There are no boundaries or limits to what obsessive-compulsive disorder chooses to torment a person with. Obsessional themes can range from a fear of getting sick to violence, sexual identity, religion and more. Nothing is off-limits to OCD. So, it’s no surprise that OCD can also instill doubt and uncertainty when it comes to a person’s gender identity. This is what has been termed transgender OCD (TOCD). While it is commonly known as TOCD, a more accurate description may be Gender Identity OCD (GOCD).
People with TOCD are focused on trying to know for sure whether their thoughts are a sign of an underlying, unrecognized desire to transition their gender presentation. Like other forms of OCD, it is the inability to tolerate uncertainty — not simply the idea that a person might be transgender — that creates anxiety and drives the disorder.
As the idea of transitioning away from your gender assigned at birth has entered mainstream public discourse, there has also been a rise in reports of TOCD. Hearing about transgender people in the media or at school may cause someone to question their own gender identity, which is perfectly healthy and for some may lead to a fulfilling and appropriate gender transition. For many people, it’s a fleeting thought that disappears. But for people with TOCD (also referred to as GOCD), that momentary doubt can snowball into an ever-deepening cycle of obsessions and compulsions, as the person gets caught up in a circle of doubt and wondering that in reality has little to do with their true gender identity.
Transgender OCD is a subtype of OCD in which a person obsesses over their gender identity. These intrusive thoughts cause the person significant amounts of anxiety and uncertainty, which they desperately try to relieve with compulsive behaviors such as emotional checking, memory review, reassurance-seeking and researching. It is important to note that TOCD is not the same thing as gender dysphoria, which transgender people often experience.
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Despite their attempts to gain certainty over their gender identity, people with TOCD remain plagued with doubt and fear, which in turn prompts more intrusive thoughts and compulsions. This downward spiral can eventually take over a person’s life, resulting in impairment in both social and occupational functioning as well as other mental health problems such as depression, substance abuse and suicide.
Example of Transgender OCD: James questions his gender identity after seeing a childhood photo of himself dressed as a girl.
James is a 24-year-old heterosexual male. James has identified as a male for his entire life and never questioned it before.
He was recently flipping through old photographs when he noticed a particular childhood photo of himself dressed up as a girl one year for Halloween. He then experienced an intrusive thought: “What if I’m actually a female?” James felt a sudden paralyzing fear shoot through his body. His thoughts began to race. “What if I have been living a lie? How do I know for sure I’m male? What if I have to tell my family and friends? What if I never know for sure?” James is overcome with fear and uncertainty. He attempts to suppress his thoughts, only to realize that they increase in frequency over the next few days. “I have to figure this out,” he thinks to himself.
Over the next several weeks he compulsively engages in various attempts to find certainty and proof of his gender identity. He repetitively tests and checks his emotional responses to certain thoughts and images. In several instances, he puts on women’s clothing and checks to see how he feels in them. He spends hours poring over transgender forums seeking reassurance by comparing his thoughts and feelings to those who are transgender. He frequently imagines himself as a woman and checks to see if it feels better or worse than being a man. He takes several online gender identity quizzes, which give him varying results. Despite this compulsive research, James can’t find the certainty he is looking for, and he grows more and more desperate to find the answer.
As his obsessional thoughts increase in severity and frequency, he finds himself having a difficult time focusing at work and engaging with his friends and family. He is plagued with the fear that he will never know for sure whether he is truly male or female.
Gender dysphoria is the significant distress a person may feel when their gender identity does not match their gender as assigned at birth. People who experience gender dysphoria often identify as transgender, and they may take steps to transition, which may alleviate the discomfort they feel about their gender. But gender dysphoria and TOCD are very different, with different root causes and treatments, and it’s important to understand the distinction.
There are several points that may help differentiate between gender dysphoria and Transgender OCD.
One primary difference is that people with TOCD don’t have a longstanding history of questioning their gender identity. Instead, they often report that the fear was triggered suddenly and in response to a specific event, such as James seeing the old photo in the example above.
Secondly, with further assessment, it is frequently found that those with TOCD have a history of obsessions and compulsions, and may have experienced other OCD subtypes. While obsessing over gender identity in particular may be new, these people often have prior experience with the symptoms of OCD.
Third, those with TOCD are often more focused and anxious about the uncertainty of their gender than about any actual feelings of distress related to their gender. In other words, they don’t find distress in their gender. Instead, people with TOCD find distress in not being able to prove with 100% certainty that they are accurate in their gender identity.
TOCD is not unique to those who are cisgender. Just as those who are cisgender can have obsessions about being transgender, those who are transgender can obsess that they are cisgender. The fear is not that cisgender or transgender is wrong or bad, in fact, it really has nothing to do with gender at all. While the actual core fears can vary from person to person, they typically revolve around three central themes: 1. What if I am not who I have always thought I was? What if I have been living a lie? 2. How will this cause pain and suffering to those closest to me? 3. What if I never find certainty around my true identity and suffer in endless misery as a result?
All types of OCD include obsessions and compulsions. Obsessions are unwanted and intrusive thoughts, feelings, urges and doubts, while compulsions are repetitive physical or mental actions performed in an attempt to relieve distress and anxiety.
People with TOCD become preoccupied with fear and doubt over their gender identity. They can spend hours dwelling on these fears. Common obsessions include:
In response to these fears, people with TOCD engage in various compulsions in the hope of reducing anxiety and obtaining certainty regarding their gender identity. Common compulsions include:
The fear and uncertainty experienced by someone with TOCD don’t just go away once they perform their compulsions. As with all OCD themes, the compulsive attempts to reduce anxiety are not effective long-term solutions. Obsessive thoughts are recurrent, coming back over and over again. The more the obsession-compulsion cycle is repeated, the more frequent and intense a person’s OCD can become.
It’s common that someone with TOCD would experience difficulty in both occupational and social areas of functioning. As they are preoccupied with obsessions and compulsions, they find it difficult to focus on anything else.
There is evidence documenting the correlation between OCD and major depressive disorder. Research suggests that major depressive disorder is 10 times more prevalent in those with OCD than in the general population. It is also estimated that over 25% of those who seek treatment for OCD also meet the criteria of a substance use disorder. Drugs and alcohol are often used as a way to cope with the overwhelming anxiety and fear.
As with all themes of OCD, both therapy and medications have been proven to be effective in treating and reducing the symptoms. A specific form of Cognitive Behavioral Therapy called Exposure and Response Prevention (ERP) is the recommended treatment for all types of OCD, including TOCD. This evidenced-based treatment has been shown to be effective in over 80% of patients. When combined with ERP, antidepressants, particularly SRIs, have also been effective in reducing the symptoms,
ERP involves systematically exposing a person to their obsessive thoughts while assisting them to resist the urge to perform the familiar compulsions. This allows the person to learn that their anxiety will come down on its own and that the compulsive behaviors are not necessary.
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In the case of TOCD, ERP therapy would focus on gradually exposing patients to the various fears and uncertainties around their gender identity. For example, a patient may be asked to watch various media on the subject of gender while resisting the urge to check how they feel. Or a patient may be asked to write a story about what it would feel like to never be certain about their own gender or to come out to their family as transgender. The patient would then read the story over and over throughout the course of a week while abstaining from all compulsions.
Throughout the process of ERP, the patient’s obsessions and compulsions decrease, their anxiety improves, and the patient returns to a healthier level of living. In addition, the patient learns to accept the uncertainties of life and to better tolerate anxiety and fear.
From my personal experience treating OCD, people are shocked at how quickly they experience relief from symptoms once they start ERP therapy. If you or someone you know is dealing with any form of OCD, I encourage you to take steps to get more informed.
You can get started with personalized, face-to-face ERP therapy by scheduling a free phone call with the NOCD team.