To our knowledge, no large studies have specifically examined obsessions about sexual orientation within OCD. The rates of lifetime obsessions about sexual orientation in the current study mirror rates found in a research sample (Pinto et al., 2008
). While Grant et al. (2006)
did not find that gender was correlated with sexual obsessions, we found that significantly more males reported sexual orientation obsessions. Age does not appear be uniquely associated with obsessions about sexual orientation. Our sample of patients with obsessions about sexual orientation was similar in age to other treatment-seeking populations (i.e., Abramowitz et al., 2003
), and this did not vary from patients with other OCD symptom types. Additionally, patients in the current study with obsessions about sexual orientation reported moderate OCD severity and comparable levels of insight to patients with other types of OCD symptoms, which is consistent with findings by Grant and colleagues.
Our findings indicate that obsessions about sexual orientation in OCD may be uniquely associated with increased time spent on obsessions, increased levels of distress, more interference, and more avoidance, all which may be clinically relevant for the assessment and treatment of OCD. Notably, as males tend to have an earlier age of onset of OCD symptoms, they may experience more distress from symptoms because the symptoms have been presenting for a longer period of time. Sexual orientation obsessions may be more distressing, resulting in greater disability and greater need for treatment services. Likewise, the stigma and/or misdiagnosis of homosexuality-themed OCD might result in delays in finding the most appropriate treatment, resulting in increased distress as symptoms progress untreated.
People with OCD may have a number of different obsessions and compulsions, thus careful assessment of OCD symptoms is necessary. Other types of obsessions may be more recognizable to clinicians (e.g., concerns about contamination) and more comfortable for patients to discuss, which may result in obsessions about sexual orientation being missed in treatment. It is important to note that the clinicians administering the YBOCS in the current study were primarily from specialty clinics, so were highly familiar with assessing OC symptoms. OCD can pose a unique diagnostic challenge to clinicians, and among those not experienced in the assessment and treatment of sexual obsessions in OCD, misdiagnoses or ineffective treatment can result (Gordon, 2002
; Grabill et al., 2008
; Sussman, 2003
). Patients presenting with OCD should be asked directly about the presence of sexual obsessions, including fears surrounding sexual orientation. Clinicians should be careful not to imply that they believe the patient is homosexual, as this will cause distress and potentially a loss of rapport (Williams, 2008
Contributing to misunderstandings about the nature of sexual obsessions, some research categorizes sexual obsessions and compulsivity together with deviant behavior (e.g., Branaman, 1996
). The DSM specifically notes while engaging in excessive sexual behaviors may be often referred to as ‘compulsive’ behavior, this is actually incorrect. In such situations, the “individual derives pleasure from the activity and may wish to resist it only because of its deleterious consequences” (APA, 2004
). What is often described as “compulsive sexual behavior” is actually more accurately describing impulsivity, as individuals experience thoughts, impulses, and behaviors as enjoyable, not distressing. This differential distinction is essential when considering a diagnosis of OCD, as obsessions are unpleasant and do not represent fantasies or wishes.
There is no evidence to suggest that people with sexual orientation-themed OCD should receive any treatment other than what has already been established as efficacious for OCD in general. The most common pharmacological treatment for obsessive-compulsive disorder is a selective serotonin reuptake inhibitors (SSRI) or the tricyclic medication clomipramine, where dosages for the anti-obsessional qualities are often higher than typically needed for anti-depressant effects (Blanco et al., 2006
; Bystritsky, 2004
). It is not known if people with sexual orientation obsessions fare better or worse than people with other OCD symptom profiles. For example, in a study investigating the treatment effects of citalopram, sexual thoughts were a predictor of positive medication response (Stein et al., 2007); however, in another SRI study individuals with sexual obsessions had poorer long-term outcomes (Alonzo et al., 2001).
In terms of psychotherapeutic interventions for OCD, research suggests that, compared to most other forms of OCD (i.e., contamination or checking), sexual obsessions take longer to treat (Grant et al., 2006
), and response may be less robust (Alonso et al., 2001
; Mataix-Cols et al., 2002
; Rufer et al., 2006
). However, EX/RP remains the treatment of choice for those with sexual obsessions, with cognitive therapy as a possible second-line alternative (e.g., NICE, 2006
). People with sexual obsessions are less likely to have overt rituals, and more likely to engage in mental compulsions and repeated reassurance-seeking (Abramowitz et al., 2003
; Farris et al., 2010
), so special attention should be given to covert rituals during treatment.
The current study has a few notable limitations. We examined patients with lifetime symptoms for most comparisons as we did not have adequate power to examine only those with current sexual orientation symptoms. This approach as has been utilized previously to examine symptoms dimensions based on the YBOCS check list (Pinto et al., 2008
). It is possible that those without current symptoms may be different in some important ways than those with only a history of such symptoms, although it appears that presence of sexual obsessions tends to be stable over time (Besiroglu et al., 2007
). A future study should examine this issue with large numbers of people with past, present, and no history of sexual orientation symptoms for comparison. Additionally, it is possible that obsessions about sexual orientation are associated with another type of particularly distressing or impairing obsession or compulsion (e.g., aggressive obsessions), which could result in higher YBOCS severity scores. It was not possible to test this idea in the current study due to limitation concerning the availability of all variables; however, future studies should explore this as well. An examination of the similarities and differences between different types of sexual obsessions would also be a useful and interesting avenue of future research.
Obsessions about sexual orientation are consuming to those experiencing them, and sometimes puzzling to clinicians assessing and treating them. Our findings suggest that those with obsessions about sexual orientation spend more time worrying and ruminating, feel increased distress and shame, and may be more impaired. Thus it is critical that people with sexual orientation concerns be properly diagnosed and treated. Failure to identify these symptoms can result in incorrect treatment, incomplete treatment, and/or relapse.
It has not been established how to best tailor cognitive-behavioral treatments to this particular group of patients, and likewise it is not known if some medications may be more effective for sexual orientation obsessions than others, thus more treatment-focused research is needed. Future studies should include analyses of symptom data from epidemiological studies and investigation of treatment outcome data, as it would provide greater insight into this often misunderstood symptom of OCD.