Fred Penzel is the author of Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well. I asked him about the efficacy of “exposure” treatment as a cure for HOCD, given that exposure to gay/transsexual porn is a cue for sexual arousal, a powerful “reward” at a brain-chemical level. (In other words, someone trying to reduce his reactivity to it by viewing it would, at the same time, be wiring his brain more tightly to the reward he gets from sexually arousing material.)
I think that people with true and classical OCD are quite different from people who are addicted to pornography. People with gay obsessions suffer from a crushing sense of doubt about their sexual identities, and aren’t using it to derive any real enjoyment from the porn they watch. If they do experience any enjoyment, it only increases their doubt and guilt. Doubt is one of the chief hallmarks of OCD. They are actually testing and double-checking their own reactions in order to try to get a sense of whether or not they like what they are watching, but paradoxically, it only makes them more doubtful and anxious. This is true of all forms of OCD.
Basically, I think that people react sexually to sexual things. This is where people with OCD trap themselves and get caught in a spiral of symptoms. I know of any number of straight people (who don’t happen to have OCD) who are stimulated by gay porn (although they are not addicted to it), not necessarily because it is gay, but simply because it is sexual, and for some, forbidden.
OCD has an insidious way of picking up on such things. Sufferers whole lives come to revolve around trying ascertain whether or not they are gay. No doubt a subgroup of the people who visit your website are OCD sufferers who are looking for new and better ways to resolve their doubts, not realizing that it is the compulsions that are the problem, and not the anxiety. My patients would dearly love to stop having to look at porn and to just be at peace knowing their true feelings. The porn is only a means to an end, and not an end in itself. The porn is not the reward. The escape from anxiety and doubt is the reward.
When we assign exposure homework, we never advise people to masturbate in any way, shape, or form. This would be rather unhelpful, and in my opinion, unethical. What we do expose people to is the idea that either they really are gay, or else won’t ever really know what they are. In exposure therapy, we try to get people to habituate to the thoughts of being gay so that the thoughts no longer have any impact on them, and they no longer feel the need to do compulsions.
When people with OCD try to not test themselves, they don’t go into a withdrawal, but just become anxious again, because this checking is the only way they have come up with to manage their anxiety (even though it is paradoxical and ineffective). When we first get them to resist in therapy, they do get more anxious, but find that if they keep at it, the anxiety subsides without their having to do anything.
You might take a look at my article, “How Do I Know I’m Not Really Gay” on my clinic’s website (www.wsps.info). We don’t treat people with porn addiction at my clinic – this is not among our specialties, and we wouldn’t pretend to be experts in this area. We do not treat addictions, in general, but specialize in OCD and problems relating to anxiety and phobias. I, myself, would not undertake to treat someone with a porn addiction. I have had a few of these folks come to see me, thinking that they were suffering from OCD, but they are not like my OCD patients in any way that I can see (I’ve been treating OCD for nearly 30 years). I would certainly not use exposure to treat those with porn addiction. I have always believed that abstinence is probably the best treatment for addictions of all kinds (although I could be wrong, not being an addictions expert).
I have not read any of the research on porn addiction, so I am not familiar with any of the theories about causes or treatment. I have my hands full just trying to keep up with the literature in my own field.
If you do get people who seem to be more interested in resolving what look like severe doubts about their sexual preferences than in simply quelling an addiction, I would certainly suggest referring them to the website of the Int’l OCD Foundation or my own website, where they can find relevant articles. I wrote my articles because there aren’t many good sources of info for these folks. Perhaps if they find out that there really is help for OCD, they can get themselves recovered. OCD is quite treatable if you do the correct treatments.
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