This document summarizes the treatment approach of exposure and response prevention therapy for individuals struggling with sexual identity obsessive-compulsive disorder (OCD). It describes the intrusive thoughts and compulsive behaviors commonly experienced, such as obsessively questioning and testing one's sexual orientation. The treatment involves gradually exposing patients to anxiety-provoking situations related to their obsessions while resisting the urge to perform compulsive rituals. Examples are provided of exposure exercises and response prevention assignments used, such as reading gay literature, wearing ambiguous clothing, and avoiding reassurance-seeking behaviors. The goal is to help patients learn anxiety naturally reduces when compulsions are eliminated.

1. But I Thought I Was Straight:
The Treatment and Experience
of Sexual Identity OCD
Fred Penzel, Ph.D.
Western Suffolk Psychological Services
Huntington, New York
IOCDF National Conference
Chicago, July 31, 2016

3. Obsession:
An intruding, unwanted thought, image, or
impulse that is usually unpleasant or negative
in some way, and tends to cause anxiety. It is
usually persistent, and may keep repeating
itself in different variations on particular
themes. It is perceived by the person, at least
to some degree, as not being their own thought
or desire, and they attempt to resist it.

4. “They seem so real!”

5. Question
Why do people get the particular
obsessions they end up with?
Answer
No one knows.

6. A study published in the Journal of Sex
Research found that among a group of
171 college students, 84% reported the
occurrence of sexual intrusive thoughts
(Byers et al, 1998)

7. Compulsion:
• Performed for the purpose of eliminating or neutralizing
anxiety caused by obsessions.
• Systematic avoidance of people, places, activities,
words, numbers, pictures, etc.
• Observable physical acts involving movements,
recitations, or activities. These may be repetitive or
ritualistic, or not.
• Unobservable mental acts involving the thinking of
words, numbers, images, or actions. These may be
repetitive or not.

8. Compulsions start out as
solutions to the problem
of having obsessions,
but soon become the
problem itself.

9. Obsessive Thoughts Associated With
Doubting One’s Own Sexual Identity
• How do I know whether I prefer men or women?
• Why do I react sexually to same sex stimuli?
• Maybe I really don’t know what I am.
• Maybe I’ll never know what I am.
• How will I ever be able to tell for certain?
• How does anyone tell what sex they are?
• What will happen if I make the wrong choice and get
trapped in a lifestyle that really isn’t for me?

10. Compulsions Associated With
Homosexual Obsessions
• Looking at attractive men or women or pictures of
them, or reading gay literature to see if they excite
you
• Imagining yourself in sexual situations to test how
you feel about them
• Observing yourself while behaving heterosexually to
see if you are really enjoying it
• Having sex repeatedly just for the purpose of testing
your own reactions

11. Compulsions Associated With
Homosexual Obsessions (cont.)
• Observing yourself to see if you look, talk, walk,
dress, or gesture like someone who is either gay or
straight.
• Compulsively reviewing and analyzing past situations
you were in with other men or women to see if you
acted like a gay or straight person
• Checking the reactions of others toward you to
determine whether or not you were acting
appropriately, or if they were looking at you strangely

12. Compulsions Associated With
Homosexual Obsessions (cont.)
• Checking your own behavior or preferences to
determine whether they appear masculine or
feminine

13. Compulsive Questioning Associated
With Homosexual Obsessions
• Do you think I could be gay?
• How can I tell if I’m really gay?
• At what point in their lives do people know that
they’re gay?
• Can you suddenly turn into a homosexual even if you
have never felt that way?
• Did I just act sexually toward you?
• Do I look gay to you?
• Did I just touch you?
• If I feel sexual when viewing gay or same sex things,
does I mean I’m gay?

14. Compulsive Avoidance Associated
With Homosexual Obsessions
• Avoiding standing close to or brushing against
members of the same sex.
• Not reading or looking at videos, news reports,
books, or articles having to do with gay people or
subjects
• Never saying the words ‘gay,’ ‘homosexual,’ or any
related term
• Trying to not look or act effeminately
• Not dressing in ways that would make you look
effeminate
• Not talking about gay issues of subjects with others
• Avoiding associating with anyone who may be gay or
who seems to be leaning in that direction

15. Compulsions Associated With Doubting
One’s Own Sexual Identity
• Ruminating over how you can ever be really sure what
your sexuality is
• Analyzing what makes a person homo- or heterosexual
• Trying out different sex roles
• Questioning others to determine how they view you
• Observing yourself walking, talking, dressing, gesturing,
etc. to determine your orientation
• Observing others as sex role models to see whom you
resemble
• Exposing yourself to sexual materials to test your
reactions
• Exposing yourself to different sexual situations as a test

16. So what do you do about
all this?

17. Behavioral Therapy for OCD

18. There is no escape from the
things you fear!

19. Because –
• You cannot run away from your own fearful
thoughts – the more you try to not think a
thought, the more you will think it
• There is no such thing in life as perfect certainty
(except for two things) so you will never be able
to perfectly protect yourself
• Risk is an essential part of life, so there is simply
no such thing as a risk-free existence
Why not?

20. You can only overcome a fear by
facing it.

21. Facing what you fear is a way of
getting closer to the truth.

22. The anxiety isn’t the problem.
The compulsions are the problem.

23. If you think that the anxiety is the
problem, you will do compulsions
that will maintain or increase it.
If you realize that the compulsions
are the problem and eliminate
them, you will ultimately eliminate
the anxiety because you are no
longer avoiding things.

24. “Suffering begins to dissolve
when we can question the belief
or hope that there's anywhere
to hide.”
- Pema Chödrön
(Buddhist nun and author)

25. Exposure And Response Prevention
(E&RP)
You gradually expose yourself to
increasingly fearful and challenging thoughts
and situations that will cause obsessive
thoughts, while at the same time resisting
the urge to do the compulsions you
commonly use to relieve the anxiety.

26. There Are Two Basic
Types of Exposure
***(Despite what
you may have
heard, behavioral
therapy isn’t really
like this at all.
Honest!)

27. In Vivo

28. Imaginal

29. Typical Exposure Homework for
Homosexual Obsessions
• Reading books by or about gay
persons
• Watching videos on gay themes or
that have gay characters
• Visiting gay meetings, browsing in gay
bookstores, or visiting areas of town that are
more predominantly gay
• Wearing a T-shirt (at home or in your room
alone) that says “I am gay” on it

30. Typical Exposure Homework for
Homosexual Obsessions (cont.)
• Agreeing with thoughts of being gay
• Wearing clothes in fit, color, or style that
could possibly look effeminate for a
man, or masculine for a woman
• Looking at pictures of good-looking people of
your own sex and rating them on
attractiveness
• Reading magazines such as Playboy if you
are a woman or Playgirl if you are a man.
• Visiting gay websites

31. Typical Exposure Homework for
Homosexual Obsessions (cont.)
• Standing close to members of your own sex.
• Making casual physical contact with members
of your own sex (touching someone's arm,
hand, or shoulder).
• Hugging a same sex friend.
• Doing a series of writing assignments of a
couple of pages each that suggest more and
more that you actually are gay or wish to be.
• Making a series of two-minute audio recordings
suggesting more and more that you are gay,
and listening to them 6 times per day.

32. Typical Exposure Homework for
Homosexual Obsessions (cont.)
• Listening to gay rock or music by gay
singers or groups.
• Writing graduated sentences 25x per
day that are challenging and raise
anxiety.
• Reading a gay romance novel
• Reading coming-out stories by people of
similar ages and situations
• Reading mainstream gay magazines such as
Out or Curve.

33. Typical Response Prevention Assignments
for Homosexual Obsessions
• Not checking your reactions to attractive
members of your own sex.
• Not imagining yourself in sexual situations
with same-sex members to check on how you
might feel about it.
• Don't behave sexually with members of the
opposite sex just to check your own
reactions.

34. Typical Response Prevention Assignments
for Homosexual Obsessions (cont.)
• Resist reviewing previous situations where you
were with members of the same or opposite sex
or where things were ambiguous to see if you did
anything questionable.
• Avoid observing yourself to see if you behaved in
a way you imagine a homosexual or member of
the opposite sex would.
• Resist reassuring yourself that you are not gay,
and also do not seek reassurance from others.

35. Typical Response Prevention Assignments
for Homosexual Obsessions (cont.)
• Don't avoid being around members of
your own sex.
• Don't avoid taking part in conversations
that are about gay people or gay subjects.
• Don't question, argue with, or analyze your
thoughts. Simply agree with them.

36. Question
How do you know when you’re
finished?
Answer
When you run out of material.