HOCD Symptoms, Cause & Treatment
What is HOCD? Understanding Sexual Orientation OCD
Homosexual OCD (HOCD), now more accurately termed Sexual Orientation OCD (SO-OCD), is a form of OCD characterised by intrusive, distressing thoughts and anxieties about your sexual orientation. These thoughts don’t reflect your true feelings or desires, but rather stem from an underlying anxiety disorder. It’s like having a mental alarm bell constantly going off, questioning your sexuality even when you know deep down who you are. This can lead to significant distress and compulsive behaviours aimed at reducing anxiety, but these behaviours often provide only temporary relief. HOCD can affect anyone, regardless of their actual sexual orientation; indeed I have worked with women with HOCD.
It’s important to note the term “homosexual obsessive-compulsive disorder” or HOCD is outdated and inaccurate. It has been replaced by the term Sexual Orientation OCD (SO-OCD).
Here’s a breakdown of why the old term is problematic and what SO-OCD truly entails:
- Inaccurate and Stigmatising: The term “HOCD” implied that the obsession was specifically about being homosexual, which is is too narrow a lens of people who can experience HOCD. People of any sexual orientation can experience SO-OCD, with obsessions related to being gay, straight, bisexual, or any other orientation. It’s important to address how HOCD affects different sexual orientations. The old term also perpetuated stigma around homosexuality by framing it as something to be feared or avoided.
- Focus on Intrusive Thoughts: The core of SO-OCD lies in the intrusive thoughts that cause significant distress and anxiety. These thoughts are ego-dystonic, meaning they go against the individual’s actual feelings and beliefs.
- Compulsive Behaviours: Individuals with SO-OCD often engage in compulsions to try and alleviate the anxiety caused by the intrusive thoughts. These compulsions can include:
- Mentally reviewing past experiences or interactions
- Seeking reassurance from others
- Avoiding situations or people that trigger the obsessions
- Researching sexual orientation online
- Engaging in excessive self-analysis
It is important to remember that SO-OCD is a treatable condition. If you or someone you know is struggling with these types of obsessions, seeking professional help from a therapist specializing in OCD is crucial.
Clinical Insights into HOCD
In my clinical experience as a therapist , I’ve found that many individuals with HOCD initially struggle to understand the nature of this condition. They often mistakenly believe it’s related to prejudice, political correctness, or even their own internalized homophobia leading them to falsely believe in a fear of denial. However, it’s crucial to emphasize that HOCD has nothing to do with prejudice or a person’s actual sexual orientation.
The obsessions in HOCD stem from a fear that one’s long-standing sexual identity has changed. It’s an anxiety-driven condition focused on intrusive thoughts that contradict a person’s true nature.
To better understand how these intrusive thoughts operate, consider this analogy: Imagine you’ve always been right-handed, and suddenly, someone starts insisting you’re actually left-handed and should start using your left hand for everything. The more you resist, the more they pressure you, making you doubt your own natural inclination. It’s like having a broken record playing in your mind, constantly repeating a message that you know isn’t true, but you can’t seem to turn it off.
While the term “HOCD” is still used, “Sexual Orientation OCD” or “sexual-themed OCD” are more accurate labels. As Bhatia & Kaur (2015) (1) noted, the condition isn’t limited to males questioning their heterosexuality. It can affect anyone, regardless of their true sexual orientation.
Symptoms of HOCD
Obsessions
The word ‘obsession‘ comes from the Latin’ obsidere’, which means ‘to besiege’. Obsessions are the unwanted intrusive thoughts that you get in your head. They are egodystonic in nature, meaning they are inconsistent with what you hold dear or firmly believe in.
Intrusive Thoughts about Sexual Orientation
- Questions like, ‘what if I am gay?’ or ‘ did noticing that person mean that I am gay?’ are common, notably in real-life examples of HOCD.
- Concerns about whether your friends or other people think you’re gay and if those perceptions are correct.
- Worried about being perceived as gay by others.
- Unwanted distressing thoughts about engaging in sexual acts with someone of the same sex.
- Noticing something beautiful about members of the same sex may make you see this as evidence that you are gay..
- You are worried you are indeed gay and are denying your sexuality.
- Worrying if you cannot get an erection or are aroused if you are female could mean you are gay.
- I feel like I’m in denial, and if I come out as gay, it will ruin my life.
- It feels like there’s something wrong with me because I can’t stop thinking about people of the same gender sexually.
- I know deep down inside that I’m not straight, but how can I be sure?
Doubts and Fears
- Significant fear and anxiety about being attracted to someone of the same sex.
- I’m scared that I might be gay.
- You are going over previous sexual encounters with members of the opposite sex to reassure yourself that you are not gay.
Intrusive Images
Intrusive images, just like unwanted thoughts are spontaneous, and some common intrusive images relating to HOCD can be, for example, seeing someone of the same sex on the street, and having a sexual image of the person and yourself in your head
In my clinical practice, one of the more prominent obsessions I found with clients, was the fear that they would act on their obsessions, but as I explained to them, and now you reading this, this is a concept known as thought action fusion; just because you have the thought, doesn’t mean that it is true.
There are many different symptoms of Sexual Orientation OCD and it is impossible to list them all, for example, in my practice, I’ve noticed a distinct pattern in some people with HOCD where they become fixated on the tiniest physical sensation, like a slight increase in heart rate or a fleeting feeling of warmth, especially in the groin, and see this as ‘evidence’ of same-sex attraction. It was becoming such a theme with clients, that I wrote an article to explain the feeling of arousal within HOCD, and what it really means. One technique that you can use is to learn to interpret your HOCD thoughts differently; see them as data and not reality.
Compulsions
Mental Compulsions
- Constantly seeking reassurance about your sexual orientation from yourself, friends, family, or online sources
- You worry about things that may have occurred in the past, proving that you are now gay.
- You might have remembered an event from your childhood that you now see as evidence that you are gay. Children can engage in a type of exploration play; you heard it called ‘doctors and nurses.’ If you recall this type of game, you may mentally go over it, matching it up with other pieces of ‘evidence’ to help you understand what is happening to you.
Checking
- You might try to imagine being with a member of the same sex to check out your theory that you might be gay.
- Looking at members of your own sex to check if you feel attraction or not
- Actively seeking out same-sex couples to see if you ‘feel anything.’
- Repeatedly checking your body for any signs related to homosexuality. For example, someone with HOCD might constantly touch or look at their groin to see if they feel aroused.
- Going to gay bars to see if you are attracted to anyone
- Watching same-sex porn to see if you get aroused
- Watching straight porn to see if you get aroused
- Continuously checking for signs of homosexuality, such as analyzing your reactions to others or scrutinizing your behaviour.
Avoidance
- Turning off television programmes, when you see a same-sex couple
- Avoiding gay friends
- If you avoid things as you are afraid they may trigger your HOCD, this can be a compulsion in that you are changing your behaviour in response to thoughts in your head.
- This could be certain songs or artists you associate with being gay, types of TV programs, magazines or books that you might associate more with same-sex couples.
- Avoiding triggers like certain media, places, or situations associated with the LGBTQ+ community.
- Avoiding social situations, changing rooms, making eye contact with members of the same sex, or engaging in conversations related to sexual preference.
- You might avoid going out, mixing with a same-sex couple, or showing support for same-sex couples. You may avoid many things, fearing that they could ‘trigger’ your HOCD
What Causes HOCD?
Genetics
Brain
Psychological
If you or someone you know might have HOCD, it’s essential to talk to a mental health expert. They can help diagnose and treat it.
Although this is not technically a cause, I’ve noticed in my clinical practice, that clients who have other conditions such as anxiety or mood disorder (these are called co-occurring disorders) find it more difficult to manage their intrusive thoughts and compulsions, and this, in my clinical opinion is due to the extra heightened anxiety that they bring to the condition. It is therefore crucial that when getting treatment, you get help with your anxiety or mood disorder and not just HOCD.
Treatment Options for HOCD
Self-Help
Professional Help
Seeking help from a therapist specializing in OCD and sexual orientation issues is crucial. When speaking with clients over the years, many make the mistake of seeking a therapist that specialises in HOCD, when you should be looking for a therapist that is expert in treating OCD, (remember HOCD is OCD.) Specifically you should seek someone who is expertly trained in Cognitive Behavioural Therapy (CBT) as the recommended treatment for HOCD is CBT, particularly Exposure and Response Prevention (ERP)
Cognitive Behavioural Therapy (CBT)
This therapy focuses on identifying and challenging negative thought patterns and beliefs. Through CBT, individuals learn to understand their intrusive thoughts and reduce their significance.
- Understanding Thought Patterns: CBT helps you understand how your thoughts and behaviours contribute to your experience of HOCD; in particular it helps you to understand cognitive patterns in HOCD.
- Coping Strategies: You’ll learn to correct your thought processes and relate to your thoughts differently. CBT focuses on teaching you how to understand and cope with intrusive thoughts without necessarily getting rid of them.
Exposure and Response Prevention (ERP)
ERP is a specific form of CBT that involves exposing individuals to their fears (e.g., watching same-sex interactions) and preventing the compulsive responses that usually follow. For example, a person with HOCD might be set a homework to watch a program that has a same-sex relationship without engaging in checking behaviours or seeking reassurance.
Over time, ERP helps individuals learn that they can tolerate their anxiety without resorting to compulsive behaviours, gradually reducing the power of intrusive thoughts.
Exposure and response prevention ERP involves gradually exposing someone to what they’re afraid of, then preventing them from rituals or behaviours that usually relieve the anxiety caused by the fear.
If you have tried therapy before, please do not be discouraged. ERP is designed to eliminate compulsions. Suppose your therapist was not well versed in sexual-themed OCD. In that case, they might have missed helping you uncover mental compulsions or reassurance-seeking behaviours because they can be easily overlooked, according to Wiilliams et al. (2011) 2.
Acceptance and Commitment Therapy (ACT):
This model suggests that suffering arises from how we relate to our thoughts.
- Acceptance: ACT teaches you to accept your thoughts rather than trying to change or control them. Read more on how ACT helps with HOCD.
Mindfulness: This technique helps manage intrusive thoughts and reduce anxiety by being present in the moment and observing thoughts without judgment.
Real-life examples of HOCD Recovery
Case Study: Paul
Paul was a 25-year-old man who referred himself for therapy. He stated that he wished to begin treatment because he believed he was suffering from anxiety, which affected his ability to work.
I undertook an assessment and found that Paul was indeed anxious. No previous history of mental illness. He had a full social life and friends.
Paul did not say he was having intrusive or uncomfortable thoughts regarding his sexuality during our initial assessment. This is not uncommon, as many people come for therapy because they feel anxious or depressed. It is up to the therapist’s skill to determine why.
Paul made a ‘throwaway’ comment regarding his sexuality during the assessment session. I explored this topic with him as I could see that he was feeling uncomfortable, and later, he informed me that this was the first time he had spoken about it. He stated he had been heterosexual all his life and would have no problem if he was attracted to men. Still, he could not understand what was happening to him.
Paul has been sexually active since he was 17, always with women, and has been in a long-term relationship with his girlfriend for three years. Two months ago, he started having intrusive thoughts that he might be attracted to men.
Before the intrusive thoughts, his work colleagues teased him about his love of clothes and how he maintained his physique and hair. He started comparing himself to other men regarding their appearance and how well they kept themselves.
Paul stated he noticed men more often when walking down the street as he compared himself to them in terms of ‘maintenance levels.’ He noted which men were attractive and which were not, and this is when he questioned the content of his thoughts.
Paul was clear that he did not wish to have a sexual or romantic relationship with a man and that he wanted to stay in his current relationship with his girlfriend. Still, his intrusive thoughts were affecting the quality of his relationship. He had obsessed with his appearance and choice of clothes and how he appeared to other people. He also looked at other men to test if he felt an attraction.
I discovered that Paul had mild OCD in his late teens during the session. I explained that thought processes alone could not change a person’s sexuality. It would appear that he was experiencing unwanted intrusive thoughts about his sexuality that affected his relationship and made him anxious.
The psychological explanation for what was happening to Paul
We found Paul had a faulty belief system
Quote from Paul
- men who care for themselves are effeminate.
- Men should be rough.
When teased about his appearance, Paul was very aware of his choice of clothes and how he liked to use products for his hair and skin. This did not match up with faulty belief systems he did not know he held until he began therapy.
He focused on how he behaved, walked, and talked (the spotlight of attention I mentioned above.)
Over time, Paul avoided people and places that made him question his sexual identity. He found being intimate with his girlfriend difficult, making him question his sexuality.
We agreed to meet for six initial sessions to start treatment using CBT and Exposure Response Prevention.
This case study shows the complexities of HOCD, and that having this condition is not about changes in your sexual orientation, but rather, the difference is in your thought processes in that you start to experience obsessive thoughts about your sexual orientation.
If you suspect you might have this form of OCD, the remainder of this article will detail what the obsessions and compulsions are like, and if you recognise yourself in some of the signs and symptoms, I will encourage you to discuss this with a mental health professional.
Frequently asked questions about HOCD
Can HOCD change my sexuality?
HOCD is a form of Obsessive Compulsive Disorder and cannot change your sexuality, as your fears are only obsessions, .i.e. they are part of the condition and will go away when you no longer suffer from HOCD.
How long does it take to recover from HOCD?
Once your obsessions no longer bother you and you do not feel urge to perform a compulsion, your HOCD will go away. The time it takes varies, depending on when you start treatment and the work you put it.
Is HOCD a from of OCD?
Yes, HOCD is a form of Obsessive Compulsive Disorder (OCD) where all your thoughts about your sexual orientation are the obsessive part of OCD and, for example, the checking you perform, as the compulsions.
How Common is HOCD
According to a study by Grant et al., approximately 8% of individuals with OCD have obsessions related to sexual orientation. From my personal experience working as a psychologist treating OCD for 20 years, people do not attend therapy stating that they are having difficult thoughts about their sexuality, this only comes out during a careful assessment.
Who is Affected by Sexual Orientation OCD?
HOCD can affect anyone, regardless of their actual sexual orientation. It doesn’t discriminate based on gender or sexual identity. You can read more on this here. Both men and women are susceptible to HOCD, impacting diverse demographics. I think the name given to the condition suggests it just happens to men, but in this article, I discuss that women also can suffer from HOCD.
How do I know if I have HOCD?
There are particular symptoms unique to HOCD, but to know for sure, getting a diagnosis from a licensed mental health professional is recommended. In my experience working as a psychologist for 20 years, it can be challenging to get a diagnosis.
Neither Homosexual OCD nor Sexual Orientation OCD are diagnosed in their own right; instead, they fall under the umbrella of OCD, which means if you meet someone like myself, a psychologist, you will not be given a diagnosis of HOCD; rather you will be diagnosed with OCD.
For a diagnosis of OCD to be made, the person needs to;
- have obsessions and compulsions that take up over one hour per day and
- cause distress or disruption to the person’s life in that they find it challenging to carry out day-to-day activities.
If you are not yet ready to meet with a psychologist or other mental health professional, I shall outline the main characteristics below before going into more detail with obsessions and compulsions.
What is the personal impact of HOCD?
HOCD can significantly impact a person’s life. The intrusive thoughts and compulsive behaviors often disrupt daily activities, making it difficult to concentrate, maintain relationships, and engage in social activities.
Damaged Relationships: The constant doubt and anxiety can strain relationships, particularly romantic ones. Individuals may withdraw from their partners, fearing that their intrusive thoughts mean they cannot genuinely love or be attracted to their partner.
Inability to Concentrate: The persistent nature of OCD makes it hard to focus on work, studies, or even casual conversations. The mind is often preoccupied with trying to resolve the uncertainty of the intrusive thoughts.
Increased Isolation: The fear of judgment or rejection may lead individuals with HOCD to isolate themselves from others, avoiding social interactions and relationships to prevent triggering their obsessions.
What is The Groinal Response?
Previously, I wrote an article on sexual arousal within HOCD, but I shall touch on it here again on my main page on HOCD. An unfortunate aspect of the condition is that not only are you actively searching for some sensation or feeling in your groin, which has been named ‘the gronial response’ but when you find it you take the sensation as some sort of evidence of sexual identity.
Like all forms of OCD, there are many physical sensations. most caused by the anxiety experienced by the condition, but one of the most difficult sensations people with HOCD have is the “groinal response.” It is simply a physical sensation in the groin area that can occur in response to intrusive thoughts.Individuals with HOCD often misinterpret this sensation as a sign of sexual attraction, which intensifies their anxiety. It’s important to understand that the groinal response is simply a physical reaction that can happen for many reasons and does not indicate actual sexual attraction. The heightened focus on this area due to OCD makes these sensations more noticeable, leading to more anxiety and confusion.
Quick experiment; look at the tip of your index finger on your right hand. Really focus on it, just the very tip. Does it feel different to the rest of your finger, hand or body? Can you feel heat on the tip of your finger? More than likely, you feel something, and that is because you are bringing 100% of your awareness to one specific part of your body. Think about that the next time you are experiencing sensations in your groin. It is not evidence of anything but the fact that you are paying attention to it.
What’s the difference between HOCD and being gay?
It’s straightforward, HOCD is Obsessive-Compulsive Disorder, and being gay is enjoying and wanting romantic relationships with members of the same sex. If you have HOCD, your thoughts are about being gay–not your actions. If you are gay, your actions and thoughts show you are gay; you want, seek and enjoy romantic relationships with the same sex.
What about sexual fantasies?
Unlike fantasies, people with HOCD feel distressed by their thoughts – not aroused by them – which is the opposite of what typically happens during a sexual fantasy. This means that people with HOCD are not getting the same pleasure from their thoughts as those who do not have OCD.
What about finding members of the same sex attractive?
Human beings find many things attractive. Houses, cars, people, gardens, and the list goes on. If you think of the word attractive as meaning ‘pleasing,’ you can find and appreciate many things as pleasing; this also includes respecting the physical characteristics of the personality of someone the same sex as you. This does not mean you want a physical and romantic relationship with them.
What about getting aroused?
If you are heterosexual, you have experienced sexual arousal while thinking about or watching members of the same sex. In that case, you can run into difficulty as you see this as evidence that you must be gay. This is a mistake. Ask yourself when you experience the arousal. Were you watching porn? For example, of course, you will feel arousal; we are sexual beings! But you could just be looking at a member of the same sex–but how are you looking at them? If I walked past you now in the street, I wouldn’t be thinking, do I feel anything? Am I getting aroused? I would just walk past you in the street. But the difference between you and me is that you would selectively attend to members of the same sex to check how you are doing. Your brain is actively searching them out; they might as well be walking about flying a flag to get your attention, and then you make the mistake of checking out how you feel in your genitals. You can read more about sexual arousal here.
How do I know I’m not just in denial?
This is the question I get asked the most. “How do I know that this is HOCD and that I am not gay and don’t know it.” I will explain to you what is happening, and it has a lot to do with ‘doubt.’
Do I need to come out?
HOCD is not having thoughts about ‘coming out.’ Coming out is where you choose to think about your sexuality, knowing you are attracted to members of the same sex and want to think about how to live your life as gay or lesbian. The thoughts in HOCD are symptoms of a mental health condition, OCD. OCD is characterised by having continual doubt. For example, doubt about cleanliness and germs, doubt about doing something correctly, and in this case, doubt about sexuality. HOCD has nothing to do with sexuality but with the doubt and uncertainty that exist within OCD.
Is HOCD a from of OCD?
Yes, HOCD is a form of Obsessive Compulsive Disorder (OCD) where all your thoughts about your sexual orientation are the obsessive part of OCD and, for example, the checking you perform, as the compulsions.
My thoughts must mean something
This is a faulty belief system. Random thoughts mean nothing, thinking that they must mean something is called thought action fusion.
Resources for people with HOCD
- International OCD Foundation. This is an excellent site where you can read articles as well as search for therapists.
- OCD-UK
- Anxiety and Depressional Association of America (ADAA).
Books that I recommend;
- Overcoming unwanted thoughts: A self-help guide using Cognitive-Behavioural Therapy by Sally Winston and Martin Seif.
- The last word
If you think you have HOCD, it is essential to understand that your sexual identity is not changing. Instead, you are suffering from the obsessions and compulsions within OCD, which can be treated.
Further Reading
Centreforanxietydisorders
NCBI - IOCDF
2 Sources
All content on MoodSmith is written and researched by Dr Elaine Ryan and uses only peer-reviewed research on journals, government bodies, universities and professional bodies to support the article.
FOOTNOTES
- HOCD is not a diagnosis that can be found in the Diagnostic and statistical manual of mental health disorders; DSM. DSM is used by mental health professionals to diagnose conditions. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
- Bhatia & Kaur J. Homosexual Obsessive Compulsive Disorder (HOCD): A Rare Case Report. J Clin Diagn Res. 2015;9(1):VD01-VD02. doi:10.7860/JCDR/2015/10773.5377
- Williams MT, Farris SG, Turkheimer E, Pinto A, Ozanick K, Franklin ME, Liebowitz M, Simpson HB, Foa EB: The myth of the pure obsessional type in obsessive-compulsive disorder. Depress Anxiety 2011;28:495-500.