Last summer, a new client (I’ll call him Cameron) reached out to me shortly after being discharged from an inpatient psychiatric unit. I’m a psychiatrist who works mostly with young adults in the LGBTQ community. Cameron had required hospitalization because he’d been planning his suicide so carefully that he composed his own obituary, with instructions for his funeral. A pharmacopeia of pills and even electroconvulsive therapy had scarcely put a dent into his intent to kill himself. The psychiatric unit, it should be noted, hadn’t actually offered him the safest environment; one night he’d woken up with his roommate’s penis in his mouth.
Cameron traced his decline to a few months prior, when he and his long-term boyfriend decided to open their relationship. After many years of monogamy, he was now re-entering the dating game, and it unnerved him. He became increasingly preoccupied that he would become the subject of gossip in the small, tight-knit queer enclave where he and his partner lived. And not just any gossip: He became fixated on an incident from his childhood. After years of sexual abuse by his father, he once approached a younger boy and offered a sexual favor. Though the other boy declined, Cameron never let go of his shame about what he’d tried to do. Now, with a newly open relationship, all he could think about was that terrible skeleton in his closet as he scrolled through dating apps. He felt certain it would somehow come out, and when it did, he would be blacklisted not only from dating but from polite society. To cope with his fears, he began repeatedly asking his partner for reassurance. Sometimes he’d check social media to see if the news of his youthful transgression was making public rounds. But nothing could convince him he was in the clear.
I realized the reason so many treatments for Cameron’s depression had failed (some leaving him worse off) was because its root had not been addressed. Cameron was depressed because he had OCD. The form of his OCD was not the kind you may be familiar with from TV characters like The Big Bang Theory’s Sheldon Cooper, with his classic contamination phobia, or neurotic detective Adrian Monk, who lived his life in a perpetual state of cleaning and symmetricalizing. What had taken over Cameron’s life were obsessional fears of being canceled. And this was paired with compulsive reassurance-seeking that consumed his time and exhausted those around him.
It was a little as though I was witnessing a new cultural manifestation of OCD. If germaphobia is one common expression of OCD, then it was as if cancel culture was the new invisible ubiquitous germ, and compulsively assessing one’s risk for it was the repetitive handwashing.
Over the next few months, I evaluated four other clients with a very similar picture: young queer adults torturing themselves with obsessional thinking about a sexuality-related misdeed from their remote past. They’d become overwhelmed by fears of social ruin.
Like Cameron, all had experienced traumatic events in childhood. A woman in her late 20s I’ll call Jillian told me after some probing that she carried tremendous shame about mean-girl behavior on her part at age 15, which had resulted in outing another girl. Jillian struggles to leave the house sometimes because she is so fearful of running into someone who might know about times she’s messed up in the past. She wasn’t sure she’d ever be able to forgive herself. I had to remind her what had been going on in her life at age 15: She watched her father go to prison after massive corruption at the city level had been exposed. Here was the trauma at the core of her present-day fears, an unhealed wound that reminded her every day what happens when past misdeeds come to light.
In medical school we learned that the prevalence of schizophrenia is 1 percent, and I was fascinated by the fact that this figure is perfectly consistent internationally. It’s the exact same, every single place on the globe. In the remote village in eastern Mali where I’d spent six months as a college student doing anthropology research, I knew a woman who displayed symptoms of schizophrenia. But she lives in a place where people take care of each other, and that makes her prognosis better than an American with state-of-the-art antipsychotics available to him. And it would be hard to imagine any delusional beliefs she had would be about the FBI planting a microchip in her skull. I’ve been thinking about this even though my patients have OCD, not schizophrenia. Mental health disorders have the same underlying genetic factors and neurocircuitry no matter where someone lives, but their manifestations flow directly from the patient’s cultural context. When that culture is awash with news and debate over “cancel culture,” it seems only reasonable that this is one way OCD can present.
I wondered if this is especially true for queer people, many of whom have spent long periods concealing important parts of their identity from others, living with a gnawing worry about slipping up. Many have already had painful experiences of exposure, which led to shunning and exclusion by families and religious communities. When they’re able to find chosen families in the LGBTQ community, the threat of losing that network of support—as the punishment they’ve seen coming for years—is a devastating prospect.
When I’ve spoken with colleagues, they, too, have seen cases of OCD centered on fear of cancellation. I’ll be teaming up with one of them to write a case series for an academic journal, to encourage further study of what seems to be a striking pattern. In the meanwhile, I’m left with the sadness of watching traumatized clients torture themselves because they’re convinced something they did as a child will lead to their imminent social exclusion.
As their psychiatrist, I have a set of tools, but they can also feel inadequate to the task. The gold standard for exposure and response prevention is psychotherapeutic modality for OCD, where clients are exposed to progressively more anxiety-provoking situations. When successful, this treatment will have a germaphobe licking toilets by the end of it. It’s a miracle cure if you can get buy-in, but the buy-in can be hard to get. For this variation of OCD, the client would essentially be exposed to the idea of being exposed. I had one client, a closeted gay man who compulsively looked up the age of a previous hook-up to keep making sure they were 18 at the time (the birthday remained the same every time; it didn’t matter). Hooking up with an 18-year-old while in your mid-20s isn’t the best of looks, but it also isn’t the literal or figurative crime he fears it is. I explored with him whether coming out might allow him to live more authentically—to first experience a kind of exposure that is widely embraced. I told him that his fear that his past will haunt him was essentially becoming a self-fulfilling prophecy.
I try to play this encouraging role, but most clients know that shrinks have to give “unconditional positive regard,” so it doesn’t quite mean as much. I listen to their stories and encourage them to forgive themselves for how they acted in a state of trauma, when they didn’t know any better. Either way, I try to get my clients to see themselves as so much more than what they did at their lowest, and remind them that there are people out there who will treat them with the grace we all deserve. We all have skeletons in our closets. And we could all stand to have more compassion for ourselves, and each other.