Dr. Olson: The book, published last year, is called Finally Out: Letting Go of Living Straight, A Psychiatrist’s Own Story. My transition from straight to gay began when I was 40 years old, married with two kids, and successful in my career as a psychiatrist. I fully believed that I was heterosexual. Then issues developed in the marriage, and through a series of bad or good choices, I began a relationship with a man. After I admitted to myself that I was in love with him—and with an intensity that I had not experienced previously—then I knew that I had to deal with it by coming out.

TCPR: What went through your mind as you were carrying on this affair and recognized your sexuality and yet were still in the closet and in a marriage?
Dr. Olson: One of the things that I worried about was that if I stayed married, I could not put away the attraction that I felt for men. And my reason ultimately in leaving the family was the fear that I would be publicly exposed and this would hurt them far more than my coming out would hurt them. I have always been very committed to the ideals of family and monogamy, and so these were things that were going against my real basic values. I really resisted accepting that I am gay.

TCPR: In your experience, is this a common theme with other people who are in heterosexual relationships and yet want to come out?
Dr. Olson: Absolutely. I primarily work with men, and many of them struggle with this purgatory, as I call it, of being attracted to men, but being committed to the advantages of a heterosexual life. Many of them are extremely good fathers and love their wives. What makes it more complicated for people to come out as mature men than when they are younger is that they have developed networks of relationships through work, social lives, and churches that are based on the assumption that they are heterosexual. And when you walk away from that, you may have to walk away from all of it.

TCPR: It’s taking a big risk. It almost sounds like overcoming an addiction.
Dr. Olson: It is very much the same kind of thing, having to develop a network that in many ways is totally different from the one you were in before. There is a great sense of isolation and loneliness when you are struggling with coming out and have nobody really safe to talk to. Of course, this is where the role of the therapist and the psychiatrist comes in. The psychiatrist’s office should be a safe place to explore these issues—but that is not always the case.

TCPR: How common is this? How prevalent is homosexuality in opposite-gender married couples?
Dr. Olson: It is hard to know exactly because it is such a hidden community. I think it is a little different now than it was when I came out because the Internet helps people make many connections with other people. Somewhere around 4% of all men openly identify as gay, but the number of men married to women who experience same-sex attraction may be as high as 10% (Pathela P et al, Ann Int Med 2006;145:416–425). There are some people who will tell you, “I knew I was gay when I was four years old.” But for a lot of different reasons, some like me had to figure it out much later.

TCPR: What can we as psychiatrists do to help individuals who confide that they are in heterosexual committed relationships and yet they feel that they are gay or lesbian and want to come out?
Dr. Olson: I think the first thing is to accept how painful and hopeless the struggle can seem. Co-occurring problems such as depression or alcoholism or substance abuse must be treated as is the case for every patient we see. In a good therapeutic relationship, patients tell us all kinds of secrets. What they are looking for is not just tolerance, but acceptance and some empathic understanding of what that is like. It is a complex question because I think people don’t want to be pushed to make a choice in a direction that is not right for them. They need to consider all of the potential losses and all of the potential gains, and really make a clear choice based on the reality of those possible losses and gains. I think psychiatrists need to focus on not pushing these patients into a kind of polarity—you are gay or you are not gay.

TCPR: So the patient is in your office and confides in you and then asks, “So doctor, what should I do?”
Dr. Olson: I have found that the big issues always come down to family and religion. Those are the ones that most men are going to struggle with and I presume women, too. How are you raised and what were the values you were taught? How does that put you at odds with your belief in your god? Then, how can you either continue being an active parent if you already have a family or, if you are young, begin a family with a gay partner? A lot of homosexual men want to have the experience of being a parent. These are very heavy questions and those that your patients will most likely need to talk to you about if you are doing any type of psychotherapy in your practice. Finally, their own beliefs in the stereotypes about gay people must be confronted. The psychiatrist can be very helpful by encouraging them to meet a diverse group of other gay people.

TCPR: Are there other issues and concerns—depression, substance abuse, or other psychiatric comorbidities&mash;we need to be aware of in these patients?
Dr. Olson: The biggest of course is suicide. There is no good research because it’s such a hidden population, but we know the risks for men in middle age are very high. I think the issue here is for every psychiatrist to consider that a conflict about sexual orientation might be part of the problem when somebody feels hopeless and helpless in his or her life or struggles with issues of alcohol or drugs. Another issue that the psychiatrist needs to address is whether people who are experiencing same sex attractions are practicing safe sex. If patients are having illicit sex with people who may have multiple partners, there is an enormous risk for HIV. The CDC estimates that the rate of new HIV diagnoses among men who have sex with men (MSM) is more than 44 times that of other men. Men who have clandestine sex often do not use protection or access preventive services.

TCPR: If you suspect your patient has a conflict about sexual orientation what are some of the sensitive ways of bringing this up?
Dr. Olson: Well, I would say that one of the ways you shouldn’t do it is to say, “Do you think you might be gay?” A more sensitive and less threatening way is to ask, “Have you experienced sexual attraction to someone of the same sex? Have you engaged in sex with a same-sex partner?” You can normalize the question by saying, “Ten percent of adult men have had a sexual relationship with another man to the point of orgasm.” That puts it in a safe context, but I would again just emphasize if you say the word gay that is going to be very threatening to a lot of people who are still questioning their sexual identity.

TCPR: You recommend not asking patients, “Are you gay?” or saying, “You are gay.” Why is this?
Dr. Olson: A lot of people who have just come out resist being labeled gay even though they may think they might be. They resist that label because it carries so much baggage, so many stereotypes, with it. In my experience, men tend to move toward becoming more openly homosexual over time, more comfortable in that progression, while women have greater likelihood of moving back and forth, perhaps labeling themselves as bisexual (which may be the case for some men as well). Lisa M. Diamond wrote about this in Sexual Fluidity: Understanding Women’s Love and Desire.

TCPR: The other side of the picture is the spouse and the children of people who have come out. If we have patients in these situations, what sort of stages would we expect them to be going through?
Dr. Olson: A gay person often has struggled with the decision to come out for many years. However, resolving that conflict for himself may turn the world upside down for his wife and children, who are just beginning the process. Many spouses of people who come out tend to blame themselves and think, “If I had been a better sexual partner, if I had been a better spouse, this would have never happened.” There are resources available to get some good information about what it is like to be caught in that situation. One is a book, The Other Side of the Closet, by Amity Pierce Buxton, who founded “The Straight Spouse Network.” Carol Grever wrote When Your Spouse Comes Out: A Straight Mate’s Recovery Manual; she blogs at “The Straight Spouse Connection.” There is also a support group for children of LGBT parents who have come out called “COLAGE” (www.colage.org).

TCPR: You spoke about the particular struggles of older people coming out. What about our younger patients? What are their particular struggles?
Dr. Olson: I think they experience a great fear of loss. First of all, there is the possible loss of their parents. There is the loss of the heterosexual ideal for your life—for example, the fear of never having children or a long term relationship. For many people there is a struggle against religious values.

TCPR: Thank you Dr. Olson.