According to the minority stress model, sexual minorities face chronic social stress resulting from their stigmatized identity (Meyer, 2013). This includes experiencing discrimination, rejection, victimization, and internalized negative societal attitudes.
The accumulation of these minority stressors is believed to partially explain the higher rates of mental health issues among sexual minorities.
Pinciotti, C. M., & Orcutt, H. K. (2021). Obsessive-compulsive symptoms in sexual minorities. Psychology of Sexual Orientation and Gender Diversity, 8(4), 487–495. https://doi.org/10.1037/sgd0000437
Key Points
- Sexual minorities reported significantly more severe obsessive-compulsive (OC) symptoms overall, likely driven by significantly more severe unacceptable thoughts.
- 23.5% of the total sample met criteria for probable OCD, including 37.7% of sexual minorities compared to 21.8% of heterosexuals.
- Sexual minorities endorsed less severe contamination OC symptoms compared to heterosexuals.
- OC symptoms related to violence, sex, or religion appear to be more common in sexual minorities.
Rationale
Prior research demonstrates that sexual minorities face unique stressors related to their sexual orientation, known as minority stress (Meyer & Frost, 2013). This includes experiencing external discrimination, trauma, rejection, and internalized stigma or shame.
The accumulation of these minority stressors puts sexual minorities at higher risk for mood, anxiety, and substance use disorders (Cochran, Mays, & Sullivan, 2003).
Though minority stress is believed to explain much of the mental health disparities faced by sexual minorities, less attention has specifically been paid to how it might impact obsessive-compulsive disorder (OCD).
Given the link between adverse life events and OCD development (Ceschi et al., 2011), along with sexual minorities’ elevated rates of trauma exposure (Roberts et al., 2010), OCD may be more common in this population.
Indeed, studies using student samples have found higher rates of self-reported OCD diagnosis among sexual minority groups compared to heterosexuals (Pelts & Albright, 2015; Przedworski et al., 2015). However, no research has examined how the presentation of OC symptoms may differ.
This study aimed to address this gap by investigating OC symptom profiles between sexual minorities and heterosexual undergraduates. Understanding diversity in symptom expression has implications for proper diagnosis and culturally informed treatment.
Examining nonclinical samples also aids in early OCD detection, as most cases are initially undiagnosed in the community (Glazier, Calixte, et al., 2013).
Overall, this research explores an understudied mental health outcome in an at-risk group.
Method
Participants provided information on sexual orientation, gender, race, ethnicity, marital status, and employment status. These were dichotomized for correlation analyses.
Independent samples t-tests, chi-square tests, and profile analysis were used.
Measures
515 nonclinical undergraduates completed self-report measures of OC symptoms, trauma exposure, and posttraumatic stress.
Dimensional Obsessive-Compulsive Scale (DOCS):
- 20-item self-report measure of OCD symptoms across 4 domains: contamination, responsibility for harm, unacceptable thoughts, and symmetry/order
- Items rated on 5-point Likert scale assessing symptom severity
- Total scores range from 0-80
- Cutoff of 18 suggests probable OCD
- Strong reliability and validity
Life Events Checklist (LEC):
- Self-report checklist of potentially traumatic events
- Assesses if events were directly experienced, witnessed, learned about, or part of one’s job
- Adequate test-retest reliability
PTSD Checklist for DSM-5 (PCL-5):
- 20-item measure of PTSD symptoms related to an index trauma
- Items correspond to DSM-5 PTSD criteria
- Rated from 0 (not at all) to 4 (extremely) reflecting past-week distress
- Total scores range from 0-80
- Cutoff of 37 suggests probable PTSD in undergrads
- Strong reliability and validity
Sample
89.8% heterosexual, 7.6% bisexual, 2.0% gay/lesbian. Mean age 19.2 years. 56.1% female, 42.9% male. 60.2% White, 21.8% Black.
Results
Results showed that sexual minorities reported significantly more severe obsessive-compulsive (OC) symptoms overall compared to heterosexuals.
Specifically, sexual minorities endorsed greater severity of “unacceptable thoughts” OC symptoms related to violence, sex, or religion. This difference remained even after controlling for trauma exposure and posttraumatic stress symptoms in the analyses.
In addition to more severe symptoms, sexual minorities exceeded the suggested cutoff score on the Dimensional Obsessive-Compulsive Scale (DOCS) for probable OCD at a higher rate than heterosexuals.
Based on the cutoff score of 18, 37.7% of sexual minorities met the criteria for probable OCD, compared to only 21.8% of heterosexual participants.
This indicates that sexual minorities were nearly twice as likely to be characterized as having clinically significant OC symptoms or probable OCD based on the self-report measure.
Insight
These results suggest sexual minorities experience elevated rates of OC symptoms, especially surrounding unacceptable or taboo thoughts. The findings are consistent with the notion that stigma and shame may sensitize sexual minorities to intrusive thoughts linked to potential social rejection.
The higher prevalence of probable OCD also aligns with previous research showing greater vulnerability for OCD diagnosis in sexual minority groups.
Minority stress increases the risk for OCD in sexual minorities. Stigmatized OC symptoms like unacceptable thoughts may be sensitized because they expect increased social rejection.
This may lead to overreaction and avoidance behaviors that inadvertently reinforce the obsessive thoughts.
Strengths
- Used validated measures of OC symptoms and posttraumatic stress
- Included trauma exposure and posttraumatic stress as covariates
- Diverse, nonclinical sample allows generalization.
Limitations
- Convenience sample of undergraduates may not generalize
- Small sexual minority sub-sample have limited power to detect differences
- Did not directly measure minority stress
Implications
Mental health providers treating sexual minorities with OCD face dual responsibilities:
- Sensitively responding to OCD symptoms without further stigmatizing:
- Avoid expressing reactions that could shame patients or imply symptoms are unacceptable
- Inappropriate responses may be perceived as biased even if unintentional
- Providing culturally competent care to sexual minority patients:
- Competence requires ongoing education as norms evolve
- Important for correctly identifying symptoms vs. identity development
Research shows clinical trainees often misdiagnose less common OCD presentations like sexual/violent obsessions (Glazier et al., 2013; 2015).
Thus providers should take care to accurately assess unacceptable obsessive thoughts in this population rather than dismissing them.
However, rumination around sexual orientation is common during identity development. Distinguishing normal questioning from OCD requires a nuanced functional analysis regarding the ego-dystonic nature of intrusive thoughts.
Overall, mental health professionals must appreciate the interplay between OCD and minority stress for sexual minorities to deliver sensitive, ethical services.
References
Primary reference
Pinciotti, C. M., & Orcutt, H. K. (2021). Obsessive-compulsive symptoms in sexual minorities. Psychology of Sexual Orientation and Gender Diversity, 8(4), 487–495. https://doi.org/10.1037/sgd0000437
Other references
Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., … & Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychological assessment, 22(1), 180.
Ceschi, G., Hearn, M., Billieux, J., & Van der Linden, M. (2011). Lifetime exposure to adverse events and reinforcement sensitivity in obsessive–compulsive prone individuals. Behaviour Change, 28(2), 75-86.
Cochran, S. D., Mays, V. M., & Sullivan, J. G. (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71(1), 53-61.
Glazier, K., Calixte, R. M., Rothschild, R., & Pinto, A. (2013). High rates of OCD symptom misidentification by mental health professionals. Annals of Clinical Psychiatry, 25(3), 201-209.
Gray, M. J., Litz, B. T., Hsu, J. L., & Lombardo, T. W. (2004). Psychometric properties of the life events checklist. Assessment, 11(4), 330-341.
Meyer, I. H. (2013). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychology of Sexual Orientation and Gender Diversity, 1(S), 3-26.
Pelts, M. D., & Albright, D. L. (2015). An exploratory study of student service members/veterans’ mental health characteristics by sexual orientation. Journal of American College Health, 63(7), 508-512.
Pinciotti, C. M., & Orcutt, H. K. (2020). Obsessive–compulsive symptoms in sexual minorities. Psychology of Sexual Orientation and Gender Diversity, 8(4), 487–495.
Przedworski, J. M., VanKim, N. A., Eisenberg, M. E., McAlpine, D. D., Lust, K. A., & Laska, M. N. (2015). Self-reported mental disorders and distress by sexual orientation: Results of the Minnesota College Student Health Survey. American Journal of Preventive Medicine, 49(1), 29-40.
Roberts, A. L., Austin, S. B., Corliss, H. L., Vandermorris, A. K., & Koenen, K. C. (2010). Pervasive trauma exposure among U.S. sexual orientation minority adults and risk of posttraumatic stress disorder. American Journal of Public Health, 100(12), 2433-2441.
Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD checklist for DSM-5 (PCL-5).
Keep Learning
- How might sexual minorities experience OCD symptoms differently than heterosexuals? What factors contribute to this?
- What is minority stress and how might it relate to the development of OCD in sexual minorities?
- How can mental health professionals provide culturally sensitive care for OCD among sexual minority patients?
