A distinguishing feature of obsessive-compulsive disorder (OCD) is that it is egodystonic as opposed to egosyntonic. When something is compatible with a person’s true beliefs or self, it is considered egosyntonic – that is, in sync with a person’s ego. Conversely, if something is incongruent with a person’s true nature, it’s called egodystonic. Although it’s commonly known among OCD therapists that the disorder goes against a person’s true nature, there are times when the two coincide. This makes treatment, specifically exposure and response prevention (ERP), more challenging.
When a clinician utilizes ERP, the exposures are focused on embracing uncertainty about the accuracy and probability of the intrusive thoughts. When incorporating Acceptance and Commitment Therapy (ACT), the aim is for patients to behave in accordance with their own values. The difference is thus less about the behavior and more about the mindset. However, what happens when a person’s values aren’t incongruent with their obsessional fears? Some OCD clinicians would argue that either it’s not OCD or that the distinction is based on fear rather than conflicting values. But, a theme some OCD therapists – myself included – have witnessed is a person with sexual orientation OCD (SO-OCD) also being homophobic. Without setting off on a tangent, there’s also the challenge of the word homophobic, which entails fear of people who identify as homosexual rather than the dislike or hate implied in the word’s popular usage.
When people with SO-OCD seek treatment, one of their first statements to the therapist is typically to insist that they aren’t homophobic. OCD therapists are accustomed to hearing this, and we get it. SO-OCD isn’t about not wanting to be gay because it’s wrong, but because it’s not who they believe they truly are, and because being gay might have a number of serious consequences. These include ending a loving and healthy heterosexual relationship, which would hurt the other person and their partner’s family, as well as come out to family and friends and risk rejection. For those who identify as gay, the fears related to coming out are often valid, but they nonetheless make the decision to go forward with it because living an authentic life is more important than potential rejection.
SO-OCD was previously referred to as homosexual OCD or HOCD, but this was updated when patients who identified as gay reported being fearful that they were in fact straight. For this piece, the focus is on straight people worried that they’re homosexual.
However, for people who don’t support homosexual relationships, being gay has far more significant consequences. So, what’s an OCD therapist to do if a patient both has SO-OCD and is homophobic?
If we return to the basic goal of ERP, it’s not about accepting that the fear is true but that there’s no guarantee it’s not true. With hit-and-run OCD, we don’t ask patients to convince themselves that they did injure someone while driving and to be okay with that – we encourage them to recognize that there is no 100% guarantee that they didn’t hit someone while driving, and yet they can continue on with their day as they would want to spend it. We ask them to take the same potential risks that someone without OCD takes, and nothing greater than that. The thread connecting all OCD themes is the intolerance of uncertainty, not that the sufferer is in fact malicious and hurtful.
With SO-OCD and cooccurring homophobia, the ERP solution might rely on the Kinsey scale. Biologist Alfred Kinsey’s research into sexology led him to the belief that sexual orientation is not a binary state but a spectrum, which was dubbed the Kinsey scale. The scale is based on a bell curve where individuals fall on a 0-6 scale, with 0 being exclusively heterosexual, 3 equally heterosexual and homosexual, and 6 exclusively homosexual. Kinsey postulated that only 5% of the population was a 0 and 5% a 6, leaving the remaining 90% on a curve of some degree of bisexuality.
One of the challenges in treating people with OCD is the all-or-nothing, concrete thinking that rejects intellectual flexibility and uncertainty. So, if patients are firm in the belief that they are a 0, a success in treatment might not be about having someone be open to the idea of being gay, but about being a 1 or even a 2. Kinsey never said that these feelings or urges needed to be acted upon for the rating to be accurate, and with ERP that isn’t necessary either. For patients with SO-OCD who aren’t homophobic, we wouldn’t encourage them to have sex with someone of the same gender, or even kiss for that matter. There would be no conversation about coming out to one’s loved one as “potentially” gay, and it’s unlikely that ERP would include masturbating to gay porn.
So, we wouldn’t ask someone with SO-OCD who happens to be homophobic to do any of those things either. We can root ERP in the idea of the risk that a person is either a 1 and predominantly heterosexual and only incidentally homosexual or a 2 and predominantly heterosexual but more than incidentally homosexual. These exposures could include reading stories about people finding themselves attracted to someone of the same gender, watching video clips of people questioning their sexuality, writing scripts, going through a magazine and picking out the best-looking or sexiest person of the same gender, and so on.
Just as we encourage patients to be flexible with their thinking, we as clinicians must be as well, especially when it comes to creativity of exposures and OCD.