This is a guest post by Alegra Kastens, a licensed Marriage and Family Therapist who founded the Center for OCD, Anxiety, and Eating Disorders.
We live in a heteronormative world designed for and catered to straight, cisgender folks. LGBTQIA+ folks face erasure across multiple domains of life and it’s important that the OCD community is not one of them. There are ways to utilize evidence-based therapy for OCD without insulting or injuring marginalized communities, just as we can advocate for OCD advocacy while remaining inclusive of all.
Below are five ways that both OCD advocates and clinicians may intentionally or unintentionally perpetuate harm toward the LGBTQIA+ community, and ways to combat them.
1. Only discussing Sexual Orientation + Gender Identity obsessions from a heterosexual, cisgender perspective
OCD does not discriminate based on a person’s sexual orientation or gender identity. Gay, lesbian, transgender, queer, and all other people live with OCD, but are often left out of conversations about sexual orientation and gender identity obsessions. The predominant narrative surrounding such obsessions assumes that the obsessions only target cisgender, heterosexual folks and typically includes examples like “What if I’m gay” or “What if I’m transgender?”. Education around sexual orientation obsessions is often void of obsessions that impact the LGBTQIA+ community such as “What if I’m straight and lying to myself?” and “What if I’m not actually transgender?” This lack of inclusivity and awareness of other lenses has been so significant that, until recently, this OCD theme has been called “Homosexuality OCD”. This is, in part, due to heteronormativity—people assuming that being straight and cisgender is the default while not considering other identities and orientations. Only discussing sexual orientation and gender identity obsessions from a cis, hetero lens contributes to the erasure LGBTQIA+ folks already face. It’s double erasure.
When discussing obsessional themes, it’s important to utilize inclusive language (ex. utilizing “Sexual Orientation OCD” instead of “Homosexual OCD”) and provide examples for all gender identities and sexual orientations. This goes for social media posts, the websites of OCD practices, media interviews, etc. OCD advocacy saves lives and we want to make sure we are advocating for all lives with OCD, not just straight, cisgender lives.
2. Calling Sexual Orientation Obsessions Taboo
The word taboo implies that something is forbidden, unacceptable, unspeakable, and even immoral. People commonly refer to sexual orientation obsessions as taboo when they are referencing straight people who have obsessions about being gay, but there is nothing immoral or wrong with one’s sexual orientation. Some cultures and religions assert that being gay is wrong, which is bigotry and not immoral sexuality. Calling sexual orientation obsessions taboo reinforces prejudice against those who are gay, lesbian, queer, etc. by asserting that being gay is bad or wrong. It is especially harmful when sexual orientation obsessions are listed next to pedophile obsessions as being taboo, because it implies that both obsessions are on the same level of immorality and illegality. It is both immoral and illegal to abuse a child. The same does not apply to being queer, transgender, etc. It is sadly illegal in certain countries, but not rightfully so. Violently harming someone is taboo. Pedophilia is taboo. Bestiality is taboo. Sexual orientation is not.
3. Excluding LGBTQIA+ Folks From OCD Protection Conversations
Clinicians and advocates within the OCD community are passionate about making sure that OCD is properly diagnosed. The last thing we want is for someone with OCD to be mistaken for a pedophile or homicidal person. We want to protect our OCD community, but can end up harming certain groups within the OCD community if not careful.
Consider the following statement: “I want to make sure that cisgender clients with OCD don’t get misdiagnosed as transgender and medically transition. That would be so harmful.”
While technically true, as we would not want this to happen, it reinforces a strawman argument that people utilize against toward transgender folks: anyone can just walk into a doctor’s office and transition tomorrow. This narrative is inaccurate and harmful, and fuels transphobic rhetoric—and even legislation. The World Professional Association for Transgender Health (WPATH) recommends that, prior to medically transitioning and receiving gender-affirming surgery, a patient receives an assessment and documented referral from a mental health professional. Psychotherapy is recommended, but not required. In some states, it is required that a patient receives an evaluation by a health care professional prior to surgery.
It is highly unlikely that a person would walk into a doctor’s office and receive gender-affirming care without proper assessment. Any doctor or clinician knowledgeable about gender-affirming care should be able to differentiate between true gender dysphoria and OCD. Furthermore, OCD is an ego-dystonic disorder. The person does not align with their obsessions or compulsions, making it very improbable that someone with OCD would walk into a doctor’s office and say that they desire medically transitioning.
In addition to the microaggressions present in the above statement referenced, it excludes LGBTQIA+ folks in the OCD community that we also want to protect. Transgender people can experience obsessional doubt about their gender orientation and we do not want them seeing a therapist or doctor who misunderstands their symptoms and does not offer gender-affirming care because of them. Given transphobia and anti-trans legislature, this scenario is far more likely than that of a cisgender person with OCD transitioning.
Cisgender folks are far more protected than transgender folks are. While we want to protect cisgender folks with OCD, it is imperative to include LGBTQIA+ folks with OCD in all conversations because they are facing systemic oppression.
4. Having clients do exposures that harm the LGBTQIA+ community and perpetuate stereotypes
If a heterosexual male experiences obsessional doubt about being gay, it would be inappropriate to dress him up in a feather boa and have him strut down the street like he’s on a catwalk. This plays into the “all gay men are flamboyant” stereotype, which is inaccurate because gay does not have a look. Not all gay men are flamboyant and assuming someone is gay based on their appearance is a microaggression. Furthermore, it’s unhelpful if it doesn’t target the client’s core fear, which is likely not being certain of their sexual orientation. Because the way that someone dresses and walks is not indicative of their sexual orientation, it would not make sense to have the client harm the gay community with such an exposure.
What if the client is worried about looking flamboyant in the outfits they desire wearing because they do not want someone thinking that they are gay? The values-based exposure would be to have the client wear the clothes they want to wear, despite what others might think. It might also be applicable to explore internalized bias and homophobia that colors such an obsession.
Another off-limits exposure is having a client go to a gay bar and flirt with a gay person as exposure. Gay bars are safe spaces for the LGBTQIA+ community. While it’s not necessarily wrong for a straight person to go to a gay bar, having someone who is not gay enter a safe space for gay folks and flirt with them is leading the gay person on. This can be emotionally manipulative given the context.
Exposures can and should be done in a way that does not insult or injure marginalized communities. They should also directly target a client’s core obsessional fear to be effective.
5. Saying things when triggered like “I would rather die than be gay!”
When stuck in an OCD spiral, it can be difficult to access language that does not harm others, but it’s important that we try to do so. Even if a person really means “I would rather die than my sexuality have suddenly changed overnight,” saying “I would rather die than be gay” is stigmatizing toward gay people. It is rooted in homophobia and harms gay people who already face oppression and marginalization. It is quite literally saying that a person would rather be dead, not alive, than live with the sexual orientation that so many people inhabit.
When triggered, try to say what it is that you actually mean while considering the impact that it has on marginalized communities. This could be “I don’t want to live a life that I don’t identify with” or “I don’t want my sexuality to have changed!”
Finding A Queer-Affirming Therapist
It can be hard enough finding an OCD specialist and finding an LGBTQ-affirming OCD therapist can be even more difficult. Just as we ask questions to a potential therapist to ascertain their knowledge of OCD and evidence-based treatment, a person should ask a potential therapist questions about LGBTQ-affirming therapy.
Such questions might include:
- Are you an LGBTQ-affirming therapist? If so, what does that mean for you?
- What evidence-based training have you undergone for the treatment of OCD and issues that may arise related to an LGBTQIA+ identity?
- What kind of resources do you keep up with re: LGBTQIA+ issues and how often are you accessing updated resources?
- What percentage of your caseload is LGBTQIA+?
- Have you worked with clients similar to me with similar obsessions? If so, what did treatment entail?
- What would your treatment look like for me?
If finding a clinician who shares your sexual orientation and gender identity is important to you, it is okay to ask the therapist about their orientation. This request is likely rooted in a desire for safety and it is important that you feel safe as a client. Not all therapists will share their orientation, but many queer and queer-affirming therapists will.
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If you’re struggling with OCD and your symptoms are getting in the way of your daily tasks, NOCD can help. Our licensed therapists deeply understand OCD and are specialty-trained in treating OCD with ERP. You can book a free 15-minute call with our team to get started with OCD treatment.