Transgender OCD: A New Theme Following a Familiar Pattern

April 6, 2020

This post originally appeared on the website of the Anxiety and Depression Association of America

In the early 2000s, patients started reporting a new worry to their OCD therapists: what if I’m gay? This thought was often prefaced by patients declaring that they weren’t homophobic, but the fear was still there. The theme was dubbed homosexual OCD or HOCD. However, around that the same time, patients who were gay had a very similar fear: what if I’m actually straight? The issue of sexual orientation creeping into OCD is a sign of the ever-evolving societal environment. As such, it’s not surprising that a new twist on a common OCD theme is finding its way into the minds of some patients: what if I’m transgender? Conversely, people who are transgender might worry about being cisgender, or identifying with the gender identified at birth.

Over the past decade, issues involving the transgender community have established an increasing presence in media and the political arena. From watching the gender transition of Caitlin Jenner, to laws regarding the use of public restrooms, it seems impossible to avoid these issues. The first references to transgender OCD appeared only in 2015, and there’s still little information about it online. However, because of the similarities to sexual orientation OCD (and to OCD in general), the thoughts, anxiety, and treatment follow a familiar route. 

Like sexual orientation OCD, this fear has nothing to do with a person hating, disliking, or being afraid of people who are gay or transgender. Typically, there are two primary concerns. One is the idea of being someone other than who they believe their true self to be. It’s not that being transgender is wrong or bad; it just doesn’t feel to the individual like that’s who they are. The other concern involves loved ones. With sexual orientation OCD, it’s common for people in relationships to worry that they’ll have to break up with their significant other, hurting that person and destroying the life they’ve built together. Additionally, some are worried about how “coming out” might result in rejection from others. For anyone – with or without OCD – the thought of life being flipped upside-down is scary and overwhelming.

Gender dysphoria – the diagnosis associated with being transgender – requires two of the following six criteria according to DSM-5: 1) a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics, 2) a strong desire to be rid of one’s primary and/or secondary sex characteristics, 3) a strong desire for the primary and/or secondary sex characteristics of the other gender, 4) a strong desire to be of the other gender, 5) a strong desire to be treated as the other gender, and 6) a strong conviction that one has the typical feelings and reactions of the other gender. The overarching theme is that people with gender dysphoria don’t feel comfortable as their birth gender. The desire to be a different gender presents more as a need than a want, because their body and brain don’t feel right in the gender package they received at birth. The idea of being the opposite gender seems natural, and there’s a drive and desire to transition. Conversely, people with transgender OCD are disturbed, upset, and fearful of those thoughts.

Common rituals include doing research online, asking people in the transgender community if their thoughts sound like those of someone who is trans, or trying on clothes traditionally worn by members of another gender. Treatment is the same as with any other OCD theme – exposure and response prevention (ERP). Although patients often can articulate their personal triggers, which can be used to plan exposures, some general exposures include reading stories or watching videos of people talking about when they realized they were born in the wrong body, writing and reading scripts as part of imaginal exposures, and attending an LGBT+ event.

Clinicians are likely to see an uptick in cases of patients with transgender OCD beliefs, and it’s a near guarantee that as our society continues to evolve OCD will follow quickly behind.