It is not unusual for patients to seek consultation with psychiatrists and other mental health professionals with questions about their sexuality. These questions can arise irrespective of age, gender, and actual sexual practices. They come up in people who are single—and even in those in heterosexual marriages with children. What follows are some useful definitions and clinical examples for therapists who wish to address these patient concerns.
First, it is important to distinguish between sexual orientation, sexual identity, and sexual behavior. A sexual orientation is a person’s erotic response tendency or sexual attractions, be they aimed at individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual). Sex researchers call exclusive homosexual attractions a “Kinsey 6” and exclusive heterosexual attractions a “Kinsey 0.” Someone who is equally attracted to men and women is a Kinsey 3.
A sexual identity—sometimes referred to as a sexual orientation identity—refers to the subjective experiences of one’s own sexual desires, attractions, or behaviors. Sexual behavior is a descriptive term that does not account for motivation or identity. For example, the CDC tracks HIV infections using the behavioral definition of men who have sex with men (MSM) because not all MSM identify as gay.
Consider the case of Bob, a 35-year-old heterosexual married father of 4. He sought consultation because, in recent months, he had become increasingly sexually and emotionally involved with another heterosexual married man. Their wives were unaware of the relationship as the 2 men had met on a social media app. Nor were they likely to as the heterosexual couples were not close in age and traveled in very different social circles.
Bob reported fleeting, anonymous homosexual encounters since age 15 and then throughout his marriage of many years. While he and his wife were no longer sexually active, he wished to preserve their marriage and keep his family intact. Thus, he became distressed a year before the consultation when he began to think he might be “bisexual.” He was seeking professional help because he was obsessing about the other man, which made him think “I might be gay.” When asked how he had previously understood his many years of having sex with men, he sheepishly replied, “I thought I was just fooling around.”
Behaviorally, Bob had been bisexual because he was having sex with men at the same time he was having sexual relations with his wife. It was possible he had a bisexual orientation if he was aroused by the idea of having sex with both men and women. However, he readily admitted at the consultation that he had always thought about men when having sex with his wife or even when masturbating.
Is Bob gay? Not really. A gay identity usually requires some level of acceptance of one’s homosexual attractions and fantasies. Bob was in a state of panic because he was not accepting those feelings as part of his identity. How might one think about Bob’s sexual 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.