Homosexual OCD (HOCD): Understanding and managing HOCD

HOCD stands for Homosexual Obsessive-Compulsive Disorder. The H for homosexual represents the obsessions that exist within this type of OCD, where the person fears that they might be gay. A more recent name for the condition is Sexual Orientation OCD, where the person’s intrusive thoughts are in relation to their sexual orientation. HOCD is like having a very annoying and persistent voice in your head that keeps questioning your sexual orientation. It’s not based on reality but feels very real and scary. It’s like your brain is playing a trick on you, making you doubt yourself even though you know deep down who you are.

If you want to understand HOCD, you must first understand its parent, Obsessive Compulsive Disorder.

OCD can show itself in many different forms – a bit like the shape-shifting prototype in Arnold Schwazenegger’s Terminator, but rather than the shapes shifting; with OCD, it is the obsessions that shift. Depending on the form that your obsessions take, you might struggle with cleanliness, worried that you could hurt someone, or as in today’s article, obsess about your sexual identity.

OCD is characterized by obsessions and compulsions.

• Obsessions: These are all the unwanted and intrusive thoughts, images, urges, feelings, or sensations that cause you an extreme amount of anxiety and distress. Individuals with OCD often feel overwhelmed by these thoughts because they go against their values or beliefs. They are egodystonic in nature, meaning they are inconsistent with what you hold dear or firmly believe in.
• Compulsions: To alleviate the anxiety caused by obsessions, individuals engage in compulsive behaviours. These can be physical actions, like checking or hand-washing, or mental activities, like counting or seeking reassurance. Although these behaviours provide temporary relief, they ultimately perpetuate the cycle of OCD by reinforcing the fear that the obsessions are important and need to be managed.

It is essential to understand that HOCD is not about an individual’s sexuality, but rather HOCD refers to the obsessive thoughts a person has about their sexuality. For example, a person with HOCD, if they have always been heterosexual, shall still be heterosexual, but they experience intrusive thoughts that make them doubt their sexuality even though they are not attracted to members of the same sex.

When I have been working with clients or talking with the public, they appear to struggle more with the concept of this type of OCD, and I think that is due to thinking it has something to do with prejudice or political correctness. It has not. It has nothing to do with prejudice or homophobia—the obsessions are related to a fear that long-standing sexual identity has changed. It is an obsessive-compulsive disorder and has nothing to do with the person’s sexuality at all; it is all about the intrusive thoughts that go against the person’s true nature. For example, if you adore dogs and have always had dogs as part of your family, and I start telling you, actually that’s not true, you much prefer ferrets, get a ferret. The more you ignore me, the louder I get, screaming at you, you do not like dogs, you like ferrets. If I do this long enough and loud enough, eventually I might confuse you. This is kind of like intrusive thoughts relating to a person’s sexual identity when they are struggling with sexual orientation OCD.

When the condition first entered the public domain, it was labelled HOCD and, according to Bhatia & Kaur, 2015 (1), was marked by excessive fear of becoming or being homosexual. However, Sexual Orientation OCD or sexual-themed OCD is a more accurate and acceptable label, as the subtype is not confined to males doubting their heterosexuality.

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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.

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.

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.

Signs of Hocd

Symptoms of HOCD

The defining symptoms of HOCD are being afraid that you are gay and repeatedly checking to see if this is true or not. In terms of OCD, these symptoms represent obsessions and compulsions, where the obsessions are all the confusing thoughts and images, and the compulsions are the acts you carry out to ease anxiety or get some form of assurance that you are still you. I shall explain obsessions and compulsions in more detail below.

The word ‘obsession‘ comes from the Latin’ obsidere’, which means ‘to besiege’. Obsessions are the unwanted intrusive thoughts that you get in your head. 

When you get these obsessions, i.e., the thoughts about your sexuality that are uncomfortable for you, like many other people, you do some things to help ease the stress they cause and reassure yourself that your sexual identity has not changed. The things you do are known as compulsions and I shall give some examples below.

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 causes HOCD?

Genetics

• If someone in your family has OCD, you might be more likely to have it too.
• Certain genes might be linked to OCD, but we’re still learning about this.

Brain Factors

• Brain scans show that people with OCD have some differences in their brain.
• There might be a link between OCD and the brain’s fear centers.
• There could also be an imbalance in brain chemicals. Medicines like SSRIs help balance these out and treat OCD.

Psychological Factors

In Summary:

• HOCD and other types of OCD are complex. No single reason explains why someone has it.
• 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.

Misunderstandings and Myths

• Misconceptions: HOCD is often misunderstood as repressed homosexuality or part of the coming out process. It’s vital to recognize these are misconceptions and that HOCD is a subtype of OCD characterized by intrusive, distressing thoughts about sexual orientation, regardless of your actual sexual preferences. If you are interested, you can read more on myths and realities here.

I found the difficulty in getting the correct help lies in the skill of the therapist and their knowledge of OCD, as was noted in a case report where the authors mention the lack of tools to diagnose this type of OCD. This report details a case where the person noted repetitive thoughts since age four. This was not the case in my clinical practice, where all people I have worked with started having obsessive thoughts about their sexuality as adults, as seen in the case study below.

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.

Treatment and Management of HOCD

HOCD Treatment and Therapy Options

Cognitive behavioral therapy (CBT) and exposure and response prevention (ERP) are the most effective treatments for HOCD.

• 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.
• 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.

If you are struggling with HOCD, there are things you can do on your own that help. Many resources on MoodSmith contain psycho-educational material to help you.

Start by reading

• this introductory series on intrusive thoughts.
• Learn how to do ERP yourself in this article ERP for intrusive thoughts.

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).

Exposure Response Prevention.

Exposure and Response Prevention (ERP): A type of CBT that involves confronting anxiety-triggering thoughts and situations while resisting the urge to engage in compulsive behaviors.

• ERP Exercises: These exercises involve purposefully exposing yourself to anxiety-evoking situations and refraining from seeking reassurance or engaging in compulsions. Over time, this helps you tolerate intrusive thoughts and reduces the hold of HOCD.

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.

Cognitive Behavioural Therapy.

Cognitive Behavioral Therapy (CBT): This approach focuses on identifying and challenging negative thoughts and behaviours and learning coping strategies to manage symptoms.

• Understanding Thought Patterns: CBT helps you understand how your thoughts and behaviours contribute to your experience of HOCD. You can read more on the thought patterns here.
• 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.

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.

Misconceptions about HOCD

It’s crucial to understand that HOCD is not about an individual’s true sexual orientation. The intrusive thoughts and fears are a manifestation of OCD and do not reflect the person’s actual desires or identity.

• Ego-Dystonic Nature of HOCD: OCD is known as ego-dystonic, meaning that the thoughts and fears it produces are in direct conflict with the individual’s values and beliefs. For example, a person with HOCD who identifies as heterosexual will find these intrusive thoughts distressing precisely because they go against their self-identity.
• False Attribution of Meaning: The thoughts experienced in HOCD do not mean anything about a person’s sexual orientation. They are just random, intrusive thoughts that the mind misinterprets, leading to unnecessary anxiety and doubt.

FAQs

In this last section, I shall answer some of the questions I have been asked while working as a psychologist. In doing so, I shall hopefully dispel some myths.

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.’

My thoughts must mean something.

This is a faulty belief system if you get an HOCD-related thought. Random thoughts mean nothing.

I can think I am 21 years old and a multi-millionaire, and it is not valid, as thoughts mean nothing. Thinking that they must mean something about your sexuality is, in fact, thought-action fusion, and you read more about that here.

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.

Hopefully, this last section helped answer some questions and dispel some myths.

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

1. 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.). 
2. 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
3. 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.