1. Homosexuality Anxiety:
Originally presented at the Quarterly Meeting, “Homosexuality Anxiety: A Misunderstood Symptom of OCD,” OC Foundation of New Jersey, Robert Woods Johnson Hospital, New Brunswick, NJ, : Sep 8, 2008
A Misunderstood Form of OCD
Monnica Williams, Ph.D.
OC Foundation of New Jersey, Robert Woods Johnson Hospital

2. 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:
Specializes in research and treatments for OCD & PTSD

3. 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)
Kessler RC, Berglund P, & Demler O. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6):

4. OCD is Serious: Human Toll
Severe Distress
Anxiety
Depression
Suicidal ideation
Disability
Social Impairment
Family Problems
AD Lopez, CCJL Murray, The global burden of disease, , Nature Medicine, 4, 1241-
1243, 1998.

5. 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
Abramowitz, Franklin, Schwartz, Furr. (2003). Journal of Consulting and Clinical Psychology. Vol. 71, No. 6, 1049–1057

6. 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)
Sexual obsessions seem to be equally prevalent in both male and female OCD patients. People with sexual obsessions are particularly likely to have co-occurring aggressive and religious obsessions, clinical depression, and higher rates of impulse control disorders (Grant et al, 2006).
Gordon WM. (2002) Sexual obsessions and OCD. Sexual and Relationship Therapy, 17 (4).
Grant JE, Pintob A, Gunnipb M, Mancebob MC, Eisenb JL, & Rasmussen SA. (2006). Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Comprehensive Psychiatry, 47:

7. 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

8. 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
Keller D & Foa EB. (1978). Phenothiazines combined with systematic desensitization in a psychotic patient with obsessions about homosexuality. Journal of Behavior Therapy and Experimental Psychiatry, 9(3),
Foa & Kozak, DSM-IV Field Trial: Obsessive-Compulsive Disorder. Am J Psychiatry, 1995; 152:90-96.

9. What Is “H” OCD? Obsessions Compulsions
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
Started BrainPhysics.com 8 years ago

10. 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

11. 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)
Goldberg RL. (1984). Heterosexual panic. American Journal of Psychoanalysis, 44(2): 209.

12. HOCD vs Real Sexuality Crisis (1)
Sexual Identity Crisis
feels more sexually aroused by people of the opposite sex
thoughts about engaging in same-sex relationships are unappealing
feels anxious about romantic relationships with people of the same sex
feels more sexually aroused by people of the same sex
thoughts about engaging in same-sex relationships are arousing
feels excited about romantic relationships with people of the same sex

13. HOCD vs Real Sexuality Crisis (2)
Sexual Identity Crisis
have most enjoyed sexual experiences with a person of the opposite sex
worry about same-sex thoughts mainly because don't want to give up opposite sex
not able to stop thinking about same-sex relationships, and the thoughts are a severe distraction
have most enjoyed sexual experiences with a person of the same sex
worry about same-sex thoughts mainly because of what others might think or religious concerns
often thinks about same-sex relationships but able to stop

14. HOCD vs Real Sexuality Crisis (3)
Sexual Identity Crisis
feel emotional intimacy with a partner of the opposite sex
worry that people of the same sex might be attracted
fantasize about physical relationships with opposite sex (including dreams)
feel emotional intimacy with a partner of the same sex
like when people of the same sex are attracted
fantasize about physical relationships with same sex (including dreams)

15. HOCD vs Real Sexuality Crisis (4)
Sexual Identity Crisis
tries to learn more about sexual identity issues to reassure self that not gay
tries to learn more about sexual identity issues to better understand self and others like self

16. Treating HOCD Misdirected Intervention Cognitive Understanding of HOCD
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)
Grant JE, Pintob A, Gunnipb M, Mancebob MC, Eisenb JL, & Rasmussen SA. (2006). Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Comprehensive Psychiatry, 47:

17. 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!

18. EX/RP for HOCD Exposure ideas No rituals before or after exposures!
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

19. 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
Elmore JL. (2002). Fluoxetine-Associated Remission of Ego-Dystonic Male Homosexuality. Sexuality and Disability, 20(2):
A Bystritsky, Current Pharmacological Treatments for Obsessive-Compulsive Disorder, Essent Psychopharmacol, 5:4, 2004.
HB Simpson, EB Foa, MR Liebowitz, et al, A Randomized Controlled Trial of CBT for Augmenting Pharmacotherapy in OCD, Am J
Psychiatry in Advance, 1-10, March 2008.

20. Results of Augmentation Research
Patients on an SSRI continue to improve when CBT (EX/RP) is added
Simpson HB, Foa EB, Liebowitz MR, et al. (2008). A Randomized Controlled Trial of CBT for Augmenting Pharmacotherapy in OCD, Am J Psychiatry in Advance, 1-10.
QUESTIONS?

21. 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

22. 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
NeuroticPlanet OCD Discussion Forum
Scholarly articles about HOCD:

23. References
Bystritsky A. (2004). Current Pharmacological Treatments for Obsessive-Compulsive Disorder. Essential Psychopharmacology, 5:4.
Elmore JL. (2002). Fluoxetine-Associated Remission of Ego-Dystonic Male Homosexuality. Sexuality and Disability, 20(2):
Foa EB, Kozak MJ, Goodman WK, Hollander E, Jenike MA, & Rasmussen SA. (1995). DSM-IV field trial: Obsessive- compulsive disorder. American Journal of Psychiatry, 152(1):
Goldberg RL. (1984). Heterosexual panic. American Journal of Psychoanalysis, 44(2): 209.
Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Heninger GR, & Charney DS. (1989). The Yale-Brown Obsessive Compulsive Scale, I: development, use, and reliability. Arch Gen Psychiatry, 46:1006–1011.
Goodwin R, Koenen KC, Hellman F, Guardino M, & Struening E. (2002). Helpseeking and access to mental health treatment for obsessive-compulsive disorder. Acta Psychiatr Scand, 106: 143–149.
Gordon WM. (2002) Sexual obsessions and OCD. Sexual and Relationship Therapy, 17 (4).
Grant JE, Pintob A, Gunnipb M, Mancebob MC, Eisenb JL, & Rasmussen SA. (2006). Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Comprehensive Psychiatry, 47:
Keller D & Foa EB. (1978). Phenothiazines combined with systematic desensitization in a psychotic patient with obsessions about homosexuality. Journal of Behavior Therapy and Experimental Psychiatry, 9(3),
Kempf EJ. (1920). The psychopathology of the acute homosexual panic. Acute pernicious dissociation neuroses. In: Psychopathology. Kempf EJ.; Mosby Co., St Louis, MO. pp
Kessler RC, Berglund P, & Demler O. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6):
Meyer IH. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5):
Rudden M, Busch FN, & Milrod B. (2003). Panic disorder and depression: A psychodynamic exploration of comorbidity. International Journal of Psychoanalysis, 84(4):

24. More Information
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