Sexual addiction/compulsivity is a trendy diagnosis these days and I have written much on this topic here and here . However, some studies have indicated a cormobid diagnosis of OCD for many individuals struggling with compulsive sexual behavior. Indeed one of the most common situations I have seen in my practice, which in my opinion has often been self-diagnosed by clients as sex addiction, could more readily be called homosexual OCD or HOCD, in which case the entire established paradigm is completely wrong. I will go into this in more detail further down in this post, for the moment, the most important point is that OCD type symptoms can create a tremendous amount of sexual distress and are very poorly understood and as a result, diagnosed.

I’m going to assume that everyone reading this has a basic notion of what OCD means, but I think few people understand some of the underlying mechanisms fueling this disturbance. First and foremost, OCD sufferers experience a tremendous amount of fear, which might seem obvious as OCD has been historically categorized as an anxiety disorder (although in the DSM 5, the two are split into adjacent categories). But there’s a big difference between a general feeling of anxiety and a very deep and pointed fear. In the case of OCD, the sufferer fears something very specific, which the symptom itself only touches on superficially. In therapy, the client and therapist work together to dig deeper and figure this out. Often times the fear has less to do with sexuality itself and more to do with the underlying worry of being exposed, embarrassed or ashamed. In this way, shame and OCD often work hand-in-hand. At other times, there’s a creeping dread of things “falling apart,” of being helpless or incapacitated in one form another. OCD sufferers often feel helpless and fear helplessness.

Let’s take a look at the aforementioned HOCD as an example. In my experience, certainly, the individual experiencing HOCD is afraid of discovering himself to be gay. Hence the constant checking of men in the street and gay porn. But the fear isn’t just about homophobia; if one digs deeper there is a fear of losing everything– one’s relationship, family, and identity. His wife or girlfriend, for example, may no longer want to stay with him if he reveals his orientation, she may then take the kids in the divorce, his entire life will fall apart, etc. This is a much more logistical fear than only a concern regarding orientation– the more the client fears he will lose it all if he is indeed gay, the more likely he is to be consumed with these thoughts.

In this way, both shame of homosexuality and fears of losing it all collide in a powerful mix. For this reason, someone struggling with HOCD has a very difficult time with standard CBT type of interventions. The client may reframe things and distract himself, but his overpowering fear remains. And because the consequences cannot be completely and immediately tested out, standard response and prevention type of interventions also fall short.

What I have seen work in this realm, however, is a kind of graded exposure treatment in which the client seeks to gradually become more open and test the waters with his partner. For example, he may suggest some sexual activities in which he is anally penetrated or reveal that he has in the past noticed some guys and then gauge his partner’s response. He may be pleasantly surprised that her reaction is more positive than he has suspected. But this kind of experimentation carries great risk, obviously, as his partner may also reject him. In this case, we plan out a course of action that is subtle enough to be a safe first step.

Sometimes the obsessions are about specific fantasies and fetishes. As I mentioned in previous articles, the more something is shamed or feared, the more it is likely to become compulsive. For this reason, I often spend plenty of time providing my clients with accurate psychosexual education so that they can make more sense of their desires and depathologize them as appropriate (click here to see when fetishes are deemed pathological or not). Again, the client may not only be afraid of what the fantasy or fetish means to him (and again, it’s usually a male), but also of the reactions of others and the potential for subsequent destabilization of life situation.

As is the case in HOCD, discussing these matters with a significant other (if they have one) can feel very freeing and the client can move towards integration. Unfortunately, sometimes the response is not as affirmative. In these cases, I have written the following articles on what couples can do when they are sexually not on the same page: Working With Relationships in Transition, Common Issues in Partners’ Sex Therapy. In those cases where the individual doesn’t currently have a partner, finding an appropriate community that feels accepting and nonjudgmental is essential.

Sexual dysfunction, such as ED, also can be a manifestation of OCD. The sufferer is so preoccupied with fears of losing his erection that he also loses his ability to relax at all in the moment. Instead of surrendering himself to the experience, he is stuck observing his genitals and thinking the most catastrophic outcomes in his mind. Once again, the fear of shame is present, but there is also the fear of everything collapsing lurking in the background. I’ve seen plenty of guys who are deathly afraid that their inability to get hard will turn away potential girlfriends/boyfriends or even end existing relationships.

The fear again is emotional as well as logistical– the individual certainly wants to avoid sexual embarrassment, but the potential loss of his current relationship often poses an even greater threat. Unlike the fears discussed above, which I’ve found to ease once the client is reassured, in this case, the partner may offer reassurances over and over till the cows come home, but the individual may still struggle in believing. The reassurances often ring hollow. Instead, if I can help the client imagine a scenario where he does not mind losing it all, his fear will diminish and he is also less likely to lose his erection. In other words, he must learn to be less outcome-dependent.

In summation, a lot of the sexual difficulties that I see in my office can either be partially attributed to OCD-like symptoms or are direct manifestations of OCD. To help my clients, I want them to identify the underlying fears and then to take specific and actionable steps to not only just think about or mentally challenge the fear and/or shame, but to actually challenge it through lived experience if possible. Staying curious and testing the waters has helped a number of my clients finally shake the fear that drives OCD symptoms in their sexual lives.