Homosexuality Anxiety:
A Misunderstood Form of OCD
Monnica Williams, Ph.D.
OC Foundation of New Jersey, Robert Woods Johnson Hospital
Introductions
 Assistant Professor of Psychology in Psychiatry
 Center for the Treatment and Study of Anxiety
University of Pennsylvania, School of Medicine
Department of Psychiatry
 Phone: 267-626-6018
 Specializes in research and treatments for OCD & PTSD
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Obsessive-Compulsive Disorder
 Obsessions
 Unwanted, recurrent, disturbing thoughts that the person
cannot suppress and which can cause overwhelming
anxiety
 Compulsions
 Repetitive, ritualized behaviors that the person feels driven
to perform to alleviate the anxiety of the obsessions
 Prevalence of OCD
 Lifetime prevalence at 1.6% in the general population
(Kessler, Berglund, & Demler, 2005)
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OCD is Serious: Human Toll
 Severe Distress
 Anxiety
 Depression
 Suicidal ideation
 Disability
 Social Impairment
 Family Problems
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OCD Sub-Types
 Sub-types of OCD
(Abramowitz, Franklin, Schwartz, & Furr, 2003)
 Aggression & Harming (by accident or on purpose)
 Contamination & Washing
 Hoarding
 Symmetry & Ordering
 Unacceptable thoughts & Mental Rituals
 Common unacceptable thoughts
 Religious or blasphemous
 Violent
 Sexual thoughts
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Sexual Obsessions
 25% experienced sexual obsessions currently or in the
past (Grant et al, 2006)
 Actual prevalence rates may be higher
 Common themes include unfaithfulness, incest,
pedophilia, unusual behaviors, AIDS, profane thoughts
combining religion and sex, and homosexuality
(Gordon, 2002)
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Obsession vs. Fantasy
 Sexual obsessions ≠ Sexual fantasies
 Normal sexual fantasies are enjoyable and generally harmless
 They may consist of wishes or memories of past sexual
experiences
 Sexual ideation in OCD is unpleasant and distressing
 The individual with OCD does not want the thought to become
real
 Sexual obsessions in OCD rarely produce sexual
arousal
 Obsessions usually decrease sex drive
 The obsessions result in guilt, shame, distress, anxiety
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About Homosexuality Anxiety
 Homosexuality fears have been documented in people
with schizophrenia, panic disorder, and other disorders
 Few studies have focused specifically on homosexual
anxiety in OCD
 DSM 4 Field Trial identifies 12% with current or past
concerns based on YBOCS (Williams & Farris, 2011)
 8% with present concerns
 4% with past concerns
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What Is “H” OCD?
 Obsessions
 The obsessive fear of being or becoming homosexual
 The experience of intrusive, unwanted mental images of
homosexual behavior
 The obsessive fear that others may believe one is homosexual
 Compulsions
 Usually a form of checking
 More about this…
 Term “HOCD” (Homosexual Obsessive Compulsive Disorder)
evolved out of the online community
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Examples of Homosexuality Anxiety
 Lesbian obsession
 heterosexual female health worker finds obsessions are
triggered by contact with attractive women patients
 Compulsive checking
 20 year old male masturbates to images of men to measure
his sexual valence
 Worry about appearing gay
 a high-school student who worries that others of the same
sex might find her attractive
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Differential Diagnosis
 Mental health professionals may misdiagnose HOCD
 HOCD ≠ Internalized Homophobia (“ego-dystonic
homophobia”)
 Few instruments address homosexuality anxiety (1 item
on the YBOCS checklist)
 Most with HOCD have OCD symptoms in other areas
 Diagnosis may be hard if symptoms limited to
homosexuality obsessions
 Gay people with HOCD may have heterosexual worries
too (Goldberg, 1984)
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HOCD vs Real Sexuality Crisis (1)
OCD
Sexual Identity Crisis
1.
feels more sexually
aroused by people of the
opposite sex
1.
feels more sexually
aroused by people of the
same sex
2.
thoughts about engaging
in same-sex relationships
are unappealing
2.
thoughts about engaging
in same-sex relationships
are arousing
3.
feels anxious about
romantic relationships with
people of the same sex
3.
feels excited about
romantic relationships with
people of the same sex
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HOCD vs Real Sexuality Crisis (2)
OCD
Sexual Identity Crisis
4.
have most enjoyed sexual
experiences with a person of
the opposite sex
4.
have most enjoyed sexual
experiences with a person of
the same sex
5.
worry about same-sex
thoughts mainly because don't
want to give up opposite sex
5.
worry about same-sex
thoughts mainly because of
what others might think or
religious concerns
6.
not able to stop thinking about
same-sex relationships, and
the thoughts are a severe
distraction
6.
often thinks about same-sex
relationships but able to stop
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HOCD vs Real Sexuality Crisis (3)
OCD
7.
feel emotional intimacy
with a partner of the
opposite sex
8.
worry that people of the
same sex might be
attracted
9.
fantasize about physical
relationships with opposite
sex (including dreams)
Sexual Identity Crisis
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7.
feel emotional intimacy
with a partner of the same
sex
8.
like when people of the
same sex are attracted
9.
fantasize about physical
relationships with same
sex (including dreams)
HOCD vs Real Sexuality Crisis (4)
OCD
Sexual Identity Crisis
10. tries to learn more about
10. tries to learn more about
sexual identity issues to
reassure self that not gay
sexual identity issues to
better understand self and
others like self
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Treating HOCD
 Misdirected Intervention
 Therapist told male patient to try being with a man, and that
everybody is bisexual
 Symptoms became worse and patient became suicidal for 5
months
 Cognitive Understanding of HOCD
 Patient receiving CBT came to realize he was dealing with
OCD-induced thoughts and an underlying distorted belief
system contributing to depression
 People with sexual obsessions may need a longer and
more aggressive course of treatment (Grant et al, 2006)
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Dos and Don’ts for Therapists
 DO: Educate the patient about OCD and how
obsessions are maintained
 DON’T: Focus on the possible meaning of the
obsessions
 DO: Psychoeducation about sexual thoughts and
sexual orientation
 DON’T: Suggest the patient is really gay
 DO: Exposures!
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EX/RP for HOCD
 Exposure ideas
 Devise a detailed story about the patient actually becoming




gay
Visit gay clubs and bars
Wear some clothing items of the opposite sex
Display a Gay Pride button
Confront obsessions with thoughts like “I guess I might be
gay”
 No rituals before or after exposures!
 Understanding the specifics of the patient’s fears
essential to devising best exposures
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Medications
 SSRI medications will help alleviate obsessions,
compulsions, and anxiety
 One case report of a remission with Prozac of HOCD
 Will also cause sexual dysfunction in at least a third of
patients, which may panic HOCD patients
 Most OCD patients experience only a 30% reduction in
symptoms
 Partial responders may benefit from augmentation with
EX/RP or risperidone (Risperdal)
 Current augmentation study underway at Penn and NYC
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Results of Augmentation Research
 Patients on an
SSRI continue to
improve when
CBT (EX/RP) is
added
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Summary
 Sexual obsessions are a common symptom of OCD
 Homosexuality anxiety is not to be confused with a
sexual orientation crisis
 Cognitive-Behavioral Therapy (EX/RP) and medication
are considered the treatment of choice
 Research needed to define scope of problem and how to
best tailor treatment to this population
 Research is underway to address these questions
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Resources
 M. Williams: Homosexuality Anxiety: A Misunderstood
Form of OCD. Leading-Edge Health Education Issues. L.
V. Sebeki (eds.). Nova Publishers, 2008
 BrainPhysics OCD Mental Health Resource
www.brainphysics.com
 NeuroticPlanet OCD Discussion Forum
www.neuroticplanet.com
 Scholarly articles about HOCD:
www.MonnicaWilliams.com/publications.php
References
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More Information
 This slideshow is available as a powerpoint at
www.monnicawilliams.com/publications.php
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