Exposure Therapy for HOCD? (2012)

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WTF?Porn-related HOCD may call for its own treatment protocol

Intrusive worries that someone has become gay—although he (she) has been straight for years with no doubts—have gained the label HOCD, homosexual obsessive-compulsive disorder. More properly such worries would be called sexual orientation obsessive-compulsive disorder because they also strike gay people who suddenly wonder if they are straight.

Therapists who treat HOCD, such as Steve Seay PhD, often recommend a standard OCD treatment: Exposure & Response Prevention. "Exposure" refers to willingly entering situations that are likely to trigger compulsions, and "response prevention" refers to purposefully inhibiting one’s coping rituals. For example: resisting the urge to wash one's hands compulsively in certain situations.

Yet the scientific reason that exposure therapy often helps with some forms of OCD is the very reason that it can backfire in the case of porn-related HOCD.

Some experts conceptualize OCD as sharing important elements of behavioral addiction because of the role that reward plays. The OCD sufferer keeps performing his particular rituals because they trigger the neurochemicals associated with reward. Relief feels good.

When the OCD sufferer consistently denies himself this neurochemical reward ("response prevention"), his triggers gradually lose their power. Why? They no longer lead to rewarding feelings. No hands are washed. No relief. No reward. Eventually the brain says, "Meh...no point in getting activated by that germy doorknob because I'm not going to get a neurochemical reward."

The same principle operates in addiction recovery. Abstain from the "rewarding" behavior for long enough, and (after a period of intense withdrawal discomfort) the brain eventually stops activating the related brain circuits with the same vengeance. This gets easier as the entire constellation of addiction-related brain changes reverses itself.

Two types of HOCD

Briefly, the difference between HOCD and porn-related HOCD is:

  • OCD + homosexual fears (or event) = HOCD
  • Years of porn use + distress about escalation to gay/transsexual porn = porn-related HOCD

Random events in life, such as unthinking comments by peers at vulnerable moments, can cause some people to start questioning their sexual orientation compulsively (HOCD).

However, today an emerging impetus for HOCD is chronic overstimulation, which leaves the brain less responsive to everyday pleasures and thus desperate for sensation. Highspeed pornography makes chronic overconsumption easy. Compared with erotica of the past it's so stimulating that, in some users, it produces addiction-related brain changes. No wonder. Quite apart from nonstop sexual titillation, today's Internet porn activates the brain's reward system for all evolutionarily salient stimuli, augmenting memory formation (wiring):

Moreover, it's possible that those who develop HOCD may have brains that are particularly plastic for some reason. According to a Chinese study, those with OCD tendencies prior to exposure to the Internet face increased risk of addiction. 

In any event, a porn addict's brain can grow numb to normal pleasure even as it becomes hyper-reactive to select cues. Here's a guy describing a common progression, which is often reported by those who slip into porn-related HOCD:

29 y/o with 17 years of MO (to softcore and imagination) and 12 years of masturbating, escalating to extreme/fetish porn. I started to lose interest in real sex. The build up and release from porn became stronger than it was from sex. Porn offers unlimited variety. I could choose what I want to see in the moment. My delayed ejaculation during sex became so bad that sometimes I couldn't orgasm at all. This killed my last desire to have sex.

Classic sexual conditioning

Once this degree of desensitization has set in, the stage is set for porn-related HOCD. Non-conforming porn violates expectations, releases more dopamine and norepinephrine than earlier porn genres, and furnishes the extra kick that fires up sluggish (addicted) reward circuitry. A user may begin to question why he can get off to fetish porn with transsexual/gay action yet not be attracted to real sex partners who aroused him in the past.

His brain, however, automatically begins to wire its sexual response to this novel, stimulating genre—in a classic case of sexual conditioning. As explained in an earlier post, sexuality can be conditioned to most anything, even the smell of death, so it's not surprising that many of today's porn users report that their porn tastes morph all over the place as their pleasure response declines. 

Now, our user may find that he can only climax to his latest (and therefore most stimulating) genre. If it's one that he views as inconsistent with his underlying sexual orientation, the shock value is greater...and releases even more stimulating/anxiety-producing neurochemicals. His arousal is heightened, in part, by his own stress. Three guys describe their experience:

First guy: I seriously thought I was turning gay. My HOCD was so strong at that time, I was contemplating taking a dive off the nearest high-rise. I felt so depressed. I knew I loved girls and I can't love another dude, but why did I have ED? Why did I need transsexual/gay stuff to jolt me into arousal?Sexual attraction puzzlement

Second guy: The scary thing is that I've been seeing women as crazy attractive, and men or the idea of men pretty nonsexual. As a gay man who's pretty much exclusively had relations with other men since high school, this is kind of weird. Even when I see "ugly" ladies walking on the street, I can't help but picture what it'd be like to have crazy sex with them right there. Will it stop? Is it reversible?

Third guy: The first two days I had serious anxiety, almost wanting to kill myself because I lost all attraction towards any female. These thoughts make me think that I am gay, making me question what I do, what I say, making me sick. I can't eat. I think intrusive thoughts...making me feel like I'm gay, when I know I'm not.

The users' desperation to understand whether their sexual orientation has suddenly changed can lead to constant, compulsive "testing" and other reassurance rituals. As with other varieties of OCD (including non-porn-related HOCD), the testing and searches for reassurance offer temporary relief. Each "test" reinforces the unwanted arousal—either with rewarding relief, or electrifying distress if the test fails. In this way, they reinforce the problematic triggers.

What's a therapist to do?

Keep in mind that behavioral addictions and compulsions run on reward. We know from addiction therapy that addictions gradually heal as those rewards are no longer forthcoming due to abstinence. Slowly, the brain weakens related pathways.

The therapist may best be able to help by correctly evaluating the rewards behind a particular client's HOCD. If his motivating reward is primarily relief from "testing" or from repeatedly declaring his orientation has changed (to get the temporary relief of certainty), then exposure and response prevention (no more testing or anxiety-motivated declarations) may do the trick.

In the case of porn-related HOCD, however, the rewards of addiction may comprise the lion's share of the client's challenge. There could well be two addictive rewards in the mix: fear and sexual arousal.

Fear as reward

Distress may not sound rewarding but fear activates the reward circuitry of the brain in some folks. Think roller coasters and horror films. To a brain desperate for sensation (due to the brain changes brought on by chronic overstimulation/addiction), fear-induced activation can register as especially compelling. It jacks up both dopamine and norepinephrine (a form of adrenaline).

But there's more going on at a biological level. The stress neurochemical cortisol can also heighten rewarding effects by triggering the release of dopamine. Eventually, brain changes can make someone hyper-responsive to stressful cues. Research confirms that extreme stress and drugs of abuse both increase the strength of related (addiction) brain pathways. Researchers believe cortisol thus plays a pivotal role in reward-related behavioral pathologies.

The situation is akin to BDSM, where physical pain heightens a person's sexual buzz because of the effects on the brain. In HOCD sufferers, arousal and panic achieve a similar end. Bottom line: Despite intense emotional or physical discomfort, heightened arousal can make a behavior very hard to stop (addictive).

The HOCD sufferer's brain has learned to obtain part of its reward from its own distress. Worse yet, when the sufferer tries to give up porn, his anxiety will naturally increase for an extended period. Withdrawal raises anxiety in all recovering addicts, fueling powerful cravings for more stimulation quite apart from HOCD concerns.

For HOCD sufferers this predictable increase in anxiety tends to set off intense spikes (panics about orientation) and frantic "checking," often driving them back into addiction. Indeed, some report that their HOCD fears were trivial until they quit porn. As the addicted brain targets the strongest "fix" it can think of: panic+checking+sexual arousal to HOCD-related stimuli, straight feelings seem to evaporate.

Sexual arousal as reward

An addiction to Internet porn is an addiction to an orgasm-aid. Sexual arousal is the most powerful natural reward the brain can produce. Yet arousal from porn's constant novelty (each scene offers another hit of stimulating neurochemicals) can produce a surprisingly potent reward. Sex, or even orgasm, may pale in intensity as porn addiction progresses and response to everyday pleasures declines. Some users end up hooked on the neurochemical buzz from edging to novel porn for hours, intentionally deferring, or avoiding, climax.

The brain evolved to assume that a source of intense sexual arousal is a potential fertilization opportunity. If someone arouses himself with something that releases maximum dopamine and norepinephrine, the brain will automatically wire it up as "valuable." It doesn't matter if it's not consistent with his innate sexuality—because the brain measures salience according to levels of reward circuitry activation, not orientation. (It just so happens that in a brain responding normally to pleasure, stimuli appropriate to one's orientation generally produce the most satisfying feelings.)

Not surprisingly, sensitized brain pathways for intense sexual cues are different from less stimulating cues (even sexual ones). We can unwire the latter with relative ease, but not the former. This has been demonstrated in research, as recounted by James G. Pfaus et al:

Lalumière and Quinsey (1998 ) reported significant conditioned genital arousal in heterosexual men to a picture of a moderately attractive, partially nude woman that was paired with a video depicting highly arousing sexual interaction. A control group that received access to the picture alone (without the video) showed habituation [instead]. (emphasis added)

As explained above, for porn-related HOCD sufferers sexual cues are especially intense because they are heightened by the neurochemical effects of fear.

Exposure therapy backfires when porn addiction is present

For the Internet porn addict using standard HOCD therapy, exposure to real gay men doesn't address the source of his HOCD conditioning—which is not to humans or sex with humans, but rather to pixels. Yet if he tries exposure therapy with gay porn, he is engaging in the precise behavior to which he is addicted. One can't cause an addict to habituate by providing the very cues he's hooked on!

This is why exposure therapy could well be all wrong for guys trying to unravel porn-related HOCD. It's like having an alcoholic drink more on the theory that she will get bored with drinking, or a gambler place more bets until he habituates. In an addict, continued use only deepens the addiction ruts in the brain. Exposure therapy may thus deliver an unproductive mixed message to a porn-addicted HOCD sufferer instead of promoting useful conditioning (habituation).

So where does one start? Porn addicts need to eliminate Internet porn use above all. As their brains return to balance many also notice that confusing sexual cues lose their power.

If porn addicts with HOCD try to use related cues for a therapeutic purpose instead of abstaining from them they're strengthening their behavioral-addiction neural pathways. This is a Catch 22. The addict (and perhaps his therapist) may wrongly conclude that his persistent, powerful response to problematic cues is not HOCD, but rather "proof" that his sexual orientation has mysteriously transformed.

NeuronsThe point is that addiction presents an obstacle for standard OCD Exposure & Response Prevention therapy. Even if a porn addict stops seeking the reward of relief (from testing or analysis), exposure to porn still "rewards" him by activating his sensitized addiction pathways.

What does help?

We are not therapists. However, we have read self-reports by a number of former Internet porn users who describe themselves as suffering/recovering from HOCD (sample self-report). We'll summarize their experience in case it proves useful.

Guys report that giving up the reward of Internet porn and temporarily giving up the reward of sexual activity (other than relaxed, affectionate partner sex) both help resolve their HOCD. As they stop reinforcing their prime reward (porn use), their brains gradually look around for, and wire to, other sexual rewards. This can take months. In light of these guys' experience, therapists may want to invite clients to disconnect from Internet porn for a few months before introducing exposure therapy (if ever).

At first, guys may not respond normally to partners, although relaxed affection is soothing (perhaps because it releases oxytocin). Also, until the worst of the addiction withdrawal has passed, they also often experience more excruciating HOCD spikes.

Those recovering report that if they can accept the intrusive HOCD thoughts without distress, they sidestep the neurochemical reinforcement of fear. In addition, they find it helpful to learn to live with uncertainty about their sexual orientation and to avoid all testing and efforts to "figure out the truth." That way they also stop the rewarding reinforcement of fleeting relief and "certainty."

In other words, the HOCD sufferer needs to work on stopping stop three rewarding habits: Internet porn use, relief seeking and distress.

One man's self-report

This man's report is interesting because he began by weakening the porn reward, only to find that he hadn't dealt with the fear and relief (checking) rewards.

I'm now over 3 months without porn, but I had sunk into a stupor of constantly checking various HOCD message boards. I was spending hours every day on those sites, sometimes checking them as much as several times an hour: at work, while I was driving, in bed at night, etc. etc. etc. Really bad 'checking behavior.' My brain was being rewarded when I would read something that reassured me, and it would fire up and freak out when I read something that spiked my anxiety.

I had also expanded my checking onto other message boards, including gay and bisexual boards. This just perpetuated the spiral. I wasn't sleeping much on account of all my anxiety, and I wasn't really present in my life. I was either on these boards or worrying about what I read on them. Constantly. My relationship was suffering. Sometimes, alone at night, I would go on 2-3 hour binges of HOCD checking on internet message boards, and then feel awful afterward.

I decided I would stop. My mate deserves someone who is present, not totally distracted. Since then, I have only had one 15-minute session, checking for replies. I've had to struggle to resist temptation, but the result is that I feel SO much better.

It's really pretty remarkable. My HOCD has decreased significantly now that I am not constantly signaling to my brain "THESE HOCD THOUGHTS ARE IMPORTANT" by going on the boards and engaging in checking and reassurance. I hadn't read a book in months, but I'm now on my second one since I gave up the boards. My free time at night is now spent either with my girlfriend or reading by the fire. I'm sleeping a lot better.

Yes, I still get the occasional spike when I see an attractive guy. And then from the checking with thoughts of him. But it's gotten to be a lot less, and that thought fades a lot faster.

I now think that my HOCD may have been due to the fact that when I finally overdosed on PMO after years and years of it, I lost much of my attraction to real women. Without it women and men started to look the same to me, and BAM worries about being gay erupted.

Schwartz's non-exposure therapeutic approach

There is an existing therapeutic system for treating OCD that doesn't advocate exposure. Psychiatrist Jeffrey Schwartz developed it. (Read a description taken from Doidge's The Brain That Changes Itself.)

Schwartz teaches his patients how neuroplasticity works so they understand that their compulsion is arising from an unwanted, overly active brain loop (not unlike addiction). He then explains that the brain's wiring can be changed with conscious effort.

In some ways, it's the very opposite of exposure therapy. Instead of attempting to habituate via exposure, one attempts to rewire the brain by shifting gears the instant a related cue pops up. Schwartz suggests switching to a pre-selected constructive activity.

The goal isn't to avoid discomfort by seeking relief, but rather to activate unrelated brain pathways in lieu of the problematic ones so the brain disconnects from its former "rewards," and perhaps even comes to associate anxiety with a productive task.

As an aside, HOCD expert Fred Penzel also discourages exposure therapy for porn addicts, despite the fact that he recommends Exposure & Response Prevention therapy in classic HOCD cases.

Hopefully, researchers will soon determine which protocols work best for which HOCD sufferers. Many of those affected are desperate to resolve their anxiety. Indeed, of all the recovering porn addicts who visit our site, the HOCD guys suffer the worst and relapse the easiest.

At present, many are hesitant to seek help for fear that well meaning therapists will tell them they are gay (or straight) when they know they are not.

Porn-related HOCD sufferers generally have no idea how to rewire because the standard therapy doesn't work, and the most promising solutions feel so counter-intuitive (they have to walk away from relief, from analysis, and from sexual arousal for a time). Most won't figure it out without informed professional assistance. To progress, they may need to find a therapist well versed in both addiction and the role of abstinence in unhooking the brain from unwanted "rewards."

Empirical support for this article:


Clear addiction first, then seek exposure therapy if needed

I came to this site and YBOP about a year ago searching for answers. PMO had been a daily ritual for many years, 13 years I would say. I, like may of you in this forum, had become de-sensitized to the normal genres of porn. Looking for novel or shocking material became the norm really without me knowing it on a conscious level. I never had a great sex life with women in real life, I suffered from mild ED, went to Urologists for answers, got the little blue pills, etc. Confidence in the bedroom was a problem. I would always try to conjure an image in my head of a porn scene to get off while having real sex. Then came the HOCD problem.

The difference in my story is that I never really ventured into the gay/transexual world of porn but I will say that my sexual tastes had changed, I was needing stranger and more shocking thoughts to have an orgasm. The HOCD kicked in on while I was on vacation. While I was masturbating, the usual thoughts were not working and then a weird, semi gay thought popped in my head and ended up having this weak orgasm. I am not sure if the shock of it all was the culprit but I can tell you that it scared the hell out me. It was never anything that I had thought of for any sexual satisfaction, and I was 33 at the time.

I spent the whole rest of the vacation analyzing all of my reactions to people, men and women. I obsessed what my groinal sensations felt like and checked and checked, and checked. I obsessed over whether I had turned gay and the fact that my experiences with women had been mixed at best fueled the HOCD more. This obsession lasted for a for a good two months until I would seek professional help.

To back track a little bit, I found YBOP a months after through all my google searches related to HOCD, and sites dealing with "how to you know if you are straight or gay." The material on YBOP made sense to me and was very relatable. Many of the people in the forums claimed that their HOCD had been cured through no PMO. I tried it of course. BTW- I was and still am in a relationship so during this time, I would have sex but no PMO. What I learned is that my ED did go away. Sex was no longer a formation of mental images in my mind but a shared act with the person in front of me. The HOCD did not go away for me however. The questioning was as bad as ever.

This is where I want to talk about my treatment because it has to do with traditional HOCD vs porn related HOCD. I will leave you to make your own judgements based on my individual accounts. I found a therapist, who is an expert on OCD, as a matter of fact a few of his articles are mentioned on YBOP. He ventured into response prevention and exposure therapy with me. For those of you who do not know, this therapy involves exposing a patient to things they are afraid of in a gradual order, starting with things that make you a little afraid to ending with things that really scare you. The idea being, if you want to think about something less, think about it more. Resisting negative thoughts causes them to loop back into you consciousness. By agreeing with the thoughts, and exposing yourself to them, you become de-sensitized to them. It is equivalent to seeing a scary movie for the first time. At first you are shocked, but if you see it 10 more times, it will not be that scary any more. We started by making a list of things that would bother me and ranked them on a scale of one to ten, ten being the scariest. We started with reading coming out stories, reading material that might be considered gay, listening to recording that suggested that I might be gay. As the therapy went on, I had to agree with the thought that I could be gay. It was an extremely scary proposition. In the end, the material escalated to my number 10, but by the time I reached that level, I was better prepared. BTW- my number 10 was watching gay porn, for the fear I might feel something. I was never to allowed however to"check" my reactions. I had to just "be" with the shocking material, allow my self to be anxious until I realized that nothing was becoming of it. The more I did my homework, the less the material affected me. In the end, I could say "yeah, I might be gay, but who cares." You see in the end, it is the questioning and the need to find a definite answer that drove me mad. Am I really gay? I don' t think so but I do not obsess over it any more. I do not check very anymore. I still get intrusive thoughts from time to time, but I agree with them and it quickly shifts my focus. It no longer affects me the way it did, even though questions may randomly pop in my head. The questions do subside alot as time goes on.

All in all, I do agree that quitting the porn is key before starting any therapy of this kind. Porn got me into this mess but the therapy got me out of it. I do not know if this therapy will work if you are a user who has traveled into the world of gay porn or transexual porn. I would say to quit first and see where you stand with HOCD after a few months. What I also learned from my therapist is that there are many gay people who watch straight porn and think they might be straight, so this problem can go both ways. I will say that my journey is individual but this therapy was life changing for me. If you do find help, go to an OCD specialist who has dealt with this, not a general counselor. Be forthcoming, if they know what they are doing, they will not tell you judge your orientation, yet help you to stop obsessing over the questions. I hope this some can relate to my story and help you get back on track with life. Thanks.


I have OCD, and I was reading the book Brain Lock, and I found out

Deep inside the brain lies a structure called the caudate nucleus. Scientists worldwide have studied this structure and believe that, in people with OCD, the caudate nucleus may be malfunctioning. Think of the caudate nucleus as a processing center or filtering station for the very complicated messages generated by the front part of the brain, which is probably the part used in thinking, planning, and understanding. Together with its sister structure, the putamen, which lies next to it, the caudate nucleus functions like an automatic transmission in a car. The caudate nucleus and the putamen, which together are called the striatum, take in messages from very complicated parts of the brain—those that control body movement, physical feelings, and the thinking and planning that involve those movements and feelings. They function in unison like an automatic transmission, assuring the smooth transition from one behavior to another.

From book : http://www.worldcat.org/isbn/9780060987114

I then thought how caudate nucleus is affected by porn and I found

Structural brain volume

They found that higher number of hours viewing porn correlated with a reduction in grey matter in an area of the brain called the right caudate nucleus. This association remained after eliminating a second correlation with internet addiction and sexual addiction. An association was also found between higher porn consumption over many years and less grey matter in this brain area. The researchers interpreted this as a sign of the effects of longer-term porn exposure.

Source : http://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2014-05-30-watching-porn-associated-with-male-brain-shrinkage/

So abstaining from porn, may help with people with OCD.

PS : After discovering the link between the two, I feel like scientist. :P


I wanted to add some nuance to this discussion. Exposure therapy has proven to be very effective in individuals with HOCD. These are people who meet the criterion of having obsessions, which are intrusive thoughts associated by marked distress that the person tries to neutralize. This does not include someone who is actually gay and merely uncomfortable with his/her sexual orientation. An example of someone with OCD is be a man who has a fear that thinking about other naked men will cause him to become gay. This is similar to other typical OCD obsessions, such as thinking about hurting someone will actually lead to the person losing control and murdering someone. In HOCD, viewing nude same-sex images may only be part of the treatment, with the main intervention usually being developing comfort with mental images until habituation occurs.