“What if I’m secretly gay?” Mental health treatment for identity-related obsessive-compulsive disorder through a justice-based lens
“What if I go the rest of my life without ever figuring out who I really am?”
“What if I’m gay and I don’t actually love my wife?”
“Am I really trans, or am I just seeking attention?”
These are common obsessions experienced by people with sexual orientation- and gender-themed obsessive-compulsive disorder (OCD). OCD is characterized by uncontrollable, recurring thoughts (obsessions) and repetitive, excessive behaviors (compulsions). Symptoms can start at any age, but they typically begin between late childhood and young adulthood.
These OCD themes, recently termed “identity-related OCD,” are becoming more common among individuals with OCD. Obsessions about identity also can include fears of one’s identity changing or transforming in some way, such as by taking on the qualities of someone you don’t like or becoming marginalized in some way (e.g., “What if I have schizophrenia?”), or losing control and harming someone who is marginalized (e.g., “What if I blurt a racial slur in front of my Black co-worker?”)
Exposure and response prevention (ERP) is considered the gold-standard cognitive behavioral treatment for OCD. ERP aims to break a cycle of symptoms by eliminating rituals and avoidance, thereby teaching patients how to tolerate distress without engaging in counterproductive behaviors and providing “corrective information” that challenges people’s existing fear response.
Yet, there has been little guidance on how to approach ERP with individuals with identity-related OCD. A few years ago, I worked with colleagues to develop a call-to-action for clinicians treating sexual orientation- and gender-themed OCD to ensure that marginalized communities are not further marginalized through the use of ERP that reinforces stereotypes and stigmatizing responses towards LGBTQIA+ people. We offered recommendations for applying ERP using a “justice-based lens” defined as: “an equitable, thorough and compassionate lens through which to conceptualize and implement mental health treatment so that all impacted persons – client, provider and society – are respected.” We recently expanded this to include clinical recommendations for treating individuals with other identity-related OCD themes, including obsessions centered on racism, aging, disability or diagnostic status and socioeconomic status.
Justice-based ERP includes several core components:
- Thoughtful use of language, e.g., using the term “sexual orientation [SO]-OCD” rather than homosexual [H]-OCD.”
- Case conceptualization that considers the historic or systemic roots of the obsessional theme, reducing shame by allowing clients to externalize these biases onto the society that taught them.
- Collaboratively developing exposure exercises related to uncertainty and core fears, neutral and positive identity-related stimuli, and psychoeducation that corrects distorted beliefs or biases inherent in some identity-related obsessions.
Last month, colleagues and I published our first study on justice-based ERP for identity-related OCD. Adults with identity-related OCD were asked about their identity-related OCD symptoms and then presented with two lists of potential exposure exercises that might target their OCD symptoms: one list of justice-based exposure exercises and another list of “overcorrection” exposure exercises. Participants strongly preferred a justice-based approach to their identity-related symptoms and expressed greater willingness to try justice-based exposures compared to “overcorrection” exposures.
While treatment outcomes research is needed to confirm our suggestion that justice-based ERP is just as – if not more – effective than overcorrection approaches to ERP, given its adherence to the central tenets and theory of ERP, this study is exciting because it is the first to provide empirical support for justice-based ERP among individuals who suffer from these unwanted obsessions. I hope this helps pave the way for more inclusive and effective treatment options in the future.
By Dr. Caitlin M. Pinciotti, assistant professor, licensed clinical psychologist, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
