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. Author manuscript; available in PMC: 2023 May 22.
Published in final edited form as: J Obsessive Compuls Relat Disord. 2022 Apr 9;33:100724. doi: 10.1016/j.jocrd.2022.100724

Examination of Outcomes among Sexual Minorities in Treatment for Obsessive-Compulsive and Related Disorders

Andreas Bezahler 1, Jennie M Kuckertz 1, Meghan Schreck 1, Kevin Narine 2, Devin Dattolico 1, Martha J Falkenstein 1
PMCID: PMC10201929  NIHMSID: NIHMS1843913  PMID: 37220532

Abstract

The first-line psychological treatment for obsessive-compulsive and related disorders (OCRDs) is exposure and response prevention (ERP). As the first study to examine treatment outcomes for sexual minorities, it is crucial to examine: (1) how treatment-seeking individuals who identify as sexual minorities compare to heterosexual individuals in symptom severity at admission, length of stay in treatment, and (2) whether ERP is equally effective for sexual minorities. The current study explored these questions in an intensive/residential treatment (IRT) program for OCRDs. Adult participants (N = 191) completed self-reported measures of OCD severity, distress tolerance, and depression at program admission, in the first four weeks of treatment, and at discharge. No differences were found between groups for treatment outcome, although slight differences (non-significant) emerged at baseline for OCRD severity, distress tolerance, and depression. Sexual orientation was not predictive of OCRD severity at weeks 1–4, and number of days spent in treatment was not associated with sexual orientation. This is the first study exploring whether sexual orientation is predictive of treatment outcomes for individuals diagnosed with OCRDs. Results suggest that outcomes did not differ and participation in the program resulted in an overall improvement of symptoms regardless of sexual orientation, however several study limitations are discussed. Future studies should replicate these findings, attempt to collect a larger sample, incorporate qualitative feedback from treatment, and examine outcomes in gender minorities.

Keywords: obsessive-compulsive disorder, obsessive-compulsive and related disorders, sexual orientation, sexual minorities

The first-line treatment for obsessive compulsive and related disorders (OCRDs) is exposure and response prevention (ERP; Foa et al., 2005; Franklin et al., 2000). However, the majority of research on OCD and its treatment has been conducted in samples that comprise predominantly White, cisgender, and heterosexual individuals, thus it is unclear if first-line treatments remain such among diverse populations. Prior research indicates that gender minorities report greater contamination obsessions, psychiatric comorbidities, longer lengths of stay in treatment, and less symptom improvement in treatment compared to cisgender individuals with OCD (Pinciotti et al., 2022). Williams and colleagues (2015) examined treatment outcomes in minoritized ethnoracial individuals and found that minoritized individuals also required longer stays in an intensive/residential treatment (IRT) facility for OCD than non-minoritized individuals. In regard to those minoritized based on their sexual orientation, sexual minorities are at increased risk for psychopathology, experiencing both higher levels and rates of anxiety-related disorders compared to heterosexual individuals (Cohen et al., 2016; Gilman et al., 2001; Potoczniak et al., 2007; Safren & Pantalone, 2006; Seelman, et al., 2017). To date, it remains undetermined whether ERP is equally effective for sexual minorities compared to heterosexual individuals. Understanding whether therapies are effective for diverse populations involves acknowledging the intersection of social identities and how stigma may affect treatment experiences and outcomes (Wadsworth et al., 2020).

Minority stress theory posits that sexual minorities experience unique distal stressors (e.g., external stressors) related to their identities and subsequent proximal stressors (e.g., internal stressors in response to negative external experiences) that increase the risk for emotional disorders (Meyer, 2003). Thus, sexual minorities may potentially experience distal stressors such as sexual orientation related microaggressions, discrimination, and interpersonal violence; and proximal stressors such as internalized stigma, fear of rejection, and identity concealment in their daily lives (Meyer, 2003). As supported by the diathesis-stress model, the accumulation of adverse experiences may increase risk for OCRD symptoms (Ceschi et al., 2011). In the context of treatment, sexual minorities with OCRDs may also experience microaggressions and discrimination in ERP (e.g., culturally insensitive exposures that perpetuate sexual orientation-related stigma; Pinciotti et al., 2021), internalized stigma, fear of rejection by providers, and identity-related concerns connected to their OCRD symptoms that may negatively impact treatment outcomes (Pinciotti et al., 2021).

Past research involving sexual minorities with OCRDs has mostly focused on sexual orientation-related obsessions in heterosexual individuals (Williams & Farris, 2011; Williams et al., 2014), whereas the experiences of individuals with OCD who identify as a sexual minority have not been studied. Notably, sexual minorities are nine times more likely to receive a diagnosis or treatment for OCD in the past 12 months (Pelts & Albright, 2015). Moreover, research in non-clinical settings also suggests that sexual minorities are more likely to endorse obsessive compulsive symptoms (Pinciotti & Orcutt, 2020). Understanding the discrepancies in the prevalence of OCD between sexual minorities and heterosexual individuals may be explained by examining potential candidate mechanisms and comorbidities (e.g., depression) which can drive the maintenance of OCD symptoms (Hezel & Simpson, 2019).

In addition to increased rates of OCD, sexual minorities experience greater risk for worsened symptomatology commonly associated with OCD. For example, individuals diagnosed with OCD are at an increased risk for suicide attempts and dying by suicide (de la Cruz et al., 2017), and the likelihood of developing suicidal ideation or experiencing a suicide attempt is increased compared to heterosexual individuals (Meyer, 2003; Lewis, 2009). Likewise, rates of depression are disproportionately higher in sexual minorities than heterosexual individuals (Meyer, 2003). Moreover, sexual minorities experience more symptoms related to depression in their lifetime compared to heterosexual individuals (Zietsch, et al., 2012). Given significantly increased suicidality among sexual minorities and those diagnosed with OCD, high rates of comorbidity between anxiety-related disorders and depression (Abramowitz et al., 2000; Beard et al., 2016; McNally et al., 2017), and increased likelihood of sexual minorities experiencing depressive symptoms (Meyer, 2003), it is critical to examine depression as a treatment outcome measure for sexual minorities compared to heterosexual individuals, along with potential process factor differences.

Distress tolerance is an important facet in emotion regulation; experiencing low distress tolerance often relates to difficulty an individual has in experiencing negative feelings (Blackledge & Hayes, 2001). In particular, lower distress tolerance has been shown to partially mediate the relationship between sexual orientation-related discrimination experiences and anxiety symptoms in sexual minorities (Reitzel et al., 2017). Therefore, sexual orientation-related stress may possibly maintain or lead to lower distress tolerance in sexual minorities, increasing anxiety-related symptoms (Reitzel et al., 2017). Distress tolerance is also an important maintenance factor of OCRDs, which has a significant association with OCD-related obsessions (Cougle et al., 2011). Due to distress intolerance playing an important role in the persistence of OCD, and sexual minorities experiencing increased stress (minority stress theory model, Meyer, 2003), we predict that distress tolerance may be different across sexual orientation, both at baseline and across treatment. The purpose of the current study is to better understand and contextualize treatment outcomes by examining baseline levels of distress tolerance, depression, and OCD severity between sexual minorities and heterosexual individuals with OCD.

There is a critical need for research examining how sexual minorities respond to treatment and whether these standards need to be adapted, given that past research has highlighted how the presence of non-affirming care interferes with treatment for sexual minorities (Pinciotti et al., 2021). To the best of our knowledge, no past studies have examined treatment outcomes for sexual minorities in IRT setting for OCRDs, however, a single-session intervention for youth with depressive disorders was found similarly acceptable and efficacious among SGMs and heterosexual, cis-gender individuals (McDanal et al., 2021). In a transdiagnostic intensive psychiatric hospital program, Beard and colleagues (2017) results suggest that treatment outcomes in sexual and gender minorities (SGM) for anxiety, depression, and level of impairment, were similar among all SGM groups, with the exception for those who identified as bisexual. In another study in IRT for OCRDs, research highlights that individuals who hold more marginalized identities (e.g., race, ethnicity, sexual orientation) experience greater levels of OCD severity and depression (Wadsworth et al., 2020). Moreover, in a recent review, Pinciotti and colleagues (2021) describe how sexual minorities who are diagnosed with an OCRD may be at risk of worsened therapeutic interactions compared to heterosexual individuals, as a possible result of anti-affirming LGBQ+ care, historically intertwined with exposure therapy. While these findings add to the gap in research on the effectiveness of evidence-based treatment for sexual minorities, further research in longer-term treatment settings is necessary (Pachankis, 2018).

The current study examined how sexual minorities compare to heterosexual individuals at an IRT program for OCRDs at program admission, throughout treatment, and at discharge; with the primary aim of examining treatment outcomes. Levels of OCD severity, depression, and distress tolerance were measured at program admission and discharge. OCD severity was also measured in the first four weeks of treatment due to previous research of IRT for OCRDs suggesting the largest amount of symptom reduction occurs within the first four weeks of treatment and that this period is most predictive of outcomes (Krompinger et al., 2017).

We examined: 1) differences in levels of OCD severity, depression, and distress tolerance between groups at program admission and discharge while also comparing length of stay, and 2) whether sexual orientation predicts OCD severity for sexual minorities in the initial stage of treatment. We hypothesized baseline differences in symptom severity such that sexual minorities would report more symptoms at baseline compared to heterosexual individuals, and as well as poorer treatment outcomes for sexual minorities.

Methods

Participants

Data were collected from heterosexual (n = 157) and sexual minority (n = 34) participants at program admission, the first four weeks of treatment, and at discharge at an IRT program for OCRDs in the Northeastern US from April 2018 to March 2020. The mean age of participants was 28.81 (SD = 10.35), with the majority of individuals identifying as heterosexual (82%), White (70%), and non-Hispanic (94%); detailed demographic information is presented in Table 1. Participants were recruited for research participation as a part of routine admission procedures to the program. Participants experienced moderate to severe OCD symptoms (M = 24.79, SD = 6.50), have typically been referred for a higher level of care from outpatient treatment, and a subset of participants are on their second or more admission to the program.

Table 1.

Demographic Characteristics

Sample (N) = 191 M (SD) or N (%)
Age 28.81 (10.35)
Average length of stay (in days) 62.2 (22.65)
Gender1
 Male 93 (48.7)
 Female 95 (49.7)
 Not listed: participant’s write-in response “none” 1 (.5)
 Gender Non-Conforming 2 (1)
Race/Ethnicity
 African American 3 (1.6)
 American Indian/Alaskan Native 3 (1.6)
 Asian 4 (2.1)
 Caribbean Islander 1 (.5)
 European American 132 (69.1)
 Latino/Latina 6 (3.1)
 Native Hawaiian or Pacific Islander ---
 Do not know 10 (5.2)
 Not listed 43 (22.5)
Sexual Orientation
 Heterosexual 157 (82.2)
 Gay 8 (4.2)
 Lesbian 1 (.5)
 Queer 3 (1.6)
 Asexual 6 (3.1)
 Bisexual 14 (7.3)
 Not Listed 7 (3.7)
Education N (%)
 8th grade or less 1 (.5)
 Some high school 4 (2.1)
 High school graduate/GED 24 (12.6)
 Some college 69 (36.1)
 Bachelor’s degree 57 (29.8)
 Associates degree (e.g., community college or vocational/technical school) 6 (3.1)
 Graduate or professional degree 30 (15.7)
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1

Gender may not be reflective of participants’ identities as we did not initially include adequate options in our demographics forms that allowed participants to endorse non cis-gender identities. We have since modified our demographic forms to be more inclusive.

Most participants (76%, n = 146) completed the Structured Clinical Interview for DSM-5 Disorders (SCID-5) to categorize primary and co-morbid diagnoses, however, the SCID-5 was not able to be administered to the remaining 24% (n = 45) of the sample due to logistical, clinical, or scheduling constraints. Of participants with available SCID-5 data, 95% (n = 138) received a primary diagnosis of OCD, while the remaining 5% (n = 8) received a primary diagnosis of an OC-related, anxiety, or mood disorder. Of those with SCID-5 data available, more than half (63%) had a comorbid diagnosis of generalized anxiety disorder (GAD) and half (53%) had a comorbid diagnosis of major depressive disorder (MDD). Primary and secondary diagnoses are presented in Table 2. To be admitted to the program, prospective participants are screened by master’s-level clinicians to determine if their concerns meet criteria for OCD treatment at this facility. Based on the program’s main treatment modality of CBT/ERP, only individuals who have an OCRD would be responsive to the treatment offered, and therefore only those with a primary or secondary diagnosis of an OCRD are admitted. To maximize generalizability, we did not use additional inclusion criteria for the current study beyond standard admission criteria for the IRT program (e.g., age ≥ 18).

Table 2.

Primary and Secondary DSM-5 Diagnoses

Primary DSM-5 Diagnosis N (%)1
 Obsessive-Compulsive Disorder 138 (94.5)
 Bipolar Disorder I 1 (0.68)
 Body Dysmorphic Disorder 1 (0.68)
 Generalized Anxiety Disorder 1 (0.68)
 Major Depressive Disorder 1 (0.68)
 Panic Disorder 1 (0.68)
 Post-Traumatic Stress Disorder 1 (0.68)
 Social Anxiety Disorder 2 (1.37)
 Missing Primary Diagnosis 45 (23.6)
Secondary/Comorbid DSM-5 Diagnosis N (%)
 Attention Deficit Hyperactive Disorder (ADHD) 41 (28.1)
 Autism Spectrum Disorder 4 (2.74)
 Bipolar Disorder 14 (9.59)
 Body Dysmorphic Disorder (BDD) 18 (12.3)
 Excoriation Disorder 10 (6.85)
 Generalized Anxiety Disorder 92 (63.0)
 Hoarding Disorder 8 (5.48)
 Major Depressive Disorder (MDD) 77 (52.7)
 Panic Disorder 25 (17.1)
 Personality Disorder 7 (4.79)
 Seasonal Affective Disorder 34 (23.3)
 Tic Disorder 1 (0.68)
 Tourette’s Disorder 4 (2.74)
 Trichotillomania 8 (5.48)
 Condition Not Listed 44 (22.5)
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1

Most participants (76%, n = 146) completed the Structured Clinical Interview for DSM-5 Disorders (SCID-5) to categorize primary and co-morbid diagnoses, however, the SCID-5 was not able to be administered to the remaining 24% (n = 45) of the sample due to logistical, clinical, or scheduling constraints. Percentages above reflect percent of participants with a given diagnosis based on all available SCID data (n = 146 instead of N = 191).

Measures

Structured Clinical Interview for DSM-5 Disorders (SCID-5; First et al., 2015).

The SCID-5 is a structured clinical interview that assesses DSM-5 diagnoses and was administered by trained research staff and graduate students under the supervision of a licensed clinical psychologist.

Yale-Brown Obsessive-Compulsive Scale, Self-Report (Y-BOCS-SR; Goodman et al. 1989; Steketee et al., 1996).

The Y-BOCS Self-Report was administered to measure OCD symptom severity. Responses for 10 questions (5 on obsessions, 5 on compulsions) are rated on a 5-point Likert scale from 0 (not at all/none) to 4 (extreme) yielding a total score of 0–40. Scoring of this measure is as follows: 0–8 subclinical, 8–15 mild, 16–23 moderate, 24–31 severe, and 32–40 extreme. This self-report version of the YBOCS is commonly utilized (Steketee et al., 1996), and displays medium to strong correlations with the clinically administered measure (Federici et al., 2010; Hauschildt et al., 2019; Storch et al., 2017).

Distress Tolerance Scale, Self-Report (DTS-SR; Simons & Gaher, 2005).

The DTS is a 15-item measure of distress tolerance that focuses on beliefs about feeling distressed or upset. The measure has subcategories which relate to tolerance of emotions, appraisal, absorption and emotion regulation. Items are rated on a 5-point Likert scale from 1 (strongly agree) to 5 (strongly disagree). Higher scores on the DTS suggest that an individual has a higher ability to withstand negative emotions and lower scores suggest that an individual has a lower ability to withstand negative emotions.

Hamilton Depression Scale–6 (HAMD-6; Bech et al., 1975).

The HAMD-6 is a 6-item measure of depressive symptoms that focuses on symptom severity over the past three days. The measure assesses depressed mood, feelings of guilt, work and activities, psychomotor retardation, psychological anxiety, and somatic symptoms. Scores range from 0 to 22, with higher scores indicating greater symptom severity. The measure has been shown to have good psychometric properties (Timmerby et al., 2017).

Procedure

Participants completed the YBOCS, DTS, and HAMD at both admission and discharge. The YBOCS was also collected at weeks 1–4 of treatment. Data were collected using REDCap (Harris et al., 2009), a secure web-based survey program.

Treatment Overview

The IRT program included individual behavior therapy, family therapy, medication management with psychiatrists, and group therapy. All clinicians were licensed psychologists, social workers, or psychiatrists; or working under the supervision of a licensed clinician (i.e., psychology postdoctoral fellows). While demographic information about providers were not systematically collected, often program clinicians identified as White, cisgender, and heterosexual, and varied widely in their training and ongoing efforts related to diversity, equity, and inclusion. Participants collaborated with their behavior therapists to develop exposure treatment plans. All participants engaged in up to four hours of either coached or self-directed ERP per day for a mean of 62.2 (SD = 22.7) days in the program. For more information about the IRT program, refer to Krompinger and colleagues (2017) and Stewart and colleagues (2005).

Data Analytic Plan

For each construct of interest (YBOCS, DTS, HAMD), we submitted scores to separate 2 (Group: sexual minorities, heterosexual) X 2 (Time: baseline, discharge) analysis of variance (ANOVAs) with repeated measures on time. Most analyses were conducted using SPSS software version 24 (SPSS Inc., Chicago, IL, USA). Path analysis was conducted using Mplus, version 7.4 (Muthén & Muthén, 2017). Full-information maximum likelihood estimation with robust standard errors (MLR) was used to account for missing data and skew. Paths were estimated from sexual orientation to each of the YBOCS and distress tolerance variables. More specifically, while controlling for YBOCS score at admission (admission YBOCS), paths from sexual orientation to YBOCS scores at weeks one through four (week 1 YBOCS through week 4 YBOCS) and discharge (discharge YBOCS) were estimated. Additionally, while controlling for distress tolerance at admission (admission DTS), the path from sexual orientation to distress tolerance at discharge (discharge DTS) was estimated. Correlations between sexual orientation and admission YBOCS and admission DTS were also estimated. Please see Figure 1 for an illustration of the paths estimated.

Figure 1.

Figure 1.

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Path model illustrating regression paths from sexual orientation (SO) to YBOCS and distress tolerance outcome variables, while controlling for admission YBOCS (adm_YB) and admission distress tolerance (adm_DT) scores. Correlations between SO and adm_YB and adm_DT were also estimated. Paths of interest are displayed in bold and control paths are displayed in gray. Sexual orientation = SO, admission YBOCS = adm_YB, week 1 YBOCS = wk1_YB, week 2 YBOCS = wk2_YB, week 3 YBOCS = wk3_YB, week4 YBOCS = wk4_YB, Discharge YBOCS= dc_YB, admission distress tolerance= adm_DT, discharge distress tolerance = DC_DT.

Results

Observed (Post-Hoc) Power Analysis

Means, standard deviations and independent samples t-tests are presented for all measures in Table 3. An observed (post-hoc) power analysis using G*Power (Faul et al., 2007) with 𝛼 = .05, observed effect size of d = .369, n = 34 for sexual minorities and n = 157 for heterosexual individuals, indicated that observed power was .49 to detect between-group differences in YBOCS change. As this suggests our results are underpowered to detect potential differences between groups, we interpret the following results with caution.

Table 3.

Means and Standard Deviations for Outcomes Measures

Measure Total M (SD) Sexual Minorities M (SD) Heterosexual Individuals M (SD) Difference
YBOCS admission 24.79 (6.50) 26.53 (5.68) 24.41 (6.62) t(189) = 1.73, p = .085, d = 0.34
YBOCS discharge 15.12 (6.65) 15.01 (6.22) 15.22 (6.76) t(189) = −0.15, p = .878, d = .03
DTS admission 39.36 (14.93) 35.13 (11.79) 40.27 (15.41) t(178) = −1.78, p = .078, d = 0.37
DTS discharge 45.06 (14.58) 45.25 (13.95) 45.01 (14.75) t(178) = 0.08, p = .934, d = 0.02
HAM-D admission 8.78 (5.37) 10.24 (5.45) 8.46 (5.31) t(186) = 1.76, p = .081, d = 0.33
HAM-D discharge 4.93 (5.11) 5.62 (4.66) 4.78 (5.20) t(186) = 0.87, p = .388, d = 0.17
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Note. YBOCS = Yale-Brown Obsessive Compulsive Scale. DTS = Distress Tolerance Scale. HAM-D = Hamilton Rating Scale for Depression.

Effect of Sexual Orientation on Length of Stay

An independent samples t-test highlighted there was no significant difference, t(188) = 1.07, p = .428, d = .20) in number of days spent in treatment between sexual minorities (M = 65.97, SD = 24.44) and heterosexual individuals (M = 61.38, SD = 22.23).

Effects of Sexual Orientation on Treatment Outcomes

OCD Severity.

Results from YBOCS data revealed a significant main effect of time, F(1, 189) = 261.86, p < .001, 𝜂p2 = .581, indicating that OCD symptom severity decreased from baseline (M = 24.79, SD = 6.50, representing severe symptoms) to discharge (M = 15.19, SD = 6.65, representing mild symptoms). The main effect of group was not significant, F(1, 189) = 51.61, p = .368, 𝜂p2 = .004, nor was the Group X Time interaction, F(1, 189) = 3.26, p = .073, 𝜂p2 = .017.

Distress Tolerance.

Results from DTS data revealed a significant main effect of time, F(1, 178) = 25.16, p < .001, 𝜂p2 = .124, indicating that distress tolerance increased from baseline (M = 39.74, SD = 15.14) to discharge (M = 45.41, SD = 14.64). The main effect of group was not significant, F(1, 178) = 1.00, p = .320, 𝜂p2 = .006, nor was the Group X Time interaction, F(1, 178) = 3.30, p = .071, 𝜂p2 = .018.

Depression Severity.

Results from HAMD data revealed a significant main effect of time, F(1, 186) = 62.70, p < .001, 𝜂p2 = .252, indicating that depression symptom severity decreased from baseline (M = 9.00, SD = 5.37) to discharge (M = 4.94, SD = 5.11). The main effect of group was not significant, F(1, 186) = 2.42, p = .122, 𝜂p2 = .013, nor was the Group X Time interaction, F(1, 186) = 0.80, p = .797, 𝜂p2 = .004.

Effects of Sexual Orientation on Baseline Symptoms

Although the Group X Time interactions were not significant for any of our measures of interest (OCD symptoms, distress tolerance, depression), we nonetheless examined the effect of sexual orientation on baseline symptoms given that we had a priori hypotheses expecting more severe symptoms prior to treatment. Baseline differences were non-significant for all measures, including OCD symptoms, t(189) = 1.73, p = .085, d = 0.34, distress tolerance, t(178) = −1.78, p = .078, d = 0.37, and depression symptoms, t(186) = 1.76, p = .081, d = 0.33. Mean differences were in the expected direction such that sexual minority individuals demonstrated higher OCD symptoms (M = 26.53, SD = 5.68) than heterosexual individuals (M = 24.41, SD = 6.62), lower distress tolerance (M = 35.12, SD = 11.79) than heterosexual individuals (M = 40.27, SD = 15.41), and higher depression symptoms (M = 10.24, SD = 5.45) than heterosexual individuals (M = 8.46, SD = 5.31), although effect sizes were small and differences were non-significant.

Prospective Relationship between Sexual Orientation and OCD Severity/Distress Tolerance

Sexual orientation was not significantly associated with discharge DTS (β = −3.64, p = .120), discharge YBOCS (β = 1.08, p = .269), week 1 YBOCS (β = −.064 p = .920), week 2 YBOCS (β = −.10, p = .897), week 3 YBOCS (β = .369, p = .662), or week 4 YBOCS (β = .972, p = .238), indicating sexual orientation was not predictive of OCD severity at any of the first four weeks of treatment or at discharge nor predictive of distress tolerance at discharge. Sexual orientation was positively and significantly associated with admission DTS (β = .81, p = .009) and negatively and significantly associated with admission YBOCS (β = −.31, p = .028).

Discussion

The primary aim of this study was to examine if sexual minorities in IRT for OCRDs respond similarly to treatment compared to heterosexual individuals by examining levels of symptomology (YBOCS, DTS, HAMD) at admission, weeks 1–4 of treatment, and discharge, and whether groups differed in length of stay. Descriptively, sexual minorities experienced slightly higher OCD symptoms, depression symptoms, and lower distress tolerance at admission, but these differences were small and non-significant. Drawing from minority stress theory and past research on minoritized populations, additive stress may play an adverse role on mental well-being for sexual minorities, which are not proportionately experienced by heterosexual individuals (Meyer, 2003).

There were main effects of time for all measures, suggesting that treatment was broadly effective in reducing symptoms of OCD and depression, as well as improving distress tolerance. Participants work intensively with a clinical team, approaching feared stimuli and practicing useful skills which are idiographic to a participant’s individual needs. The decrease in OCD and depression severity and increase in distress tolerance regardless of sexual orientation thus highlights the general efficacy of the treatment program.

Contrary to our hypotheses, there were no significant differences in treatment outcomes for OCD severity, depression, or distress tolerance between groups, nor were there differences in length of stay. We found this result unexpected, given that sexual minorities experience unique distal stressors related to their identities in their social interactions and subsequent proximal stressors in response to internal distress (Meyer, 2003), and these stressors may be experienced during treatment, which may result in worse outcomes (Pinciotti et al., 2021). While sexual minorities may have experienced these stressors in treatment, they may have acquired skills in therapy to manage their symptoms and cope with stressful identity-related experiences, developed supportive relationships with other sexual minority participants with OCD, and benefitted comparably to heterosexual individuals in treatment outcomes.

Our program does not include formal training for clinicians in the treatment of sexual and gender minority participants, however, several factors may have contributed to our findings that outcomes did not vary for sexual minority compared to heterosexual individuals. First, the geographical and political context of our program’s New England location outside of a major city may have facilitated greater comfort and fluency among some participants and providers in having discussions around marginalized identities, including sexual orientation. Nonetheless, this sociocultural context cannot be generalized to assume similar attitudes among all clinicians or programs, nor does the context necessarily indicate that clinicians will demonstrate awareness of microaggressions or will integrate considerations around participants’ identities into their clinical work.

Within our program, several clinicians were involved in diversity, equity, and inclusion efforts through our IRT program, hospital, and professional organizations to more proactively affirm participants’ identities and understand related experiences of stigma or discrimination. For example, we have revamped our demographic forms, created opportunities for sharing pronouns, and incorporated a treatment group focused on the intersection of sociocultural identities and mental health. Although not possible to discern the impact of this context on the results from the current study, it may be that the specific factors associated with our program and its location attenuated treatment outcome disparities for individuals with minoritized identities as has been found in previous literature (Pinciotti et al., 2022; Williams et al., 2015).

Limitations

There were several limitations in this study. First, a major limitation was that our analyses were underpowered due to the size of our sexual minority sample (n = 34). As a product of conducting research in a naturalistic setting, we are not able to recruit individuals based on sexual orientation. Thus, our sample depends on both sexual minorities engaging in the program and each individual’s level of comfort in self-disclosing marginalized identities (such as sexual orientation) during treatment. Given that many studies of sexual orientation may face difficulties with achieving adequate power in naturalistic settings, we emphasize that further replication studies are crucial to increase confidence in observed findings and to close the research gap.

Second, the sample was predominantly non-Hispanic White, holding a bachelor’s degree or some level of college experience, which is not generalizable to all individuals with an OCRD. Important factors such as race and ethnicity may affect how OCD symptoms are experienced (Williams et al., 2017; Wu & Wyman, 2016), and individuals with greater number of marginalized identities may have more severe OCD symptoms (Wadsworth et al., 2020). As such, replication of these results is required in more diverse samples. Third, the majority of our measures were self-reported; other sources of information may be valuable to examine in future studies. Moreover, measures to examine specific minority stress related to sexual minority status were not administered, so we were unable to examine potential risk factors that may be connected to poorer treatment outcomes in sexual minorities.

Fourth, our sample exclusively includes individuals who can take the time away from work or family obligations to attend an intensive treatment facility. Barriers to treatment exist in marginalized communities, especially among sexual minorities (Whaibeh et al., 2020). As such, our results might not be capturing a representative sample among those who are employed or have other obligations at home.

Fifth, our sample is unique in its clinical characteristics, where participants may be in a re-admission to our program, remaining treatment refractory and presenting with many comorbid conditions. Therefore, the findings in this paper may not translate to lower levels of care (outpatient treatment) or other forms of therapeutic intervention for sexual minorities with OCD. Lastly, this study did not examine participants identifying as gender minorities because we did not initially include questions that appropriately allow people to endorse non-cisgender identities.

Future Directions

Future research on treatment outcomes should focus on both sexual orientation and gender minorities and examine subgroups within sexual minorities (e.g., bisexual, pansexual, lesbian) and gender minorities (e.g., gender non-conforming, agender) to identify if there are differences between subgroups, an analysis we could not run with such few individuals in each category. Specifically, past findings have highlighted that individuals who identify as bisexual experience increased structural and interpersonal stigma (Feinstein & Dyer, 2017), are more likely to meet criteria for a substance use disorder (Batchelder et al., 2021), have an increased risk for mood and anxiety conditions (Bostwick et al., 2010), and experience worse treatment outcomes in a psychiatric hospital setting compared to other sexual minorities (Beard et al., 2017). Given these mental health inequities, it is important to examine potential treatment outcome differences in bisexual individuals compared to other sexual minorities.

A major takeaway in examining treatment outcomes, is that while on a descriptive level there were slight differences in OCD severity, depression and distress tolerance at admission, these differences seemed to dissipate over treatment. Our results suggest that IRT is equally effective regardless of sexual orientation in improving symptoms related to OCD severity, distress tolerance and depression, while sexual minorities may enter the program with slightly different levels of symptomology. Research examining SGMs should consider other measures not included in the present study that are found to be important in both the maintenance of OCRDs and sexual minorities, such as guilt, shame and anxiety symptoms. Important factors which were not examined in this study but may add to our understanding of care could include treatment acceptability, credibility and qualitative feedback about experiences of treatment by examining treatment evaluations.

Continuing to fill the gap of literature around treatment outcomes of SGMs and OCD with more diverse populations will hopefully elucidate why health disparities occur, how to better improve experiences in treatment, and what mechanisms may be responsible for these differences. While we group individuals into broad categories it is crucial to remain cognizant that individuals in these groups may have little in common except the stigma forced on them through heterosexism/transphobia; therefore, it is important for clinicians to develop culturally responsive, individualized treatment plans. Learning more about the impacts of heterosexism/transphobia on mental health and OCD is imperative for clinicians to practice best care for each participant, as the goal of research should be to inform and improve clinical care.

Conclusions

The present study was the first to examine how treatment outcomes may differ between sexual minorities and heterosexual individuals in an IRT program for individuals primarily diagnosed with OCRDs. OCD severity, distress tolerance, and depression were measured at admission and discharge. To extend past findings on the predictiveness of the first four weeks of treatment on outcomes, OCD severity was analyzed at these timepoints. Although non-significant, findings suggested that at admission sexual minorities experience slightly worse levels of symptomology, however, these differences dissipated by program discharge, where outcomes were comparable regardless of sexual orientation. Future replication in naturalistic settings is needed, as our results were underpowered, along with more diverse samples (e.g., race/ethnicity).

Acknowledgements:

We thank the past research assistants at the OCD Institute for assistance in study preparation and running participants from 2018 to 2020; including Kara Kelly, Sriramya Potluri, and Alexandra Hernandez-Vallant. We also thank Jason Krompinger and Diane Davey for their contributions to the development and ongoing support of the OCD Institute’s research program.

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