Distinguishing normal identity formation process for sexual minorities from obsessive compulsive disorder with sexual orientation obsessions
Objectives In synthesizing a homosexual or bisexual identity, an individual may go through different stages before coming to a positive healthy identity. It is likely that there will be a period in which homosexual yearnings will be unwanted. Sometimes this distress leads the person to consult a health professional. Conversion therapy has been proven both ineffective and harmful and therefore has been ethically prohibited by all major psychiatric and psychological associations. The responsible clinician will attempt to assist the individual in his acceptance of his sexual minority. Occasionally individuals without homoeroticism consult because of distress related to sexual identity questioning which poses a different problem for clinicians especially if the situation goes unrecognized. The objective of this paper is to describe homosexual obsessive compulsive disorder (HOCD) and distinguish it clinically from the normal process of sexual minority identity formation in western culture. Methods A literature review yielded very few descriptions of homosexual OCD. A retrospective chart review of all patients seen in the last 3 years at the McGill University Sexual Identity Centre was conducted to identify all the cases of OCD. Six cases were found, 4 of which were of HOCD and are presented. Similarities between cases are highlighted. Results All cases were young men with relatively little relationship and sexual experience. Most were rather shy and had some other obsessional history in the past though often at a sub-clinical threshold. Obsessional doubt about their orientation was very distressing and did not abate over time as would normally occur with a homoerotic individual. The four patients who had an obsession of being gay despite little or no homoerotism are presented in detail. They all presented mental compulsions, avoidance and physiological monitoring. Continuous internal debate trying to prove or disprove sexual orientation was a ubiquitous mental compulsion. They all spent a majority of time monitoring their physiological reactions to members of both sexes to check for arousal. They attempted homosexual activity and were disgusted by it, yet this did not end their questioning. They avoided relationships with the opposite sex, being either too anxious to initiate, or too conflicted to maintain them. The obsession with being gay seemed like a horrific thought symptomatic of homophobia, however the level of horror was out of proportion to the patient’s overall level of homonegativity suggesting that the horror came mostly from feeling like their core identity was threatened. Conclusion HOCD can present in ways similar to normal homosexual identity formation. A thorough exploration of eroticism towards both sexes as well as prior history of subclinical anxiety should help distinguish the two. Treatment of HOCD should combine education about sexuality and OCD as well as usual OCD treatments such as relaxation techniques, cognitive restructuring, mindfulness training and pharmacology.