Queer Themes in OCD

While OCD has as many manifestations as there are colors in the rainbow, some OCD themes may present more frequently in the LGBTQIA+ community as well as the polyamorous, kink, and other non-traditional relationship communities. The purpose of this article is to identify some interesting trends and unique OCD themes I have noticed in working with these populations.

In my experience, folks in these communities have a greatly increased chance of their OCD latching on to themes involving sexual orientation, gender, and/or relationships. This may be because folks in these communities have an increased awareness of the role that sexuality, gender, and relationships play in their lives, as they may have had to fight for, accept, process, and wrestle with these concepts more than others. Therefore, when the broken alarm system that is OCD creates an urge to scan one’s life for potential problems, folks in these populations may be more predisposed to obsess around these themes.

A little precursor before we jump into some examples: it is completely healthy and even expected for a given individual to struggle at some point in their lives with many of these concepts. When I talk about OCD however, I am describing a situation where an individual finds it so difficult to tolerate fears that they may be concluding something incorrectly that they spend an excessive amount of time and energy trying to achieve certainty, which significantly impacts their daily functioning. This search can include observable actions such as googling, asking friends, or testing if one’s genitals respond to different images, as well as covert compulsions such as mentally reviewing information and engaging in an endless internal debate. If an individual has OCD, the therapeutic goal is to build an ability to identify their best guess and tolerate the uncertainty that it is wrong. For more about the nuances of treatment, check out this and this article.

The following are some themes that folks with OCD that I worked with or know have obsessed over:

Relationship OCD (ROCD): 

Many queer folks face rejection and descrimination from others, including their biological family. Therefore, the people they choose to bring into their lives can carry an extra special importance to them. Sometimes, this can lead to folks feeling extra pressure to choose the right person to be in a relationship with or especially fear losing the person they’ve chosen.

Some folks in queer communities may compulsively respond to this pressure through avoiding intimacy. For example, one trend amongst gay and bi men seems to be an increased likelihood of engaging in flippant sexual encounters either to avoid the risk of intimacy or to compulsively check elements about their sexual orientation. 

Queer folks with ROCD may obsessively ask:

• How do I know if I’ve found the one?

• How do I know if my partner will leave me?

• Is our relationship passionate enough?

• Am I sexually attracted to my partner enough?

• How do I know if I’m gay enough, masculine enough, feminine enough, or queer enough for my partner?

• How do I know if my partner is gay enough, masculine enough, feminine enough, or queer enough for me?

Sexual Orientation OCD

At first, sexuality and gender themed OCDs colloquially fell under a category (not created by psychologists, but by those within the OCD community) called Homosexual OCD (HOCD). Nowadays we understand sexuality to be far more complex than a gay-straight binary and likewise understand that OCD themes can be more nuanced as well. The umbrella these themes fall under is now usually referred to as Sexual Orientation OCD (SO-OCD).  Folks struggling with SO-OCD may obsessively ask:

• I identify as straight but what if I’m wrong? How do I know if I’m really straight?

• I identify as gay but what if I’m wrong. How do I know if I’m really gay?

• I identify as bisexual/pansexual but mostly pursue X gender. What if I’m wrong in determining the “ratio” of my bisexuality/ pansexuality? What if I’m not actually bisexual or pansexual? How do I know if I’m bisexual or pansexual?

• I identify as (any sexual orientation) but what if I’m wrong. How do I know what to identify as? Which labels describe me best?

Gender OCD (GOCD)

This theme has had somewhat of a rising trend the last few years as more folks learn that one’s gender identity is a choice, which can evoke distress that one’s choice could be “wrong”. While GOCD can come up in someone who has no innate desire to transition or alter their gender but fears that they could be wrong, it can also come up in those who genuinely want to transition and fear that they may make the wrong choice. Folks struggling with GOCD may obsessively ask:

• I identify as cis-gender, but what if I’m wrong?

• I identify as transgender, but what if I’m wrong? How do I *know* if I’m trans?

• Should I take hormones? Should I get surgery?

• How do I know how much transitioning I want to do? When should I stop transitioning? 

• How do I know what to identify as? What pronouns should I use?

Pedophilia OCD (POCD)

One harmful and baseless stereotype about queer folks, especially gay men, is that they are malevolent pedophiles. Growing up with these stereotypes can lead to internalized homophobia, which in turn can inspire OCD to manifest around the theme of pedophilia. Folks with POCD may ask:

• How do I know if I’m a pedophile?

• What are signs that I’m a pedophile?

• What if I get arrested under suspicion that I’m a pedophile because of XYZ?

Polyamory, Kink, and other Non-traditional Relationship Styles

Folks with OCD who identify as polyamorous or engage in other non-traditional relationship styles sometimes struggle with the freedom of choice and lack of imposed structure inherent in these relationship styles. They may obsessively ask:

• How open or closed should my relationship be? 

• Do I really want to be poly? What if it’s just avoidance of intimacy? 

• How do I know what labels to use for my partners?

• What if I’m making the wrong choice? Will polyamory ruin my relationship?

• For kink-centric relationships: 

  • Am I giving too much power to my partner? 

  • What if I’m too kinky or not kinky enough for my partner?

  •  What if asking to include my kink more in the relationship will ruin it?

Of course the above are all just a sampling of the many ways that OCD can manifest. If you don’t see yourself reflected above but are still struggling with obsessions and compulsions, know that OCD is as unique and diverse as humanity itself. That said, it is my hopes that pointing out these trends can help some readers feel less alone in their struggles. As I always say, OCD is very treatable. If you’ve been struggling, don’t wait any longer to seek help!

What can Therapy Change?

When folks come to therapy it is often with the hopes that their clinician can “get rid of” their Obsessive Compulsive Disorder (OCD) and help them achieve certainty about their obsessive topic. For better or for worse, therapy cannot so radically change the automatic processes of a person’s mind, nor can certainty be provided around any topic*. However, this does not mean that someone with OCD must accept all the distress that they are experiencing, unbridled and unmitigated. Therapy can be expected to reduce overall distress, but it’s important to understand what types of distress therapy targets.

To understand what types of distress therapy seeks to reduce, we must first have a language for describing distress in different ways. In OCD treatment, we often draw from the Bhuddist distinctions of “pain” and “suffering”.

• Pain can be described as the inevitable, unavoidable challenges of life. These can include bigger life events such as losing a job, going through a breakup, or suffering an injury, as well as smaller everyday experiences such as experiencing stress from deadlines or experiencing unwanted intrusive thoughts.

• Suffering on the other hand is what we add to the pain due to our maladaptive relationships to those unavoidable experiences. Examples include avoiding, ruminating, drinking, numbing through media, beating ourselves up, obsessing, and compulsing.

Pain generally makes up a small minority of the overall distress in any given person’s life. Instead, it is our engagement with suffering that really degrades the quality of our lives. In therapy we learn how to accept the slim minority of distress (intrusive thoughts and emotions) in order to dramatically reduce that which is causing the majority of our distress (obsessing and compulsing). As a result, our overall level of distress dramatically reduces and the quality of our lives improve significantly. 

There is another pragmatic way to look at the types of distress we experience and how they can be affected by effective therapy. We can measure our intrusive thoughts through four categories: duration, frequency, content, and intensity. Therapy can be expected to affect each of these variables in different ways. 

• Duration: By engaging in skillful response prevention, one can have a direct effect on the duration of each experience with an intrusive thought. The logic here is simple: by resisting the urge to respond to the question or thought our brains produce, we speed up the time it takes for the experience to pass on its own.

• Intensity: This in turn decreases the likelihood of experiencing intense distress. Rarely do we experience out of the blue a ten out of ten level of distress from OCD. Intense distress most often comes from our obsessing and compulsing and trying to escape the distress. By acting unskillfully, we add fuel to the fire and end up feeling more uncertain and more concerned. By engaging in response prevention, we can starve that fire, preventing it from reaching certain intensities far more often. 

• Content: Interestingly, our work can often have an effect on the content of OCD, but not in the way you might think. When we engage in response prevention, we send our brains a signal that we’re not going to explore the topic that it has deemed a potential emergency. As a result, the brain may search for other “emergencies” to explain why it’s experiencing distress. In fact I often see theme switching as a positive (but not necessary) sign that one is being skillful with their OCD. Essentially it doesn’t matter at all if one’s theme switches or not, but understanding that it might can help one not become surprised or dismayed when it happens but instead see it as a result of their skillfulness. 

• Frequency: In my experience in working with clients, a moderate level of adherence to Exposure and Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT) protocols can quickly have effects on the duration and intensity of intrusive thoughts, but the frequency of experiencing intrusive thoughts are more stubborn. What this means is that an individual may still experience intrusive thoughts a number of times each day, but they have the skills and ability to usually let those experiences last just a moment and remain at a low intensity. However, that is not to say that the frequency of intrusive thoughts can’t be affected at all by our work. It is my belief and personal experience that achieving a stellar level of response prevention, through self exploration and understanding the nuanced, subtle ways that we may still be compulsing, can reduce the frequency of intrusive thoughts. 
  

Knowing what change can be expected to take place through effective therapy help us invest our energy in changing what we can, accepting what is more change-resistant, and having the wisdom to identify the difference between the two. When we can skillfully balance change and acceptance, our overall level of distress plummets. It is the key to treatment success.

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*In sessions, to display this point I’ll raise my right hand and discuss how there can be no certainty that this in fact is my right hand. Maybe it’s a prosthetic, maybe the client is dreaming and I don’t exist, maybe their sense of right and left is inaccurate and they’ve never realized.

What Can Our “Gut” Tell Us?

In my early career, I often spoke ill of the phrase “gut feeling.” I would tell patients that having OCD challenged one’s ability to make decisions based on feelings because OCD creates powerful misleading emotional signals. Because much of the suffering from OCD comes from ascribing too much relevance to emotions such as a sense of dread or intense anxiety, I advised my patients to only make decisions based on their rational, logical side of their mind.

I was (sort of) wrong.

As an OCD specialist who has OCD, I am often informed not just by research in the field, but also by my personal experiences with OCD. The lesson I learned in regard to the role emotions play in decision making came from a challenge with relationship themed OCD that I experienced. In this relationship I experienced intense and frequent anxious and intrusive thoughts and feelings about whether or not it was the right relationship for me. I worked tirelessly to ascribe irrelevance to all of the signals I was experiencing because I had determined that staying in the relationship was logical and aligned with my values. However, I didn’t realize how disconnected my rational assessment was from the very real and legitimate emotions I was feeling. I had fallen into a state of mechanical logic. There were parts of the relationship that I could “feel” were not right, but I denied the validity of those feelings with lines such as “it’s against my values to judge this quality of my partner” or “rationally I understand a relationship takes work, so I need to pay this toll to be connected to someone in this way.”

My heart was sending me signals that this was not the right relationship to me, but I couldn’t tell that these were legitimate signals because at the same time, I truly was experiencing intense OCD. My relationship was a topic I could not stop thinking about, the consequences felt pressing and catastrophic, and I experienced intense anxiety for hours each day.

The most useful relationship with one’s “gut”, I finally learned through the guidance of wise clinicians, is more of a “both-and.” While it is incredibly important for anyone with OCD to learn and frequently use the skill of ascribing irrelevance to certain emotional signals, it is also integral that they be able to identify their more “authentic” or “true to self” feelings and understand what these feelings are trying to convey.

It is important to note that this should not be interpreted as me advising that every emotion should be directly listened to and dealt with, nor that they mean that acting on them is necessary. Some emotions may just be asking of us to be heard, others advise us that there is an issue that needs communication or problem solving (rather than the life or death extreme solutions OCD more often suggests).

In therapy, I still suggest that the first step is for a client to practice using response prevention ubiquitously. Prior to therapy, someone with untreated OCD has likely swung way too far in the direction of ascribing relevance to every thought and feeling. It is also easier to first focus just on learning the skill of response prevention before adding in the complex layer of when and where to apply it. However, once a client has mastered response prevention skills sufficiently, it is an important part of our work to introduce the concept of a “gut feeling” in a healthy and useful way. The client, in good therapy, learns how to distinguish what their OCD is trying to communicate versus what their true thoughts and feelings are on a given matter. In this way, the client learns how to more fully trust themselves and is able to draw from the whole spectrum of information their mind, heart, and body is seeking to convey.

When OCD Exposures Go Off Course: A Therapist Guide

It can be one of a new OCD therapist's biggest fears: you're conducting an exposure with a client and it suddenly starts to veer off course. Although you collaboratively mapped out the initial content, something shifted during the exposure. The client's mind jumped to a bigger or different fear, one they weren't prepared to face, and since this is one of your first exposures together, they feel overwhelmed and unready for what their mind is throwing at them.

The Dilemma: Pushing Forward vs. Abandoning the Exposure

As the clinician, you feel stuck between a rock and a hard place. To press on might mean pushing the client to sit with something they're clearly communicating they're not ready for. While there are times to challenge that resistance, this might not be one of them. On the other hand, abandoning the exposure could be equally problematic. After all, the goal of exposure is to teach the client that they can tolerate distress. If they start the exposure, encounter unexpected intensity, and then flee, it can reinforce the belief that distress is intolerable or unsafe.

Fret not, o burgeoning OCD expert! There is a way to gently land this plane.

Managing Exposure Intensity: The Solution

In moments like this, your job is to moderate the intensity of the experience while still creating a meaningful learning experience. One effective approach is to shift the focus away from specific intrusive thoughts and toward the physical sensations of distress. This technique, borrowed from Acceptance and Commitment Therapy (ACT), is called an expansion exercise.

How to Use the Expansion Exercise Technique

Here's how it works:

• Guide the client to focus on the physical experience of distress. Ask them to describe in detail where they feel it in their body.

• Prompt them to observe its different qualities. What shape does it take? What is its texture, color, or temperature?

• Then, help them explore the boundaries of the discomfort. Often, acute distress occupies only a small portion of the body, frequently the chest or stomach.

• Once they can identify its location and size, invite them to breathe around the discomfort—not to get rid of it, but to make room for it. Encourage them to soften any muscles they've been tensing around the discomfort, allowing space for the feeling to simply exist.

Benefits of the ACT technique in OCD Therapy

By gently turning toward the physical discomfort without amplifying or resisting it, the client still learns the main two lessons of an exposure:

1. how to skillfully sit with distress and

2. that in doing so, distress is easier to manage than they might have predicted.

This can have a calming or even relieving effect, similar to what we often see with well-structured exposures. Once you've successfully landed the plane, you can step out of the exposure and have a conversation about what new fears arose and how to gradually build toward addressing them in future sessions.