Overcritical OCD or Questioning Queer

Dr. Amanda Fialk, PhD, LCSW, LICSW: My name is Amanda Fialk. I use she/her pronouns, and I am a partner and chief clinical officer at The Dorm, which is an IOP and PHP treatment community for young adults located in both New York City and in Washington, D.C.

Today I am thrilled to be here discussing the overlap and differences between OCD ruminations and queer identity exploration in young adults. This is an area that is both clinically nuanced and deeply, deeply relevant to the communities that we serve. At The Dorm, we specialize in care for young adults, which we define as ages 18 to 30, a population that is both clinically complex and also increasingly diverse in identity. With over 50% of our clients identifying as LGBTQ+, delivering affirming care is central to our model.

And that is why we are particularly grateful to welcome Dawn Anderson from Lindner Center of Hope to share her extensive knowledge into the best practices for differentiating sexual orientation OCD from identity exploration. Dawn Anderson is a staff therapist and supervisor at Lindner Center of Hope, where she serves as Director of the Sexual Orientation and Gender Identity Treatment Team, Chair of the Diversity, Equity, and Inclusion Council, and a member of the OCD, RO-DBT, and Eating Disorder teams. With over 15 years of clinical experience across outpatient, inpatient, and supervisory settings, including Cincinnati Children’s Hospital and The Christ Hospital, Dawn specializes in treatment of trauma, anxiety, depression, and LGBTQ+ populations. So without further ado, I’m going to turn this presentation over to Dawn.

Dawn Anderson, LPCC-S: Thank you very much, Amanda. I’m so excited to be here and to be able to celebrate Pride Month with this conversation. I hope that the people who are joining us here find it a valuable addition to their clinical experience and are able to walk away with some very accessible, hands-on knowledge and tools to help you as you help your patients navigate their world. So I’m going to share my slides.

My pronouns are she/her. I would love it — especially if you have a question and you put it in the chat or the Q&A — that you include yours so that when I respond to you, I can respond to you respectfully.

So again, we are going to be looking at OCD, specifically sexual orientation OCD and gender-specific OCD, versus authentic queer exploration. Our learning objectives include being able to tell the difference between those two things, understanding that from a biological perspective and the way that that is shaped for us and identity, and getting a head start — because we only have 45 minutes — into how we can have some of those conversations with patients, both those affected by OCD and those wanting to explore their identity in your clinical practice.

And as you got a tiny preview before, we are going to talk about sex. All kinds of interesting things. It’s important to know your limits and what you need, so if you find something overwhelming or stressful, you can take a second and take good care of yourself. In general, this topic is not meant to be triggering, so I hope that it is a safe space for you. But an important part of this discussion is being able to use terms that we might tend to avoid in clinical care. So we want to be able to talk about different kinds of sex — not just penetration — but being able to talk about the way that we explore sexual behavior with our patients in a meaningful way.

And we are going to talk about a different kind of sex as well — knowing the difference between gender, sexuality, and sexual behavior — because a lot of times those things, especially with the general public, get confused. And it’s very important when you’re talking about authentic exploration to be able to tell the difference for yourself so you can help your patients navigate that as well.

And my favorite thing we’re going to talk about, which is super sexy, is the brain. This handsome gentleman on the right of your slides is a super awesome human who developed the hand model of the brain. Dr. Dan Siegel has a YouTube video that you can watch later if you find this concept really helpful. I’m going to give it to you live, because his model uses a lot of specific anatomical terms, but in order to understand the brain and how OCD develops, I think this way of understanding it is super helpful.

So when we think about the brain — the brain is two symmetrical halves. If you take your thumbs and wrap your fingers around them and put your fingers together, this represents a symmetrical model of the brain.

The first part of the brain that develops in utero is the brainstem, and it’s in control of the things that we don’t choose to do: breathing, digestion, heart rate, and the fight, flight, freeze, and fawn reflex — things that keep us alive. They live here.

And then at the top of the brain we have our cortex, which is in control of the things that we do choose to do. At the very front — the part that is still finishing development in The Dorm’s population — is the prefrontal cortex: the ability to see the future, make critical decisions, and plan ahead. More toward the top of the brain we have our elective functions, like being able to choose to look at things or smell things. And in the back of the brain we have memory, and we’re going to come back to that in just a second after I explain the limbic system.

In the middle of the brain you have this wonderful part that has a couple of components whose job, combined, is to keep you safe. Your limbic system takes in the information that you see, smell, taste, hear, and feel, and decides — based on genetics and life experience — if it’s safe or not. So, for example, if you are a professional lifeguard, your reaction to water is going to be different than if you’ve had a near-drowning experience. On the genetic side, if you tend to come from a family that is high anxiety, you’re going to have a more reactive limbic system than someone who comes from a less reactive family. Trauma also makes your limbic system more reactive.

So your brain takes in all that data you’re seeing, smelling, tasting, hearing, and feeling, brings it into the limbic system, and asks: is it safe or not? We sometimes like to think of this as the fire alarm of the brain, or like the bouncer at a club.

If that system says, “yeah, okay, I think it’s safe,” it sends it up to the cortex, and this is everyday life — we go on with our business, process information, make decisions. If our brain says, “I don’t know about that,” we go into a state of vigilance where our senses focus and sharpen. You might feel familiar with this if you’ve ever walked down a dark alleyway, or experienced a storm where the thunder and lightning and heavy rain has all the alarms going off — that feeling of pay attention, pay attention.

And then if our brain says, “absolutely not” — if you joined this conference call and there was a real life-sized tiger sitting next to me or a tarantula crawling on me — your brain would say, “absolutely no thanks,” just like mine would. It sends it down to the brainstem and we have one of those fight, flight, freeze, or fawn reactions. When that’s happening, your brain isn’t actually moving, but the movement shows you how much power is being deferred out of the thinking brain and down into the surviving brain.

And this is really important because OCD is a faulty system that affects a lot of the interaction in that safety system. If you’ve ever been somewhere where the fire alarm batteries are going bad and they’re chirping — you’re like, “oh, what was that?” — and then you need to change those batteries so that they don’t keep doing that. But if you have a faulty fire alarm and it goes off, you question: is there really a fire? What’s happening? Because we don’t know that it’s a drill.

So what happens in the brain for someone who has OCD is that the stress system is going off when there is no present danger. And because we’re intelligent creatures, their brain says, “well, clearly something is wrong.” Usually people with OCD start out by trying to figure out what that is — looking around, checking if other people are feeling this way, sometimes seeking reassurance from others.

Because that fight-or-flight system raises heart rate, quickens breathing, stops digestion — the brain stem is connected to every single internal organ in your body, so that reaction happens really quickly.

And when we talk about the progression of OCD, because we’re intelligent creatures, OCD tends to follow specific themes like contamination, religious or spiritual concerns, morality and harm, or taboo topics — am I doing something, or is something happening to me, that goes against my values or that I think is wrong?

When we talk about those consistent themes, a lot of them have to do with trying to make meaning of this sense of danger. Because if that fire alarm keeps going off and you can’t find any smoke, you start to wonder what is wrong. And then what ends up being the next step in developing OCD is that people develop rituals or compulsions to try to get the distress to stop. If I think there’s something unclean on me, I’m going to go wash my hands. If I’m worried I made a mistake, I’m going to say a couple of prayers. And when it comes to what we’re talking about today — taboo topics — that becomes: am I attracted to that? Am I gay?

Or in a similar umbrella, when we talk about people who have POCD — where they’re concerned about being attracted to children — or intrusive content related to incest. It’s not because they have those feelings. It’s because the fear of that being the thing causing their distress is where their brain went. So they start doing checking behavior: am I aroused right now? And then they might avoid sexual behavior altogether, or engage in some other compulsion to get rid of that feeling of “not okay.”

What ends up happening is that when the distress is relieved through the compulsion — because a lot of times compulsions are linked to things we’d otherwise use for regulating, so they release a little endorphin — and because the faulty fire alarm eventually stops going off, the brain throws itself a dopamine reward party. “You’re welcome. I kept you safe.” And then that cycle is reinforced. It keeps happening more and more.

On memory — I wanted to come back to this before we move on. We have three states of memory in the brain. Short-term memory is what I know right now — you might remember my name is Dawn. Long-term memory is what I know when I think about it — your childhood home address, the first president if you’re in the United States, your parents’ phone numbers. And then deep in the brain, we have state memory: things we know how to do without thinking about them. When you got dressed this morning, brushed your teeth, walked, talked, ate — you had to learn how to do all of that at one point. But because you’ve done it over and over and over again, it became state memory.

This is why whenever we’re teaching patients coping skills or regulating skills or crisis response plans, they have to practice them until they can really use them when they need them — they have to bring them down to state memory. Because the more distressed you are, the less your thinking brain is online. And this is what causes a lot of people with OCD to have such a hard time, because their level of distress is so high and linked to such activating content that it’s really hard for them to think clearly.

Looking at this a bit more visually — we have some of these subclusters for OCD: contamination concerns, symmetry and arranging, taboo thoughts around sexuality and gender and attraction, and then some related disorders like hoarding or body dysmorphic disorder. And we understand that OCD is a cycle of those distressing thoughts, the feeling of wanting relief, the act of trying to get that relief through a behavior, the momentary absence of distress, the reward circuit firing, and then starting over again.

One of the most important parts of OCD treatment is psychoeducation, because it’s super important for patients to know that the content of their OCD is mostly irrelevant. Not irrelevant as in it doesn’t matter to me — irrelevant meaning it often changes over time. As you treat one subtype of OCD, it tends to populate as a different subtype, because the brain has so much experience and data to say, “oh, I can handle this now,” and then moves on to something else. Oftentimes patients start with subtypes that feel lower-barrier to seek treatment for. It’s a lot easier to show up in a clinical practice for concerns about contamination than it is to come in and say, “I’m terrified I might be gay,” or “I’m terrified I might be attracted to children.” So it’s important for patients to know that shifting is common, so they don’t feel shame or failure when their OCD transitions to a different subtype.

Just some quick catch-up facts. Williams and Wetterneck are two of the bigger researchers in SO-OCD, which was formerly called Homosexual OCD. As we’ve evolved as a field and been more intentional with language and appropriate care, we’ve recognized that it’s not just heterosexual or straight people who worry about being gay — sometimes people who are gay worry about being straight, because OCD does not discriminate. About 1 in 50 people have a chance of having OCD. And SO-OCD is one of the more commonly misdiagnosed conditions, even by clinicians who should have that level of training. In fact, when they’ve done DSM-level research in preparation for new editions and given assessments to providers working on that, there was a shockingly significant number of people who misdiagnosed this. That’s part of the underlying drive of this talk — we want people to have access to the care they actually need. If someone is queer, we want them to have healthy, productive discussions about healthy sex lives and healthy relationships. If someone is transgender, we want them to get the appropriate care they need. And if someone has OCD, we want them to be able to access exposure and response prevention — the gold standard of OCD treatment — and medications that can help soften the volume of that alarm system. Good education is how we get there, so thank you for showing up for this.

Flipping over to the other side — some basic terms, just making sure we’re all speaking the same language. And I think it’s also important to recognize that in your community, especially outside of the United States, you may use different terms. One of the things I cherish about other languages is that sometimes there are concepts we don’t really have in English. When you see the “2S” on the end of LGBTQIA2S, that refers to Two-Spirit identity from Indigenous cultures — the concept that there is more than one spirit inside a physical being — and that doesn’t translate super well into casual English.

Gender describes the sense of who I am as a person in terms of masculinity, femininity, intersex, or non-binary. Sexuality refers to what I’m attracted to — what kinds of things I find romantically appealing, what kinds of bodies I want to engage with. And that links over into sexual behavior. Just because someone has a particular sexuality doesn’t mean they want the same amount, type, or frequency of sexual behavior as someone else with the same orientation. For example, I can have a gender of male or demi-male and a sexuality of heterosexual or straight, and that doesn’t mean I want the same kind of sexual behavior as another male who also identifies as straight.

There are a lot of ways to have good conversation with patients about these things, and some of my favorite tools are linked in the references. I would be shocked if the people in this chat haven’t seen the Genderbread Person — it’s one of the most popular, which is why I didn’t put it in my slides. I wanted to present things I use regularly. When we talk about things on a spectrum, sometimes that makes more sense to people. And when someone falls somewhere that doesn’t quite fit a category, that can feel a bit invalidating. Sometimes thinking about it as a galaxy concept, where there’s a more expansive open space, makes more sense.

Some of the ways I talk about gender: I’ll say, “Tell me a little bit about what that word means to you. Tell me about what was modeled for you growing up. When you think about masculinity, femininity, a sense of who you are — what does that mean for you?” And sometimes it helps people to talk about what stereotypical femininity or masculinity looks like in their culture. Same with sexuality — when we talk about the difference between romantic attraction and sexual attraction: who do I feel pulled to? What kind of person do I want to be in a relationship with? Do I even want a relationship? Just because I want sexual behavior doesn’t mean I necessarily want a relationship. And when talking about sexual behavior specifically, I might ask things like: what kinds of sexual behavior do you want to receive? What kinds do you want to participate in?

On the bottom here, too small to read on these slides but referenced for you — this is a kink map. Kink, as long as it involves consensual, safe behavior, is a healthy part of sexuality. And an important clinical distinction: the difference between a fantasy and an OCD distressing thought is the feeling. A fantasy can bring a sense of edgy anticipation. That is not the same as the distress and fear that comes up for someone with OCD. And so when we’re supporting healthy exploration with someone, we also have to keep in mind that most people have received very little thorough or helpful sex education. Most public school systems teach abstinence-only, with a lot of discussion about venereal disease and not a lot of discussion about anatomy or healthy sexuality. So getting a baseline and presenting yourself in a way that opens that discussion — modeling humility around it — is really important.

On the clinical side, I always start with informed consent: “How would you like me to document your gender and sexuality for charting purposes? What are your pronouns? Is this something you want reflected in your record? Are your notes aligned with your insurance documents?” Because if your insurance and your notes don’t have the same information, sometimes insurance won’t cover services. That conversation can then naturally lead into: “Is this something you’d like us to spend time on in treatment?” Most of the time people say, “Yes — not right now, but eventually.” And then I know: when we have more rapport, when there’s more trust, we can go there.

Coming into the intersectionality — now that we’ve defined our terms. One of the main points I want us to take away is knowing how to tell the difference between someone who has OCD versus someone who needs and wants to do authentic exploration.

It is totally normal for people to be unsure. Some of us have a clear image in our minds of early childhood crushes or awakenings during puberty. For other people — especially those who fall on the queer spectrum — that can be confusing. There can be messages that things are unacceptable, or a lack of accessible role models, so something is happening but they don’t see it reflected anywhere in their world. For people who are asexual or non-binary, there can be a feeling of “I don’t feel what I think other people are feeling,” which can overlap with the “not quite right” feeling that is pretty classic of OCD. So we want to be asking really thorough questions.

One of the most important elements is the level of distress. When we’re working with someone who is afraid to be gay, we want to dig into what goes into that fear. A part of wanting to be affirming providers is that sometimes when someone says “I think I’m gay,” we have the temptation to say “hell yeah, that’s awesome.” And sometimes that reinforcement — while well-intentioned — can be harmful if that person has OCD, because they internalize it as “oh, I should feel this way.” So we want to make sure we’re doing some clear, non-judgmental questioning.

A lot of times people who do have OCD will have a really strong fixation on wanting certainty. That can also happen in young adults doing authentic exploration — wanting to feel like “I’ve got this, I know what I want.” But in authentic exploration, what we find attractive and what kinds of behaviors we want to engage in can change over time. We don’t have that rigid, compulsive need for certainty. And you’ll often also see a lot of internalized marginalization — people who either have experienced ostracization in their community, or who have SO-OCD, sometimes making disparaging remarks. We have to recognize that there are valid reasons, especially in the United States, to have fear around being open with parts of your identity. But a bigger clue is when someone says something like, “I don’t have a problem with gay people. I just don’t want to be gay.” That gives you some information that maybe this isn’t as straightforward as it appears.

When we talk about SO-OCD, there’s a lot of disruption in the sex life. There are intrusive thoughts, which are a very strong symptom of OCD in general. We all have lots of intrusive thoughts as human beings every day, with or without OCD. If while you’re on this call you had the thought, “what am I going to do this weekend?” or “what am I going to have for dinner?” — those are intrusive thoughts. You didn’t choose to have them. But in OCD, some of those thoughts contain elements that activate the fear response.

For me, if someone said, “Dawn, what if you had dog poop on your shoe right now?” I don’t have contamination OCD, so my reaction would be, “ew, I hope not.” But if I did have contamination OCD, that would evoke a very strong stress response — “do I? Oh my gosh, I need to check right now.” It’s not a calm, in-control feeling. It’s strong distress.

So sometimes people who have fears about being attracted to children, family members, or people of the same sex will have intrusive thoughts — they might be kissing their partner and have an image pop into their mind. It’s very distressing. They’ll often immediately stop and avoid sexual behavior to prevent it from happening again. This can cause them to fall out of healthy patterns with their partner, create conflict in the relationship — difficulties that go beyond the symptoms themselves.

A lot of times the intrusive thoughts have such a strong distress response that it causes reduced arousal overall. It’s also really important for people to know that quite a few of the medications we use for mood regulation can have reduced arousal as a side effect — many people don’t know that and think something is wrong with them. So if they’re bringing it up, it’s worth asking: “Have you talked about that with your prescriber?”

They can also develop erectile dysfunction, or vaginismus — a very painful condition causing contraction of the vaginal walls that can make inserting tampons, fingers, etc., very difficult and painful.

Another incredibly important and concerning piece of why people avoid seeking help: we are mandated reporters. If someone comes in and says “I’m terrified that I’m going to sexually assault my child,” or “I keep having these thoughts about what if I’m attracted to kids” — it does happen that people get reported for those kinds of things. So it’s super important for us to understand the difference between the fear of a behavior and the likelihood of that behavior. We also often see people avoiding taking care of their kids, or avoiding gay people because they think it might increase their likelihood of “becoming” gay. They’re checking their bodies constantly.

On the topic of groinal response — as a species, anytime we discuss sex, there is going to be a non-elective response from the body. Even in this presentation, if you check your body right now, you may notice a reaction — not because you find this sexually arousing, but because anytime sex is mentioned, there’s a part of our brain linked to survival that goes, “huh, did you need me?” That’s a groinal response. But people with OCD will check for those responses and confuse them for attraction.

In terms of assessment, there are a couple of really helpful tools.

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is the most baseline measure for assessing OCD — it inventories the constellation of symptoms and scores severity and life interference. However, it’s not the most helpful for SO-OCD specifically, because there are only a very small handful of questions that address it. So it’s useful as a broad net, and then we bring it into the SORT.

The Sexual Orientation Obsessions and Reactions Test (SORT) is a set of 12 questions that really digs into the sexual orientation piece of OCD. It asks questions more specifically related to the fear underneath — “I need to know for sure that I’m straight,” “I check myself to see if I’m sexually aroused around other people,” “I worry that I’ll lose control and become LGBTQ.” The SORT is scored zero to four, and any score above 10 warrants further assessment for sexual orientation-based OCD.

And then there’s also a Differential Diagnosis Grid from the developers of the SORT assessment — I won’t go through it in detail for time, but it reiterates these same concepts we’ve been talking about: the difference between “I’m worried that I might be rejected from my community” versus “I’m worried because I don’t want this to be happening.”

Looking at basic treatment objectives — we start with what the patient came in for, what they want to be working on. If we’re working with someone who has SO-OCD, the level of distress can be very high, so if appropriate, we want to make sure there’s safety planning for suicidal ideation. We want to make sure we’re in good communication with their medication provider and medical team — especially when someone may have already engaged in medical services related to transition. We want to develop a treatment plan, and again, exposure and response prevention is the gold standard — that’s a whole presentation on its own. And whether someone has SO-OCD or is doing authentic exploration, working to build confidence in their identity is a very helpful and valuable part of that process.

I wish I had time to go through the clinical case presentations. I do want to save time for questions, so I’m going to stop sharing.

Dr. Amanda Fialk: Thank you so much, Dawn. There’s definitely a lot of chatter in the Q&A and in the chat. I’m going to get right to it so we can try to get to as many questions as we possibly can.

Can you differentiate the anxiety and distress that comes from OCD around gender and sexual orientation, and the distress and anxiety that comes from holding the oppression and judgment someone anticipates when coming out?

Dawn Anderson: Great question. I always start by getting a good foundation around their definitions of those words, how they’ve experienced having conversations about that, how those things were modeled, and what safety has looked like. So if someone’s coming in and saying, “I think I’m trans, my parents are very against that, I’m worried that if I come out I may be sent to conversion therapy or won’t be able to stay in my home” — those are very different conversations than a general “who am I?”

When I think about the core of that question — how do I tell the difference in the distress — I look at this: is the fear about other people and their judgment, or is the fear related to me? Someone who has SO-OCD is afraid that they are gay. They typically don’t have strong feelings about other people being gay. The fear is self-directed. And we also have to recognize that, depending on what’s happening in the political climate, some level of stress or fear or contemplation around coming out is a completely appropriate emotion to have.

Dr. Amanda Fialk: If reassurance-seeking is a compulsion, how do I avoid accidentally reinforcing it just by validating my client’s feelings in a normal and supportive way?

Dawn Anderson: When it comes to working on reassurance seeking, we always try to start with figuring out what specifically we are targeting in the reassurance. And this is where — as in one of the cases I brought — sometimes people who have OCD will not have that appropriately diagnosed, and because we want to be affirming, they may progress through getting gender-affirming care and then at some point go, “this doesn’t feel right. This doesn’t feel like me.”

So when we talk about being affirming, it’s important to think about what exactly I’m encouraging or affirming. Am I affirming their confidence to ask someone out, or to be willing to start dating after working on that in treatment? That’s different from responding to their specific reassurance-seeking. A lot of times reassurance will look like: “Is this arousing?” “If I stand like this, do I look gay?” When we know what their specific triggers are, my response is what we call a non-engagement response — something like, “What do you think I’m going to say to you about that?” or “Say more about what you’re worried about” — rather than giving them the quick yes or no they’re looking for.

Dr. Amanda Fialk: Is there a similar assessment for clients who potentially have OCD related to gender identity as opposed to sexual orientation? Can you use the SORT in a modified way, or is there something separate you’d recommend?

Dawn Anderson: There is not, to my knowledge, a specific assessment for gender identity OCD — though that doesn’t mean one doesn’t exist and I haven’t found it yet. What I do think makes sense is looking at the key component, which is telling the difference in the distress. One of the books I referenced in my resources is the Clinician’s Guide to Gender-Affirming Care, which goes through the WPATH guidelines. A really important part of that is having thorough discussions about realistic outcomes and expectations — and that gives you a good insight into what they’re hoping to get out of this. If the answer is certainty, that’s a red flag. As is any unrealistic expectation around relief, because we know that someone’s identity doesn’t necessarily benefit from being hinged on it being validated by a third party.

Dr. Amanda Fialk: How should clinicians who don’t specialize in either OCD or LGBTQ+ affirming care decide when to refer out versus when they can continue with consultation or supervision?

Dawn Anderson: In general, I find it’s really helpful to start with asking the patient what their primary treatment goals are. So often someone will have a history of OCD in their diagnosis and a clinician will say “I don’t know if I can work with them,” but they’re actually coming in for disordered eating or depression. Or someone will be trans or have a non-heterosexual sexuality, and they get referred to an LGBTQ+ specialist when that’s not really what they’re seeking treatment for. So number one — ask them what they want to work on. And then do what you’re doing right now by broadening your knowledge base. We can’t be good at everything, and at the same time, the relationship and trust you’ve built with your client is an important part of the treatment process.

Dr. Amanda Fialk: How do I support a trans teen experiencing anxiety and depression in therapy for gender-affirming care, but who does not want to engage in any conversations about gender identity?

Dawn Anderson: Create a safe space and make sure that, as we talked about with informed consent, they know you’re there when they’re ready. Oftentimes I’ll say, “I know that we don’t get a lot of good conversation about this, and it’s something I’m happy to talk about with you whenever you’re ready. Do you want me to check in on it from time to time, or do you want to wait until you bring it up?” That space can be super valuable because one of the most important parts of adolescence and young adulthood is the feeling of control and stewardship in their own lives. When they say, “I don’t want to talk about that,” that tells me there’s something I need to work on first — so we work on what they want to work on first.

Dr. Amanda Fialk: I love that answer. I’d also add that a teen who is in the room and even says “I don’t want to talk about any of this” — that is a step toward talking. Sometimes, especially with the younger population, you spend weeks talking about the Knicks winning the championship for the first time in forever, and that is relationship-building, which leads to talking about whatever they’re actually there for.

Dr. Amanda Fialk: How do you handle cases where OCD and identity questioning legitimately co-occur? How do you navigate that and affirm all sides?

Dawn Anderson: I actually enjoy that complexity quite a bit. We’re complicated human beings, and to say “I’ll only treat this part of you” just feels so invalidating. What I’ll say is that we have lots of good conversation, and when I come back to almost the beginning of my talk — where I said education about OCD is so important — when I’m having that conversation with them and saying, “let’s talk about where this causes you distress and what you want,” they get better at knowing that reaction that comes with OCD and the difference between that feeling versus curiosity. And it gives us a chance to even dive into some emotional work around curiosity — knowing how different feelings hit us differently.

Dr. Amanda Fialk: Thank you so much, Dawn, and thank you to everybody who took the time to join us today and to be a part of this really important conversation. We really hope that you’re able to share these insights within your own communities as well. Thank you for joining, and have a great afternoon.