the reaction, he had to repeat the imagery until he experienced the desired result. Sometimes it took three hours before he felt he could stop.
Reassurance seeking is a ritual that is often not recognized as a compulsion, but it is also a typical symptom of the disorder. Reassurance can be sought in many forms, including asking others (often a partner) for reassurance, self-assurance, searching the Internet for answers, or the need to confess to others to illicit reassurance.
One woman who worried about being a lesbian said, "My boyfriend claims that I am straight when I ask him, though (repeatedly)." This can be a particularly troubling symptom for those living with the OCD sufferer, as repeated demands for reassurance can cause family stress.
Somatic checking can be best described as checking one's body for any signs of unwellness. For example, a woman with hypochondria may constantly check herself for signs of fever, disease, or high blood pressure to make sure that she is not getting sick. Likewise, the person with SO-OCD may check for signs of sexual arousal when near people of the opposite sex to ensure continued heterosexuality, or check for signs of non-arousal with people of the same sex to ensure s/he hasn't become gay. For example, a male with SO-OCD might watch homosexual pornography to be sure he didn't like it as much as straight pornography. If he feels any signs of sexual arousal when watching the gay pornography, he may watch it again until the arousal goes away and he is satisfied that he has not become gay.
Some people take these compulsions even further. The following example is from a 20 year old male who masturbates to images of men as a method of measuring his sexual valence (Williams, 2008).
I'm struggling with these bloody urges, and I can't stand it any more. It keeps saying, "You want it," and eventually I say, "Fine," and I just masturbate to things I hate. It does a little bit for me, but I'm pretty sure that's the stimulation and not the content. But then as soon as I think of a girl, boom, I finish, and I know I am straight.
But how am I supposed to get these thoughts out of my head? These urges feel real. I don't like this. I don't want to be gay at all. It's a scary thought that I'd have to spend the rest of my life with a guy. I can't handle that, but something keeps telling me that's what I want, even though in reality that's disgusting to me. OCD is so confusing isn't it?
I have even heard of several cases of men having sex with other men as a form of checking. They are desperate to find out if they would enjoy a homosexual experience, even though they fear it. This experience only makes sufferers more confused and upset as they struggle to find meaning in it all.
Avoidance is not considered a compulsion per se, but it nonetheless maintains the disorder and contributes to dysfunction. People with SO-OCD may avoid situations that trigger the unwanted thoughts, such as locker rooms, movies with homosexual themes, or even people perceived to be members of the LBG community.
The following young man describes an attempt at psychological treatment for his SO-OCD. The therapist failed to recognize the fears as a symptom of OCD, resulting in a wrong intervention, leading to avoidance and suicidal thoughts (Williams, 2008).
I had a really bad experience. I have been diagnosed with OCD for a while now. The therapist I was seeing told me that I should try to be with a man, and that everybody is bisexual. It really freaked me out, and I was suicidal for five months thanks to what she said. The thoughts grew even stronger. Eventually, I couldn't be with any person of the same sex alone in the same room, watch TV, read the newspaper, or listen to music with male voices. I'm amazed that I'm still in this world after that experience. Therapists should be aware of what they are telling people like us.
Although in the example above, the patient's distress was probably not due solely to the therapist's misguided intervention, it does illustrate the need for careful attention to the possibility of SO-OCD, as proper treatment for this puzzling form of OCD is essential.
Williams, M. T., Crozier, M., Powers, M. B. (2011). Treatment of Sexual Orientation Obsessions in Obsessive-Compulsive Disorder using Exposure and Ritual Prevention. Clinical Case Studies, 10, 53-66.
Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., Simpson, H. B., Liebowitz, M., Foa, E. B. (2011). The Myth of the Pure Obsessional Type in Obsessive-Compulsive Disorder. Depression & Anxiety, 28(6), 495-500.