Having repetitive, intrusive fears or doubts about sexual orientation is a common, and often misunderstood, form of OCD (it is sometimes referred to as H-OCD). For someone with this theme, obsessions about sexual orientation and the resulting distress often lead to an ever-increasing panicked effort to prove to themselves and others that they are attracted to only the opposite (or same) sex. Someone who has had primarily heterosexual attraction may experience anxiety when she thinks about women; another individual who has had primarily homosexual relationships may fear having thoughts about people of the opposite sex. In either case, no matter how hard the person tries, doubt and anxiety inevitably creep back in and compel a new effort to to prove the nature of his or her sexuality, often with a re-doubling of effort and distress.
Often a person can identify the circumstance that triggered the initial fear, such as a joking comment by a friend or acquaintance (‘Are you sure you’re not gay?’), or an ambiguous encounter with someone (‘Was I attracted to that person?’ ‘Did my eyes linger too long?’ ‘Did that guy/girl look at me strangely?’). The person then can become hyper-aware of his or her own movements and body language, fearing s/he is acting in a “homosexual way” or have “gay characteristics.” An often co-occurring fear is that “others will think I’m gay.”
Compulsions in this condition often include frequent reassurance-seeking from others and making mental lists of evidence for / against his/her own homosexuality. Others may scour the Internet, reading articles on sexual orientation, looking at photos to confirm that s/he is not turned on, reading articles describing people who are gay to compare them to him/herself, or trying to act “especially straight.” For someone who identifies as being gay, similar compulsions may occur to reassure oneself that he or she is not heterosexual.
A person with fears of being gay may be dating people of the opposite sex, but this typically does little to assuage his/her anxiety. Typically during intimacy or sex the person is hyper-vigilant as to whether s/he is sufficiently turned on, enjoying him or herself enough, or actually attracted to his/her partner. These intrusive thoughts inevitably increase anxiety and diminish the excitement and enjoyment of the interaction, thus fueling the fears even more. Intrusive sexual images of same-sex persons may “pop up” during sex with a partner and lead to even greater anxiety and more intrusive thoughts and doubts: “Why would I think that? Does that mean I’m gay?” These experiences often lead to significant anticipatory anxiety, so that sex and intimacy may be avoided altogether. Over time, these symptoms can have a detrimental impact on romantic relationships.
Example 1
John had engaged in several intimate relationships with women over the years, but one day at work, a gay co-worker commented on John’s grooming and jokingly asked: “… are you sure you’re not gay?” At first John laughed the comment off, confident that his co-worker was just poking fun at him. But the comment lingered in the back of his mind. He casually asked his co-worker the next day to reassure him that he’d just been joking, which the co-worker confirmed, but after some time the doubt and associated anxiety crept back in. Over the next day or so John found himself repeating the scene over in his head to reassure himself that the comment was in fact said in jest. He started paying much more attention to how he dressed, and began comparing his choice of clothes to other “straight looking” guys he walked by in the street. But every time he convinced himself that “of course I’m not gay” and the anxiety came down, the doubts would inevitably creep back in and the anxiety would rise, compelling him to go over and over all the evidence for his heterosexuality. He began doing research on the Internet about “signs you might be gay,” and visited gay porn sites to confirm he was not “turned on.” Relief was short-lived and minutes a day of worry and compulsions eventually turned into hours. John found himself in a nightmare of doubt and anxiety that interfered with his work and social life.
Example 2
Sarah, a graduate student, was meeting fellow students at a coffee shop. She mentioned that she had started dating a guy she had met on an online dating site who lived in another town. One of the girls acted surprised and said “Really?” Sarah immediately thought, “Oh great, she thinks I’m a lesbian.” This scene lingered with Sarah throughout the evening, and when she had time to herself the thought “Could I be a lesbian?” emerged and sent her into a panic. She began thinking about her relationships with past boyfriends and wondering “Was I really turned on by them? Was I really attracted to them?” She mentally reviewed past sexual encounters to confirm she actually enjoyed them. But each time she felt convinced she was heterosexual, the doubt would return and she would feel compelled again to review all of her encounters. Throughout the day she’d constantly “check out” other women she passed on campus to see if she found them attractive. When the anxiety increased she confided in some trusted friends, and asked them if they thought she could be a lesbian. They would either reassure her that she “probably wasn’t a lesbian” or with good intentions declare that they would still love her either way. This only increased her doubt and anxiety. Equally well-intentioned therapists devoted time to examining the evidence for her sexual orientation, concluding and reassuring her that she indeed was straight. Ending a session feeling confident that she was straight, she found with increasing frustration that she returned the following week anxious, distraught, and needing to explore the question once again.
Treatment
Exposure and Response (or Ritual) Prevention (ERP) is the front-line treatment for someone suffering from doubts about their sexuality. The goal of therapy is not to confirm “once and for all” one’s sexual orientation. This is what the person’s been trying to do all along with disastrous results! The goal is rather to train one’s fear system to tolerate the anxiety of being uncertain. When this happens, intrusive thoughts and doubts become less relevant, and subsequently not anxiety provoking.
This works in part because the fear system doesn’t care about reason or rational arguments; the fear system only learns by watching how we react to the environment. In this case, the “environment” consists of intrusive doubts, thoughts, and images about one’s sexual orientation. So by trying to reduce distress through compulsive reassurance seeking, the fear system “learns” that not being absolutely certain is very threatening. Using EXRP, one gradually exposes the fear system to distressing thoughts, images, and uncertainties, without trying to escape the perceived threat, thus demonstrating to the fear system that in fact these fears are not threatening. The fear and anxiety associated with these thoughts, images, and uncertainties is weakened, and the fear system no longer responds with anxiety.