Could I Be Suffering From (TOCD) Transgender OCD?

Obsessive-compulsive disorder (OCD) has no limits or boundaries. In other words, OCD does not discriminate. Obsessions can range from a fear of being “contaminated” or “harmed” to violent intrusive thoughts and upsetting urges to be sexual with a minor (usually a child). Some obsessions involve religion, gender identity, and/or sexual orientation.

So, it is no surprise that OCD can trigger confusion, doubt, and ambiguity when it comes to a person’s gender identity. When this occurs, it is termed “transgender OCD” (TOCD). Sometimes, however, this condition is coined “gender identity OCD” (GOCD). If you have TOCD, you are likely focused on trying to accurately determine if your thoughts, urges, and fears are true signs of an unspoken and unidentified desire to “change” your gender identity.

Similar to other forms of OCD, transgender OCD or TOCD is characterized as an inability or unwillingness to accept or embrace uncertainty. It is this inability or unwillingness to do that creates an environment of stress and angst – key elements that can fuel this form of OCD. Only recently has the notion of “transitioning” or moving away from your gender assignment that you were assigned at birth, become acknowledged. In fact, researchers suggest there has been a rise in TOCD cases in recent years.

Young people who learn stories of transgender people or issues in the media, or at school or work, may begin to question their gender identity, especially if they have always felt “different” than their peers. Some use this time as a way to “explore” and form their personalities and individualities, while others use this time to become more in tune with their gender identities, which sometimes leads to a desire to transition to the opposite gender.

While for most people, this need to “self-explore” is fleeting, for others, it is a lifelong quest to become the people they were “meant to be.” This need to self-identify as the opposite gender can trigger TOCD with gender identity obsessions and compulsions. This can cause you to become caught up in a non-stop, vicious OCD cycle of stress, fear, doubt, and uncertainty at not knowing your true gender identity.

What Does Transgender Mean?

Transgender is a term that describes how a person’s gender identity may vary from the sex he or she was assigned at birth. People, who are transgendered, use a variety of different terms to describe themselves. For instance, some transgender individuals prefer to be called “trans people” or “trans males or females.” So, it is always best to refer to a transgender person by the term he or she prefers.

Also, keep in mind that transgender people may express their gender identities in a variety of ways. Some transgender people may use their clothing to express their gender identity preferences, while others may exhibit their preferences through their attitudes, speech, and/or mannerisms.

Some transgender people take male or female hormones (estrogen, testosterone, etc.) to match their gender preference, while others opt for a surgical procedure to help them achieve this change. When surgery is used to help a person transition to another sex, he or she is referred to as a “transsexual.”

Understand that most transgendered people reject the conventional meaning of gender as only “male” or “female,” opting instead to define themselves as “transgender,” “genderfluid,” “genderqueer,” “non-binary,” etc. Cross-dressers are also considered a type of “transgender.” However, it is important to keep in mind that being transgender is not linked to sexual orientation. In other words, a transgender person can be heterosexual (straight), bisexual, homosexual (gay or lesbian), asexual, pansexual, queer, polysexual, etc.

The transgender congruence scale describes the degree to which a person feels comfortable, genuine, and authentic in his or her skin and can honestly accept his or her real identity. Some transgender people may also develop gender dysphoria, and as such seek medical interventions, such as sex reassignment surgery, hormone replacement therapy, and/or counseling.

Keep in mind, however, that some transgender people may not want these medical or psychological interventions because they are costly or inaccessible, and some may not qualify for them because of a health condition.

Many transgender people face discrimination at their jobs and from society, and some are unable to access proper healthcare due to their gender identities. And, unfortunately, transgender people still do not receive the protection from discrimination and harm they deserve.

To sum it up – transgender people are unique in how they define or label their gender identities (the way they feel inside), gender statements (the way they dress, think, speak, and/or carry themselves), and sexual orientations (the people they are sexually attracted to).

Note: When a person’s assigned sex (from birth) and gender identity coincide, he or she is called “cisgender.”

What is Transgender OCD?

Transgender OCD (TOCD) is a type of OCD that causes you to “fixate on” or “obsess over” your gender identity. TOCD intrusive thoughts can cause you to experience excessive stress, fear, worry, concern, anxiety, and/or uncertainty. These thoughts can compel you to perform specific actions or engage in certain behaviors – i.e., rituals and routines – to relieve your stress and angst and to make the “voices” in your mind stop.

Some of the actions and behaviors associated with TOCD include repeatedly recalling memories, continuously evaluating your emotions, constantly seeking reassurance, avoiding people who may disapprove of your actions or behaviors, reading articles, or searching the web to ensure that there is nothing “wrong” with you.

Despite your attempts to ascertain your true gender identity, doubts, fears, and uncertainty may linger, possibly leading to intrusive thoughts (obsessions) and compulsions (rituals and routines). These upsetting thoughts and non-stop fears can cause you to spiral into a seemingly never-ending OCD cycle. The result? Social and occupation impairment, along with other mental health problems like social anxiety, depression, drug and alcohol addiction, and/or suicidal ideation.

What Are the Signs of Transgender OCD?

OCD always involves obsessions and/or compulsions. Obsessions are involuntary and unwelcomed intrusive thoughts, feelings, beliefs, urges, doubts, mental images, etc. Obsessions can lead to compulsions or rituals or routines designed to relieve the stress and anxiety associated with your upsetting or disturbing thoughts, feelings, beliefs, urges, doubts, mental images, etc.

People with TOCD can be “fixated” on gender identity fears and doubts. In fact, these individuals may spend endless hours dwelling on or worrying about these fears and doubts.

Listed below are common TOCD obsessions and compulsions:

Obsessions

• What if I am transgender?
• What if I am not the person, I thought I was?
• What if I do not really know who I am?
• How can I tell if I am really cisgender?
• How can I tell if I am really transgender?
• What would my family and friends say if they knew my true feelings about my gender identity?
• Should I break up or divorce my partner?

Compulsions (Rituals and Routines)

• Repeatedly checking your emotional responses to certain thoughts, urges, fears, doubts, mental images, and/or situations – i.e., Michael may repeatedly assess how he feels when he puts on makeup or slides on a pretty dress.
• Recalling memory to help determine one’s gender identity – i.e., Jessica constantly thinks about how she behaved during childhood – did she ever dress like a boy as a child?
• Scouring websites, forums, and blogs for proof of a certain gender identity – i.e., Bobby spends every evening looking for “signs” of his gender identity on these platforms.
• Ruminating or pondering various gender-based scenarios to “figure it out” a gender identity – i.e., Mariska cannot stop thinking about her gender identity. She is desperate to definitely know if she is one gender identity or the other.
• Avoiding certain people, places, and situations that could trigger intrusive thoughts, doubts, fears, urges, etc. – i.e., Barry refuses to go to social events for fear of how he will be perceived by others.
• Continuously seeking reassurance from those in the LGBTQ community – i.e., Beth spends the majority of her time on LGBTQ forums and sites, looking for reassurance, support, and comfort.
• Trying on clothes of the opposite gender – i.e., Matt tries on women’s clothing to see how it makes him feel while wearing them.
• Using reason to reassure yourself – i.e., Kate uses logic to reassure herself that she is a specific gender.
• Looking at old photos and asking family and friends if they ever noticed you acting opposite of your assigned gender when you were younger – or even now – i.e., Patrick experiences strong urges to revisit old photos and seek reassurance and validation from loved ones that he is who he thinks he is.
• Conducting multiple self-exams to try to determine if your body parts are “masculine” or “feminine” – i.e., Jamie constantly examines her body to determine if her shoulders are too broad or her figure too “boxy” to be a “female.”
• Re-reading articles or blogs on transgender issues – i.e., Tom spends his lunch breaks flipping through transgender magazines and reading articles and blogs to get a better understanding of what it is and how it applies to him.
• Using porn preferences and sexual arousal as a determinant of your gender identity – i.e., Heather enjoys watching BDSM porn where the “male” is dominant and the “female” is submissive. Watching men dominate women sexually arouses her, which makes her question if she relates more to males than females.
• Repeating mantras or phrases in your head when fears and doubts about your gender identity arise – i.e. When Izack becomes starts to doubt his gender identity, he repeats the following mantra 5x, “I am transgender.”
• Calling hotlines or helplines and asking the same gender-based questions over and over again – Jesse keeps calling hotlines and helplines and asking, “Do you think I may be trans?” He does this because he thinks it will help him “figure out” who he really is.
• Hiding sharp objects, like knives or razors for fear that you could impulsively harm yourself with them – i.e., castrating or removing your breast and reproductive organs, etc. i.e., – Paul is deathly afraid that he will castrate himself if he gets his hands on a sharp knife so he asked his brother to hide all of the sharp objects in his home.
• Continuously organizing, counting, touching, cleaning, and/or straightening up objects to take your mind off your gender-based doubts and fears – i.e., The only way that Patty can effectively block out her gender identity thoughts, fears, mental images, doubts, etc., is to stay busy cleaning – herself, the house, the dog, etc.

What Causes Transgender OCD?

Similar to traditional OCD, the cause of transgender OCD or TOCD, varies from person to person. Researchers suggest that OCD, regardless of the form, may be caused by biological (i.e., a chemical imbalance, faulty brain circuity, genetic abnormalities, etc.), genetics (i.e., a family history of anxiety or mood disorders), a chemical imbalance (i.e., low levels of serotonin or a serotonin deficiency), stress, depression, and/or environmental factors (i.e., poor parenting, trauma, a traumatic brain injury (TMI).

Some researchers also suggest that OCD or TOCD may be a “learned behavior,” however, most research disputes this finding.

Another possible cause of OCD or TOCD is pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). According to a 2011 study, children, who developed streptococcal infections (strep throat) may be at risk of also developing OCD or TOCD later in life.

Understand that streptococcal infections can trigger a hyper-immune response, which can cause some people to produce antibodies that cross-react with the basal ganglia, an essential brain region. More specifically, people, especially children or teens, may start to exhibit OCD or TOCD symptoms following a severe strep throat infection.

Researchers surmise that the OCD or TOCD symptoms and antibodies are your body’s way of protecting you from the infection. However, the jury is still out as to if PANDAS is a true cause of OCD or TOCD.

What Does Transgender OCD Look Like in Real-Time?

Transgender OCD or TOCD looks a lot like general OCD. People with OCD or TOCD experience many of the same signs and symptoms, such as obsessive thoughts and compulsive behaviors. The main difference between OCD and TOCD is that TOCD’s intrusive thoughts, urges, doubts, fears, worries, etc., are centered on gender identity, while general OCD involves a wide range of upsetting thoughts, fears, worries, doubts, etc.

Understand that over time, people with TOCD may voluntarily isolate or withdraw from other people, especially friends and family, out of fear of being criticized, judged, marginalized, labeled, or discriminated against. These individuals are likely to avoid family celebrations or events, birthday or holiday parties, and/or social events (i.e., concerts, non-LGBT festivals, etc.). Transgender people may feel a constant urge to seek reassurance from others that they are not another gender (i.e., cisgender).

Unfortunately, performing certain actions or engaging in specific behaviors (compulsions) typically do not cause the urges, doubts, and fears to disappear. If they do leave, it’s only temporary. Thus, researchers have concluded that performing rituals and routines are not long-term effective ways to manage OCD or TOCD symptoms. Remember, OCD or TOCD thoughts are involuntary and repetitive. Repeated OCD cycles can cause OCD or TOCD symptoms to worsen.

It is also common for someone with TOCD to experience work-related and social issues. Because people with this form of OCD are so focused on their gender identity, they have a hard time focusing on other things, such as performing school or work tasks, taking care of their children, practicing self-care, performing household duties, etc.

According to researchers, OCD, in general, is linked to clinical depression (major depressive disorder). In fact, it appears that clinical depression is 10x more common in people, who struggle with OCD or TOCD, as compared to those who do not. Moreover, approximately 25% of people with OCD or TOCD, who seek OCD treatment also meet the DSM-5 criteria for substance abuse disorder. Some people with OCD or TOCD may use drugs and/or alcohol to ease their doubts, fears, worries, stress, or anxiety.

Julie

Julie started questioning her gender identity after seeing a childhood photo of herself dressed as a boy. She is a 25-year-old heterosexual woman. She has identified as a “female” for her entire life and has never questioned her gender identity before.

Julie was recently flipping through old pictures in her family photo album and noticed a particular childhood photo of herself dressed up in baggy jeans and a loose basketball jersey. She also had a baseball hat turned to the side. This picture made her question her gender identity for the first time.

This was also the first time Julie experience an intrusive gender-based thought – “Do this picture mean that I am actually a man?” The mere thought of being something other than what she had grown up believing terrified Julie. Her mind began racing.

“What if I have been living a lie all this time?” How do I know for sure I am a female? What should I tell my family and friends? Will I ever never know for sure if I am male or female?” Julie became overwhelmed with fear, doubt, and uncertainty. She tried to suppress the terrifying thoughts by ignoring them, but that only seemed to make them worse.

Over the next few months, Julie started to compulsively engage in various attempts to collect evidence of her gender identity. She repeatedly assessed and checked her emotional reaction to her gender identity thoughts and fears. She even tried on men’s clothing at her local department store to see how wearing made her feel.

Julie also spent hours upon hours browsing transgender support groups, books, and forums. The goal of these fact-finding missions was to compare her thoughts, feelings, fears, and doubts to those of other transgender individuals. Over time, she began to envision herself as a “man,” checking to see how being a “man” would make her feel. She took numerous online gender identity assessments and surveys – which gave her mixed results.

This only made Julie more apprehensive.

But even with extensive research, Julie still felt uncertain, causing her to become more and more desperate for an answer. As her “fixation” on gender identity increased in severity and frequency, she began to have a hard time focusing on work, and interacting with her friends, family, co-workers, acquaintances, and/or even strangers. Julie was extremely afraid that she would never know for sure if she is truly male or female.

How is Transgender OCD Normally Treated?

As with all forms of OCD, including transgender OCD or TOCD, therapy and medication are usually the go-to treatments. Numerous studies indicate that a combination of antidepressants (i.e., SSRIs, SNRIs, tricyclic antidepressants, etc.) and psychotherapy yield the best results.

The most common psychotherapies used to treat OCD and TOCD are cognitive-behavioral therapy (CBT) and exposure and response prevention (ERP) therapy. OCD treatment that involves both CBT and ERP therapy appears to be over 80% effective in calming OCD and TOCD obsessions and compulsions.

ERP therapy is especially effective for OCD and TOCD symptoms because it involves gradually exposing you to your OCD triggers and obsessions (i.e., gender identity fears, doubts, worries, thoughts), while simultaneously helping them resist the temptation to engage in ritualistic behaviors (compulsions).

The goal of this therapy is to teach you how to reduce or manage your stress and anxiety, so the intrusive thoughts, urges, fears, doubts, and compulsive behaviors diminish or disappear. In other words, the purpose of ERP therapy is to help you realize and accept that compulsive behaviors are unnecessary.

In the case of TOCD, ERP therapy would mainly focus on slowly exposing you to gender identity fears and doubts. For instance, you would be asked to watch gender-related or gender-specific television shows, movies, and videos, while resisting urges to assess or analyze how you feel about them. Or, you would be asked to imagine how it would feel to never be sure of what gender you are or to come out as transgender to your friends, family, co-workers, and/or the world in general.

An OCD therapist would then ask you to document this information in a journal. During the next ERP therapy session, he or she would ask you to read what you wrote in your journal aloud and to continue to read and re-read until your next session. You would be instructed to pull out your journal whenever your gender-related doubts and fears arise. You would be instructed to do this without engaging in compulsions.

The hope is that the ERP therapy process eases your stress and anxiety, diminishes or eliminates your gender identity OCD symptoms (obsessions and compulsions), and helps you return to a healthier “OCD-free” life. At the end of therapy, you should be able to manage your fears and doubts more effectively, so you do not feel compelled to perform certain actions or engage in specific behaviors.

Most OCD and TOCD treatments also involve medications (i.e., SSRIs, SNRIs, tricyclic antidepressants). Understand, however, that a continuous pattern of gender identity issues is usually a prerequisite before beginning OCD treatment (i.e., identity-anatomy incongruence and cross-sex hormone therapy, both of which appear to be safe and effective for both general OCD and TOCD symptoms).

Self-help tools, like Impulse Therapy, an online OCD treatment course designed to treat all forms of OCD, can provide you with valuable resources, while you address your gender identity concerns, worries, thoughts, fears, doubts, and/or urges. Impulse Therapy offers expert content, online therapy, and even an OCD assessment. Other self-help tools may include practicing yoga and/or mindfulness meditation. Lifestyle changes (i.e., regular exercise, a healthy diet, proper sleep, self-care, etc.) can also help you better manage your OCD or TOCD symptoms.