Transgender OCD (TOCD): Symptoms, Causes, & Treatment

What Is Transgender OCD (TOCD)?

Transgender individuals have a gender identity that differs from their birth assigned sexual anatomy.⁶ In transgender OCD, also known as gender identity OCD, the central theme of obsessions and compulsions are questions and doubts about one’s gender identity.^1,2

These doubts lead to intense distress and anxiety, with many feeling an urgent need to understand their true identity so they can move forward with their lives. Excessive researching, reassurance seeking, or ‘checking’ themselves are some of the common compulsive behaviors those with transgender OCD engage in to cope.^2,3,4

Transgender OCD Vs. Gender Dysphoria

Transgender OCD symptoms can mimic some of those associated with gender dysphoria, which can make it hard to differentiate between the two. This has led to concerns about misdiagnosis in people who present with either condition, especially because OCD is one of the most commonly misdiagnosed mental illnesses.^1,3,8

Important differences between gender dysphoria and transgender OCD include:^1,2,3,6,8

• History of gender dysphoria: People with gender dysphoria often report having inner conflicts with their gender identity since childhood. Conversely, transgender OCD concerns often arise suddenly and without a long history of gender-incongruent thoughts, feelings, and experiences.
• History of OCD: It’s common for people with OCD to develop different OCD subtypes throughout their lives. An existing diagnosis of OCD without any history of gender identity issues may indicate a person is struggling with transgender OCD as opposed to gender dysphoria.
• Doubt vs. conviction: People with transgender OCD experience excessive doubts and questioning of their gender identity, whereas people with gender dysphoria are more likely to have a strong sense of conviction about their gender identity.
• Distress vs. desire: People with transgender OCD are highly distressed, anxious, or concerned about whether or not they’re transgender. Those who experience gender dysphoria tend to report feeling a desire to identify as another gender.
• Confusion vs. certainty: People with both transgender OCD and gender dysphoria may explore different gender identities. However, these experiences tend to make people with OCD feel less certain and people with gender dysphoria more certain about their gender identity.

Symptoms of Transgender OCD

The two primary symptoms of OCD include frequent obsessions and compulsions that interfere with a person’s ability to function. Obsessions are repeated, intrusive thoughts that a person fixates on, while compulsions are ritualistic behaviors or mental acts used to reduce the anxiety caused by obsessions.⁶ For people with transgender OCD, obsessions usually involve questioning their gender identity; compulsions are a response to these questions.^1,2,3

Below are some examples of obsessions that people with transgender OCD may have:^1,3,4,8,9

• Questioning one’s gender identity, even in the absence of other signs. For example, asking oneself, “What if I’m trans?” or “How do I know if I am actually the gender I think I am?”
• Excessive worry about being trans based on a belief that would mean seeking surgery to change their sexual anatomy.
• Interpreting everything as a possible ‘sign’ or ‘clue’ that they aren’t actually the gender identity they think (i.e. musical preferences, hobbies, facial features, etc.).
• Repeated thoughts about finding out they’re transgender after they’re already married, committed to someone, or have had children.
• Thinking that everything about them (traits, preferences, personality, etc.) might have been based on a lie or false assumption of their gender.
• Rehearsing imaginary conversations with friends, family members or other people where they reveal to them that they’re transgender and try to guess their reactions.

Below are some examples of common transgender OCD compulsions:^1,2,3,4,8,9

• Doing excessive research online about the signs of gender dysphoria or being transgender.
• Needing to recount and rehash old memories to try to find proof or evidence of gender dysphoria in their past.
• Seeking reassurance from other people about their observations or opinions about whether or not they’re a certain gender.
• Scheduling appointments or consultations with doctors, therapists, or other clinicians who specialize in gender dysphoria to determine if they have it.
• Experimenting with their gender identity by changing the way they talk, dress, or behave in order to see how they feel or identify if they’re transgender.
• Avoiding any triggers and situations that remind them of gender dysphoria or the doubts they have about their gender identity.

Research on Transgender OCD

More information is still needed to fully understand transgender OCD. Research has not been conducted on large groups of individuals with this OCD subtype, and there are also no known studies regarding its prevalence.^1,2,3,8 The closest subtype that has received more clinical attention is sexual orientation OCD (aka homosexual OCD), which involves obsessions with the idea that one may be gay.

While sex, sexuality, and gender seem to be relevant to transgender OCD, most experts believe that these are not the core fears or root issues causing the disorder. Instead, excessive self-doubt and questions about identity tend to drive sexual orientation OCD and also transgender OCD subtypes. These subtypes can be experienced by people of any gender, sexual orientation, and belief system.^1,2,3,8

What Causes Transgender OCD?

All forms of OCD are believed to be caused by a combination of factors, including a person’s genetic make-up, life experiences, and individual psychological factors. Certain personality traits such as neuroticism, perfectionistic tendencies, or cautiousness are also linked to higher rates of OCD. In people who are predisposed, OCD symptoms are sometimes triggered by a major stressful life event or transition.⁹

Less is known about the specific causes of transgender OCD. Often, people with OCD develop a number of different subtypes throughout their lives, without any apparent reason or explanation.⁷ For example, hearing someone talk about their gender identity may trigger initial doubts and questions that may manifest into transgender OCD symptoms.

How Is Transgender OCD Diagnosed?

Obsessive compulsive disorder can only be diagnosed by a licensed mental health or medical provider who has the necessary education and license to do so. For many, this may include reaching out to a psychologist, psychiatrist, or therapist.^4,9 A diagnosis is typically given during the first intake appointment with a provider who is designated to assess a person’s mental health symptoms.

It’s important to note that OCD is a specialized area of mental health, so finding a provider who has received special training or experience in the disorder is important. OCD is one of the most commonly misdiagnosed types of mental illness, and transgender OCD may be especially likely to be mistaken for gender dysphoria or another condition.^1,2,3,5 OCD subtypes are not recognized as distinct diagnoses, so someone with transgender OCD, harm OCD, or symmetry OCD would all receive the same diagnosis.^6,7

Transgender OCD Treatment

OCD is one of the most debilitating forms of mental illness, but it is also highly treatable. The condition can be treated using therapy or a combination of medication and therapy.^4,5,8,9,10 However, there are certain approaches that are more widely used than others.

Therapy for OCD

Therapy is often a frontline treatment for OCD that is recommended before a person is prescribed medication. Certain types of therapy have been studied and proven to help reduce the symptoms of people with OCD.

If you or a loved one suspects you’re struggling with transgender OCD, it’s a good idea to seek professional treatment from a therapist or other mental health professional. Finding a therapist who specializes in OCD is important, and will help to ensure you receive the proper diagnosis and treatment. Many people begin their search for a provider by using an online therapist directory that allows them to narrow their search by location, insurance type, and specialization.

Therapy options for OCD may include:¹⁰

• Exposure and response prevention (ERP): ERP involves helping people gradually expose themselves to fears and triggers that they normally avoid without relying on compulsive behaviors to cope. Over time, ERP can help people recondition their responses to obsessive thoughts and anxiety.
• Cognitive behavioral therapy (CBT): CBT for OCD is one of the most commonly used types of therapy in this case. It works by teaching clients to change unhelpful thoughts and behaviors that are worsening their symptoms.
• Acceptance and commitment therapy (ACT): ACT is a third wave behavior therapy that teaches people how to use mindfulness and acceptance strategies to respond to difficult thoughts and feelings differently. It also encourages people to accept anxiety as it occurs, rather than try to stop, fight, or control it.

Medication for OCD

People diagnosed with OCD often experience a lot of distress and anxiety related to their obsessive thoughts and compulsions. Some people are able to manage their symptoms with therapy alone, while others may consider adding medication to their treatment plan.

Some commonly prescribed medications for OCD include:^4,5,7,9)

• Antidepressants: SSRI antidepressants* are sometimes prescribed to people who struggle with OCD, and can help to target some of the associated anxiety and mood disturbances.
• Antipsychotics: Antipsychotic medications are sometimes prescribed to reduce intrusive thoughts and obsessions.
• Benzodiazepines: Benzodiazepines** may be prescribed to help people with OCD manage symptoms of intense anxiety or panic attacks. However, these are usually only prescribed short term or on an ‘as-needed’ (PRN) basis because of their addictive potential.

*This medication has a black box warning, the most serious kind of warning from the FDA for a risk of suicidal thoughts and behaviors in certain people. You should talk with your doctor about these risks before starting this medication.

** This medication has black box warnings, the most serious kind of warnings from the FDA for abuse or misuse, risk of physical dependence and risk of serious side effects, including death, when combined with an opioid.

10 Tips for Coping With Transgender OCD

In addition to seeking professional treatment for transgender OCD, there are also some things you can do on your own to improve symptoms. Using healthy coping mechanisms is essential for OCD recovery, and can help to ensure that symptoms don’t become more debilitating over time.

Below are 10 tips on how to cope with transgender OCD symptoms:

1. Name Your OCD ‘Thought Loops’

Many people with transgender OCD may find that their obsessions usually have similar themes and plotlines, making it easy to categorize them.⁷ Naming specific thought loops can help you quickly identify obsessive thoughts, making it easier to interrupt them early on.

Here are some examples of possible gender identity OCD thought loops:

• The “Am I/Am I Not?” loop for endless questions about gender identity.
• The “What if…” loop for obsessive thoughts about becoming trans later in life.
• The “Boy/Girl” loop for the listing of childhood traits or experiences that could indicate gender identity or dysphoria.
• The “Coming Out” loop for rehearsing possible conversations about coming out as trans to others.

2. Refocus Your Attention

Attention can be thought of as a form of food for thoughts–thoughts you give the most attention to are usually the ones that grow bigger and stronger. Keep this in mind and work on distracting yourself from obsessive thoughts, doubts, and worries when they pop into your mind. Instead, focus on more helpful thoughts that enhance your quality of life.

3. Do Things That Bring You Joy

People with OCD tend to devote too much of their time and energy to their obsessive thoughts and fears. This often worsens their symptoms over time, while also limiting their engagement with the people, activities, and things that matter most to them. Reverse this by being more intentional about doing the things you love, value, and enjoy.

4. Leave Your Comfort Zone

A person may cope with their transgender OCD by avoiding people, places, and situations that make them feel uncomfortable or triggered. This only lowers their confidence in their ability to overcome their fears. For this reason, it’s actually healthy to push yourself outside of your comfort zone, especially if you’re prone to avoidance coping.

Here are some simple examples of ways to get out of your comfort zone:

• Spark up a conversation with a stranger, neighbor, or someone new at work.
• If you work from home, try working from a library or café once a week.
• Make a weekly habit of cooking a new recipe or trying a new food.
• Take a different way home or drive across town to a different store.
• Sign up for a class, workshop, or social activity to try something new.

5. Use Grounding Techniques

When you push yourself outside of your comfort zone, you may find that your anxiety worsens before it improves. This is normal and an expected part of exposure therapy. One of the best ways to cope with these feelings is to use grounding techniques, which involve focusing fully on one or more of your five senses to become more mindful, present, and aware of your surroundings.

6. Begin a Mindfulness Routine

Mindfulness is a proven strategy that can help reduce stress, anxiety, and improve mental wellbeing, making it a great addition to your self-care routine. Mindfulness is the practice of becoming more present in the here-and-now, rather than being distracted by tasks or thoughts in your mind. Practicing mindfulness for your anxiety has never been easier because of how many great guided meditations and free mindfulness apps are available.

7. Use ‘Urge Surfing’ to Avoid Acting on Compulsions

Urge surfing is the practice of learning how to observe and experience an urge without acting on it. One of the best ways to do this is to visualize the urge (in this case, a compulsion) as a wave that’s rising up inside of you. Use this image to track the urge as it rises, crests, and subsides. This simple exercise takes most people only a minute or so to complete, and can help those with transgender OCD avoid acting on compulsive urges.

8. Surrender to the Things You Cannot Control

People with OCD often struggle with wanting, needing, and trying to control things that are out of their hands. This includes events that have already happened, haven’t happened yet, and even ones that may never happen. Making a list of things within and outside of your control is a good way to identify which ones are worth changing and which you need to just surrender to.

9. Channel Anxious Energy Into Healthy Outlets

Anxiety is a high energy emotion that tends to make people feel restless, edgy, and jittery.⁶ Finding a positive outlet for this nervous energy is helpful to a lot of people who have high levels of stress and anxiety, including people with transgender OCD.

Anxiety can be channeled into positive outlets such as:

• Creative outlets like writing, painting, designing, or crafting.
• Physical outlets like exercise, dancing, running, or cycling.
• Social outlets like activities and events with friends and family.

10. Work on Rebuilding Trust With Yourself

People with OCD often struggle with debilitating levels of self-doubt, and their compulsions tend to worsen this.² Working to recover from OCD involves rebuilding trust in yourself, your perception, and your abilities. Doing so will help you feel less anxious and more in control.

Here are some ways to rebuild trust with yourself if you struggle with OCD:

• Resist urges to ask for the opinions or advice of others before making decisions.
• Trusting your ability to handle tough or difficult situations.
• Don’t rehearse or over-prepare for things you know how to do.
• Not rehashing past interactions and experiences to try to prove or disprove something about yourself.

Final Thoughts

People with transgender OCD have persistent doubts about their gender identity that they obsess over. It is important to remember that OCD is treatable and responds well to therapy, which may be combined with medication to help people manage or overcome their symptoms.^4,5,7,9,10