From a colloquial perspective, Bob was “in the closet,” meaning that he was hiding his homosexual self from others. However, a psychologically closeted individual is unable to acknowledge to himself that he has homoerotic feelings and fantasies. This state of mind is often retrospectively captured in the expression, “I didn’t want to admit those feelings to myself.” This was the case with Bob, who used to think of those feelings as “fooling around.” By this he meant he had thought his homosexual interests were “normal” because a normal man seeks out any sexual outlet he can find.
As Bob’s feelings for his married friend intensified, he began shifting to a homosexually self-aware identity. He was beginning to acknowledge his homoerotic or same-sex feelings and attractions to himself. The dilemma that brought him into consultation was whether he would further integrate those feelings into his identity; and if he did, how would he do so? Therapists should not take an eventual acceptance for granted. Some homosexually self-aware persons consciously struggle against accepting same-sex attractions or relationships as part of a public identity. They adopt non-gay identities—some who tried to accept those feelings but later rejected them identify as “ex-gay.”
From this perspective, Bob could be described as having a homosexual orientation and as having engaged in bisexual behavior. At the time of the consultation he appeared to be shifting between a closeted and a homosexually self-aware identity. The outcome of Bob’s sexual identity crisis is unknown because he never returned after 2 visits.
John, on the other hand, is a patient with a more common presentation of shifting sexual identities. He was 25 years old when his primary care physician referred him for treatment of an anxiety disorder characterized by a recurrent fear of having contracted HIV. This anxiety emerged after a brief homosexual experience—John’s first—with a co-worker several months earlier after both of them had gone out drinking. Although their sexual behavior, mutual masturbation, was not high-risk for contracting HIV, the patient obsessed about being seropositive. At the time of consultation, John had undergone monthly HIV tests, all of which were negative, but none of those results assuaged his anxiety. What did help were several months of treatment, including short-term benzodiazepine use, starting an antidepressant medication, and weekly psychodynamic psychotherapy.
John had been raised in a religious tradition that condemned homosexuality, and he still attended services regularly. He had dated women and had a steady girlfriend with whom he had a sexual relationship in college—despite his religion’s objections to premarital sex. Yet after his HIV anxiety diminished, an ongoing question in psychotherapy was whether he was gay. John repeatedly asked the therapist to tell him if he was.
The therapist, however, declined. He told John it was not for him to define a patient’s sexual identity and that psychotherapy was a process in which he had to decide on his own. He told John that of the many men he treated who eventually came to identify as gay, most reported feelings of sexual attraction for other boys or men from an early age. He also mentioned studies of men who experienced shifts in their sexual orientation as adults. However, the therapist did not know whether John fit into any of these categories.
The therapist, rather than defining John’s identity for him, could help his patient tolerate the anxiety of uncertainty experienced as he sorted his identity out. At times, this involved taking a didactic approach to explain contemporary theorizing and research about human sexuality. For example, the therapist told John that one homosexual experience does not make a person gay; that development of any sexual orientation is complex; that to this day, no one knows the “causes” of either heterosexuality or homosexuality; and the aforementioned differences between behavior, orientation, and identity.
Dr. Drescher is a psychiatrist and psychoanalyst in private practice in New York City. He reports no conflicts of interest concerning the subject matter of this article.