The OCD Cycle

We live in a society that collectively has difficulty tolerating anxiety and accepting ambiguity. Anxiety is an emotion that is associated with a lot of negative connotations and generally leads us to quickly seek out solutions to escape the discomfort. For some people, anxiety becomes connected to everyday, seemingly neutral things such as other people, social situations, doorknobs, dogs, physical sensations, and emotions. The actions taken in attempts to evade anxiety are called safety behaviors (or within OCD, they are called compulsions). These behaviors are enacted with the hopes of decreasing distress. Unfortunately, the relief acquired from engaging in safety behaviors is only temporary and becomes increasingly short-lived over time. Some common safety behaviors include avoiding anxious triggers, seeking reassurance, researching, using substances, washing, counting, etc. Since these behaviors actually do work (but only in the short-term), people continue to use them. Unfortunately, continuing to rely on safety behaviors causes individuals to become trapped in the anxiety cycle and prevents them from learning that their fears were either unfounded or tolerable. Ironically, these safety behaviors and compulsions ultimately have the opposite effect of what the user intended, and they only preserve the fear in the long run. Simultaneously, reliance on safety behaviors prevents growth and learning, which can severely restrict quality of life. The thoughts, situations, emotions, or body sensations that create the anxiety might be different within each presentation of OCD, but the cycle that maintains anxiety generally has low variability. Please see our previous blog entry – Understanding the Cycle of Anxiety – for further information.

What is Sexual Orientation OCD?

Sexual Orientation OCD is characterized by the presence of recurrent obsessions pertaining to uncertainty or doubt about one’s own sexual orientation. These obsessions focus on the fear that one is gay, will become gay, wants to be gay, should be gay, is somewhere on the LGBTQ+ spectrum, or doesn’t fully know their own sexual orientation. Sexual orientation OCD is also experienced by individuals who identify as gay. When a gay person is experiencing Sexual Orientation OCD, obsessional worries may include anxieties about being straight or becoming straight, concerns that they might be lying to themselves about their sexual orientation or that they don’t know how they truly identify, worries about how other members of the LGBTQ+ community may react to them, worries that they may never determine their true sexual orientation, etc. Under the umbrella of this OCD subtype, people may also experience obsessions and compulsions revolving around their gender identity. Since this type of OCD targets an important component of identity, it causes significant distress and calls into question many important aspects related to self-perception. This type of OCD is accompanied by a great deal of rumination and engagement in compulsions in attempts to “prove” one’s sexual orientation is not what they fear. The obsessions and compulsions present in OCD are excessive, cause a great deal of emotional upset, and have the potential to impair the person’s functioning in important life areas such as work, school, relationships, community engagement, etc.

 Common Obsessions in Sexual Orientation OCD

Common obsessions include (but are not limited to):

• Wondering if previous thoughts, feelings, and/or behaviors were evidence of your sexual orientation being the opposite of the orientation that you currently claim
• Worrying if you thought someone of the same (or opposite) sex was attractive
• Wondering if you could be attracted to your same-sex (or opposite-sex) friends
• Thinking that taking notice of a person of the same sex (or opposite) means that you are gay (or straight)
• Worrying that experiencing groinal sensations around the same (or opposite) sex means that you are gay (or straight)
• Thinking about the same (or opposite) sex’s body parts and believing that to be evidence of being gay (or straight)
• Worries that you acted in a sexual way towards others
• Worries that you look or act gay (or straight)
• Worrying if you are attracted “enough” to your current partner
• Concerns that all these doubts you are having are proof that you have been wrong about your sexual orientation all along

Common Compulsions in Sexual Orientation OCD

Common compulsions/rituals/safety behaviors include (but are not limited to):

• Avoiding eye contact with people of the same (or opposite) sex
• Avoiding all physical contact beyond what is necessary (e.g., handshakes)
• Making sure that there is ample space between you and another person of the same (or opposite) sex (e.g., standing in line, on the train, in class/meetings, etc.)
• Avoiding reading books, articles, and other written sources that feature gay characters
• Avoiding watching television shows or movies that feature gay themes and characters and/or have gay actors in the cast
• Avoiding listening to music written or performed by gay artists
• Asking family members, friends, and/or significant others if they have ever questioned your sexual orientation or thought that you were gay (or straight)
• Researching online about the experience of coming out and/or how people knew that they were gay in order to compare these experiences to your own to increase certainty about being alike (in those that identify as gay) or being dissimilar (in those that identify as straight)
• Looking at sexually explicit images/watching sexually explicit content of the opposite sex (for people who identify as straight) or the same sex (for people who identify as gay) to check for signs of sexual arousal
• Checking your level of physical/sexual attraction to your partner
• Reviewing all of your experiences with their previous crushes, dates, significant others, etc. for proof that your sexual orientation is truly the one that you claim
• Intentionally dressing and/or acting according to traditional gender stereotypes (this may be done in ways that are beyond or are an exaggeration of the traditional norm)
• Not talking about issues related to sexual orientation and gender identity
• Intentionally talking about your crushes, celebrities that you find attractive, what you look for in a romantic interest, etc. in ways that align with the sexual orientation that you claim

 Special Considerations for Sexual Orientation OCD

• Sexuality, sexual orientation, and gender occur on a spectrum, which contains some ambiguity. Ambiguity of any sort is a hot spot for OCD as OCD tends to gravitate towards dichotomous categories and employs a rigid rule-bound system, which is structured in a black-or-white, all-or-nothing, and/or right-or-wrong sort of format. Realistically, society generally supports this dichotomy when it comes to sexual orientation and gender identity. The persisting stigmas associated with sexual orientation and gender identity serve to increase the intensity of anxiety, fear, and shame connected to experiencing Sexual Orientation OCD
• You can think someone is attractive without necessarily being attracted to them. When anxiety is in the picture, it is very common for people to jump to conclusions and become easily fused with their worries. In such instances, the brain will often dissolve the boundaries between thinking and doing, making them seem as though they are the same thing. In other words, intrusive thoughts/obsessions may lead an individual to believe that just because they found someone attractive, that they are also attracted to this person. The alarm that one might feel about this fusion will likely lead to increased feelings of anxiety and rumination, which may be interpreted as further substantiating the fear: that they are attracted to a person of the same sex (for individuals who identify as straight) or the opposite sex (for individuals who identify as gay)

• When thinking about or seeing ANY sort of sexual content, it is normal to have physical signs of sexual arousal. People have sexual responses to sexual content. We are wired to respond this way. In the context of Sexual Orientation OCD, this physical responsiveness may lead people to believe that their bodies’ cues are proof that their sexual orientation is not what they believed it to be. An additional point to note is that when thinking about any part of your body and focusing your attention there, you will notice more sensations in that area. Checking one’s groinal responses is a frequently endorsed compulsion in Sexual Orientation OCD and therefore, the groin is an area of the body that receives more focused attention in this type of OCD. Increased attention leads to the perception of increased sensation. However, while these sensations may be misinterpreted as being indicative of sexual arousal, they may actually be neutral sensations. These sensations have likely always been occurring, but flew under the radar of conscious awareness because the individual was not hyperfocusing on this region of the body

• In this subtype of OCD, individuals may become anxious about their decreased anxiety to content encountered during treatment and/or in their lives that is similar to their obsessions. In other words, they may have anxiety about no longer feeling anxious when encountering previously triggering stimuli. They may believe that this reduction in anxiety is a sign that they may actually be gay (or straight) because the content no longer provokes anxiety. Remember, the experience of anxiety is not necessarily credible proof that something is true or false. It is an emotion stemming from your thoughts and from your interpretation of events. Sometimes thoughts are just simply thoughts

Treatment of Sexual Orientation OCD

The gold-standard treatment for Sexual Orientation OCD is Exposure and Response Prevention (ERP). ERP is an evidence-based treatment, which means that there is a significant amount of research, empirical studies, and data that consistently demonstrate the efficacy of employing an ERP treatment protocol to successfully ameliorate the symptoms of OCD. In the context of Sexual Orientation OCD, the goals of treatment are to both reduce distress associated with triggering stimuli and situations and to decrease functional impairments in daily living and significant areas of life. Through ERP, individuals engage in exposure to their feared anxiety triggers in order to help them to learn become less reactive to and more tolerant of their obsessional worries. ERP facilitates opportunities to challenge worries and to differentiate between anxious predictions and the actual outcomes of encountering feared stimuli and situations. Another goal of ERP is to increase the individual’s ability to tolerate the uncertainty, discomfort, and doubt that their OCD creates. Please see our previous blog entry — What is Exposure and Response Prevention (ERP) – for more information about this treatment. It is important to note that treatment for Sexual Orientation OCD is NOT intended to confirm or deny one’s sexual orientation. Rather than trying to prove whether one is gay or straight, treatment aims to increase the individual’s tolerance of uncertainty and enhance his/her ability to live life without knowing “for sure.”

Exposures can include anything that provokes anxiety and/or uncertainty related to sexual orientation concerns. Examples of exposures that may be conducted in the context of ERP treatment for Sexual Orientation OCD include:

• Reading stories about gay characters
• Watching television shows or movies with gay content
• Reading coming out stories
• Watching videos on YouTube about people telling their stories about how they realized that they were gay
• Listening to music written/sung by gay artists
• Going to neighborhoods where more gay people live
• Looking at pictures of attractive people of the same (or opposite) sex and identifying their attractive features
• Maintaining eye contact with and/or close proximity to people of the same (or opposite) sex
• Writing your own coming out story or story of telling important other in your life that you are actually straight
• Browsing websites that support the LGBTQ+ community, such as the Human Rights Campaign website
• Making a donation to organizations supporting the LGBTQ+ community
• Wearing clothing that is stereotypically feminine (for men) or masculine (for women)
• Wearing pride merchandise
• Making recordings of statements about the uncertainty you feel about your own sexual orientation
• Making recordings of statements about your sexual orientation being the opposite of what you always believed it to be

In addition to participating in exposure work with triggering stimuli, treatment must also include Response Prevention, which involves eliminating compulsions and deconstructing rituals. Examples of Response Prevention include:

• Refraining from replacing “gay” thoughts with “straight” thoughts (or vice versa)
• Refraining from checking your reactions to attractive people of the same (or opposite) sex
• Refraining from mentally replaying what you said or did around people of the same (or opposite) sex to determine whether you behaved in ways that you imagine a gay (or straight) person would
• Refraining from checking groinal responses or other physical sensations that could indicate sexual arousal (breathing, heart rate, sweating, etc.)
• Refraining from seeking reassurance from others about your sexual orientation
• Refraining from trying to gather “proof” that you are straight (or gay)

Engaging in ERP treatment helps individuals to learn new ways to respond to stressful situations and, after engaging in repetitious practice, they will likely experience a reduction in anxiety and/or learn that they are able to tolerate the stress and uncertainty while still engaging in enjoyable and meaningful activities.

Although ERP is the first-line treatment for Sexual Orientation OCD, Acceptance and Commitment Therapy (ACT) can often serve as a beneficial adjunct. Within ACT, individuals are introduced to the concepts of mindfulness and acceptance, which aid them in being present with their anxious thoughts without trying to change them or engage in compulsions. Interventions focusing on increasing acceptance of uncertainty and doubt are necessary to supplement ERP work in the treatment of Sexual Orientation OCD. Such interventions often overlap with Response Prevention work and may include refraining from mentally replaying conversations and/or actions with members of the opposite (or same) sex, refraining from seeking reassurance about how others would label their sexual orientation, refraining from engaging in online researching about how to determine one’s true sexual orientation, etc.

In the context of ACT, acceptance is making space for the thoughts and worries to be present without feeling the need to react or respond to them. Struggling against anxious or worrisome thoughts is likely to exacerbate anxious feelings and create more emotional suffering. Through ACT, individuals come to learn that having an awareness of their thoughts without trying to change them (i.e. refraining from engaging in compulsions or rumination) is not a confirmation that the thought is true. They come to recognize thoughts as just thoughts, instead of viewing them as facts. Being able to make this distinction enables people to decrease their emotional reactivity to such thoughts, thereby reducing the perceived significance of the thoughts. Using ACT-based strategies, individuals are better able to differentiate their thoughts and values from their OCD and identify if the behaviors they are engaging in provide them joy and pleasure (which is the goal), or if they are behaving in response to anxiety and uncertainty stemming from their OCD. They are able to learn to be aware of their thoughts and fears while not paying undue attention to and/or over-engaging with them.

ACT helps to increase acceptance about unanswerable questions that we may never know the answers to “for sure.” ACT also enhances individuals’ abilities to step back from the pull of the obsessive thoughts without trying to figure them out and aids them in redirecting their focus to something more constructive. The goal is to learn to live life and participate in activities that are important, even if the thoughts are present. Thus, ACT is employed to increase psychological flexibility and reduce the cognitive rigidity seen in OCD. ACT aims to help people to defuse from their obsessive/intrusive thoughts and maintain a present-focused awareness. This awareness will enable them to engage in the activities taking place in the moment, rather than retreating into obsessive worries. In addition to psychotherapy, individuals with Sexual Orientation OCD may also benefit from medication.

 Need help or support?

If you or a loved one are struggling with OCD or any other mental health concerns, know that you are not alone. If you are a parent or a caregiver and are seeking additional information about these diagnoses and how you can best support your child, our office provides parent training with the SPACE program. Please see our November 2021 Newsletter for more information on SPACE.

For these or any other mental health concerns, please contact The OCD and Anxiety Center at (630) 522-3124 or info@theocdandanxietycenter.com. We have offices located in Oak Brook and Orland Park, Illinois and our clinicians specialize in helping individuals overcome anxiety disorders, Obsessive-Compulsive Disorders, and other co-occurring mental health conditions. We provide telehealth services that are available in Illinois, Indiana, Georgia, and Iowa.

At The OCD and Anxiety Center, we can provide treatment both in the office and at off-site locations (your home, mall, school, work etc.). We will work closely with you to create an individualized treatment plan and discuss the appropriate frequency of appointments (once a week or more, if needed). We look forward to working with you and facilitating your therapeutic journey!

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