What is ‘TOCD’ ? : Why Transgender Themes in Obsessive-Compulsive Disorder are on the Rise
First, let’s get one thing clear. OCD = / = handwashing. Or arranging your DVD collection alphabetically. Or keeping objects on your desk at right angles, or any other personal quirk vaguely related to tidying or cleaning. Regardless of insulting stereotypes on trashy TV shows (thanks, Channel 4!) Obsessive-Compulsive Disorder is in fact a debilitating brain disorder, one that causes near-constant unwanted, distressing, intrusive thoughts, provoking the anxious sufferer to repeatedly think/say/do a ritualistic ‘compulsion’ in a vain attempt to get rid of them.
I’m clarifying this right away, because the type of OCD I’m about to discuss is so utterly unrelated to tidying and cleaning, it might confuse you at first. If you’re unfamiliar with this disorder, you might not even initially recognise these symptoms as OCD.
Yet, OCD sufferers are experiencing this form on a daily basis. We’re seeing questions about it more and more on OCD help forums . We find people asking about it at OCD support groups. Mental health professionals are coming across patients with it. And documented cases are starting to be described and studied in peer-reviewed medical journals. It’s new, but it’s there. However, it’s currently so under-studied, and there are so many misconceptions about what OCD actually is, that this form of OCD seems to be going undiagnosed just as much as other forms of OCD (sadly, it’s common for OCD suffers to go years or even decades before being correctly diagnosed and treated). I’m talking about transgender themes in OCD. Or, as some informally nickname it, ‘TOCD’.
I want to be emphatically clear that there’s nothing wrong with questioning your gender or your sexuality. Of course it’s all right to ask questions. Of course it’s all right to explore. Of course it’s all right to conclude that your gender or sexuality are somewhere on the LGBTQI+ spectrums. There is no ideological stance or ‘hidden agenda’ in this article. I write merely as someone with a background in social sciences and OCD advocacy, who sincerely wishes to help fellow OCD sufferers.
I hope that by this article’s conclusion, the key differences between having gender or sexuality themed OCD and actually being LGBTQI+ will be clear.
If you’re unfamiliar with OCD, know that a sufferer can experience OCD thoughts about any theme. Any theme. Consider nothing off-limits, because OCD doesn’t. No matter how taboo, intimate, surreal, unbelievable or grotesque the idea, if it’s something you can doubt, it’s something that can trigger that pattern of repetitive thoughts in an OCD-predisposed mind. The commonest themes tend to involve fears of harms coming to yourself or others: fears of dangerous germs, fears of hitting someone with your car, fears that you might somehow be a rapist or child molester, fears that you might have committed a crime, fears of being punished by a deity, fears you’re suffering from some terrible health condition, fears that you don’t love your husband, fears that you’ll dive in front of a train for no reason, fears that you could somehow go crazy and kill your partner…or any variation on these (plus some other commonly-seen themes that don’t explicitly fit this model). The forms of OCD are like hideous, disturbing snowflakes. They’re all basically made of the same stuff, but each individual one is a little unique to the sufferer. That said, once you know what you’re looking for, you can still spot the distinctive pattern of the disorder a mile off. It’s the same with transgender OCD themes.
The main difference between legitimately questioning your identity and having OCD is that the thoughts won’t go away and you can never get a satisfying answer to them (even though it’s scaring you sh*tless not to have one). Let’s be clear on what we mean by ‘obsession’; by thoughts that are real, true, full-blown obsessions:
Does the thought bring with it zero pleasurable feelings, only an urgent sense of dread and anxiety? Is this thought the last thing you think of before you fall asleep and the first thing you think of as you wake up? Did the thought just ‘pop’ unpleasantly into your head one day, with little prior warning? Would you give anything for this thought to go away? Are you often missing activities or social events in favour of staying in your room to ruminate on this one thought? Are you haunted by this thought at times your brain isn’t fully occupied (i.e. taking a shower, sitting in a waiting room, standing by the pot waiting for your popcorn to pop etc?) Have you thought about this thought for hours and hours and still feel no closer to an answer? Have you written down lists, blog posts or essays of ‘PROS’ vs ‘CONS’ multiple times but only felt more doubtful after making them? Are you starting to feel other people around you are lucky and/or crazy for not worrying about this thought as much as you are? Are you unable to concentrate on quiet tasks like reading or studying, without the thought repeatedly butting in? Is the topic of your obsession something you’ve never worried about before? Are the people around you getting tired of your constantly asking them what they think of this thought? Have you drawn conclusions about this thought a million times…only to find doubtful questions pop back up thirty seconds later? Do you feel like not having a 100% certain answer to this question is unbearable? Are you even starting to have dark notions about suicide because it’s seeming like the only way you can escape this thought?
I hope it’s clear from the above description that OCD obsessions are qualitatively a difference experience from any other normal questioning or self-reflection.
And I’d know. The first time full-on OCD (mine didn’t have a transgender theme) hit me, it felt like my brain had broken. I didn’t leave the flat for months. I terrified my partner with my panic attacks and inability to focus on anything else. I barely ate; my body was skeletal. I didn’t notice or care. I ruminated instead of sleeping. I avoided all friends and family simply by default; I hadn’t even room in my mind to conceive of diary dates or birthday parties. Only the obsession mattered. I was no longer a person, but a screaming brain in a cadaver; a bipedal vehicle for propelling horrifying thoughts around. I spent 12+ hours a day, shaking from head to toe with anxiety and nausea, unwashed and incoherent in my dressing-gown on the couch, Googling for answers and compulsively writing them out. I frequently wept with fear, terrified my conclusion might mean I was a terrible person. I paced around the room, flailing, like the stereotypical madwoman, ranting my conclusions out loud in a desperate bid to make myself believe one way or the other. If you’d told me I could have mental peace in exchange for having my right arm hacked off, I’d have stuck it out and screamed at you to hurry the hell up with that axe. A normal period of self-reflection, it was not.
Again, whilst not all cases of OCD are as extreme as mine, I hope it’s clear that this went beyond ordinary questions or doubts. It doesn’t even resemble things we jokily call ‘obsessions’; a pleasurable preoccupation with a hobby, favourite movie or some actor we’ve got a crush on. I’ve had those too (trust me; most of my 2001–2004 was dedicated to rabid Lord of the Rings fandom). And I swear, OCD wasn’t them either.
Naturally, people who don’t have OCD can feel a bit hooked up on one thought sometimes too. A problem that’s bugging you. A song stuck in your head. A regret over something you’d like to change. A creep-tacular scene from a movie that burned itself onto your retinas. Experiencing this is normal and natural. Indeed, it’s sometimes overestimated, how much people who aren’t LGBTQI+ are ‘comfortable’ with their sexuality/gender. I’m not LGBTQI+, and whilst I don’t experience the severe distress or dysphoria that some do, I equally wouldn’t say I’m 100% delighted about my gender at all times. There are plenty of things about gender to feel ‘meh’ or even downright uncomfortable about! Pretty much every woman (and most men) I’ve ever met has had views about restrictive gender roles, and the gendered stereotypes people are expected to conform to. Mainstream society expecting you not to show emotions, or to wear high-heeled shoes, just because of what’s down your pants IS seriously daft. And recognizing that is ok too! Normal questioning does not automatically equate to mental illness, or to any particular gender/sexuality.
So what about the other half of the disorder — the compulsion that goes with the obsession? Well, one important (and often-forgotten) point to note is that a compulsion can be physical or mental. A sufferer may not be visibly performing actions with their hands and bodies, but can still be silently concentrating on a mental compulsion. If you’re experiencing transgender (or cisgender; both are possible) OCD themes, your compulsions may take the form of:
-Re-reading articles or blogs on transgender issues an excessive number of times
- Repeatedly mentally checking that your past actions were ‘girly’ or ‘boyish’ -Frequently asking others to reassure you that you’re trans/cis
- Frequently checking your arousal levels against different kinds of porn to ‘test’ whether you are attracted to the material you feel you should be
- Compulsively avoiding things that ‘trigger’ repetitive gender-related thoughts (e.g. tv shows, images, particular places)
- Repeating mantras in your head or under your breath when you feel doubts (e.g. ‘I’m definitely trans, I’m definitely trans’)
- Repeatedly ringing helplines or posting on online advice forums, to ask the same few questions
- ‘Cancelling out’ an intrusive, unwanted mental image of yourself as cisgender by picturing a mental image of yourself as transgender (or vice versa)
- Hiding sharp objects from yourself because you believe you could impulsively harm yourself (e.g. castrating yourself, damaging your breasts)
- Tapping, counting, touching, cleaning or straightening objects
- Checking your genitalia to ‘test’ whether you still feel the same way about it
- Repeatedly dressing up as the gender you’re obsessing about as a ‘test’
- Any other habitual action you do in response to repetitive, anxiety-provoking, intrusive thoughts
A red flag should also go up in your mind if you’ve previously been diagnosed with OCD or experienced anxieties you know, in retrospect, to be OCD.
Another point to note is that OCD sufferers are generally known for their high moral standards, sensitivity and wouldn’t-hurt-a-fly demeanour. We’re not perfect, but we tend to worry about hurting others. Often, the only thing that pushes the average OCD sufferer into a rage is forcing them to stop doing a compulsion before they’re ready. Therapy for OCD does involve stopping compulsions, but only in a gradual, controlled way. Forcing a sudden ‘cold turkey’ quit can cause skyrocketing levels of panic, and a resultant fearful rage. Therefore, a second red flag should go up in your mind if being prevented from carrying out any of the above compulsive behaviours makes you uncharacteristically angry or upset.
Again, it’s worth stressing that sometimes compulsions are compulsions because of how often you do them, not just what they are. Ringing a helpline one or twice isn’t OCD. Ringing it dozens of times a day, to ask the same few questions, whilst disguising your voice with different accents so they don’t know it’s you again, to the exclusion of your other activities, even after the helpline staff have told you to please go away, and still feeling no more sure than when you rang the first time (as OCD sufferer David Adam did) …well, you get the picture.
None of this discounts actually being trans and having OCD with an unrelated theme. It’s perfectly possible to be happily transgender and experience OCD themes about (for example) whether or not you turned the cooker off.
So, how do we know that transgender OCD is a thing in the first place? Why would anyone get OCD about this particular subject? There seem to be four main reasons:
1) OCD themes are culturally-dependent.
A Jerusalem-based study of OCD sufferers, for example, found that sufferers from ultra-orthodox Jewish communities were more likely to have religiously-themed OCD obsessions, whilst another 2005 study discovered a higher likelihood of religious obsessions in OCD sufferers from highly religious Middle-Eastern countries. By contrast, atheistic countries such as Sweden and Norway report much lower numbers of OCD sufferers with religious fears. Another analysis, on 50 Australian patients, also found that OCD themes related to fears of climate change increased in line with raised awareness of climate change in the Australian media. The ‘hot topics’ of the culture around an OCD sufferer seem to influence their OCD themes.
It’s no surprise, therefore, that as trans visibility in the media increases, OCD themes have been changing along with it.
(Note: This is most definitely not to blame the media for this issue’s increased visibility. If ‘TOCD’ sufferers hadn’t got transgendered themes, they would simply have got a different theme of OCD instead. It’s nobody’s fault. This current improved awareness about a difficult issue for which people need help, support and/or treatment can only be a good thing.)
2) Transgender OCD themes are a natural extension of OCD sexuality themes.
We already know OCD fears about sexuality are common. Particular types are so common they even have their own informal nickname within the OCD community — POCD is ‘paedophile OCD’ and HOCD is ‘homosexual OCD’. These are, respectively, an obsessive doubt that you might somehow be a paedophile, and obsessive fears/doubts around being gay or straight.
Although these OCD themes are well-documented within the medical literature, and are very familiar to psychologists and therapists , there can be confusion around them — usually from those who haven’t spoken to actual sufferers or to actual LGBTQI+ people. Misinformed people can mistakenly think that receiving therapy for homosexuality OCD themes, for example, is linked to ‘conversion therapy’. This is not the case at all. It’s praiseworthy to find the idea of gay conversion therapy repellent, and to want to distance yourself from it. But OCD treatment has zero to do with this.
OCD about sexuality is not usually due to homophobia, either. It’s especially not due to internalized homophobia, as the majority of ‘HOCD’ sufferers are actually straight — although reverse cases are also known where happily gay or bisexual individuals develop an OCD fear around the idea that they might be straight! Rose Bretecher, a suffer of homosexuality-themed OCD, writes in her biographical account of OCD that: ‘I’d always been comfortable finding women sexy, and I was passionately pro-gay rights. In my bones I believed that homophobia was sinister and anti-human, and that gay love was as natural as any other kind of love.’
The root of the fear is often the sheer incongruity of the sexual thoughts with someone’s sense of self, more than their actual content. An excellently detailed explanation of HOCD, written by a gay gentleman who also suffers from OCD, can be found on BrainPhysics.com, where two side-by-side examples are given — one of a straight male HOCD sufferer and the other of a closeted gay male with no HOCD. He asks: can you see the difference between these two? It should be clear to anyone reading these examples that the two individuals are suffering from two completely separate problems. He further writes that when he saw OCD sufferers posting on message boards with stories like the first excerpt, he knew for sure, as a gay male, that he was not dealing with other closeted gay folks here.
So let it be known: OCD obsessions about your sexuality are perfectly possible. It’s a small jump for the OCD mind to make, then, to start obsessing about the ‘T’ instead of the ‘LGB’.
3) An OCD-like disorder causing ‘mismatch’ between inner self and outer appearance is already medically recognised:
Body Dysmorphic Disorder is very closely linked to OCD (or, some would argue, actually a subtype of OCD). The BDD Foundation describes this disorder as:
‘a disabling preoccupation with perceived defects or flaws in appearance. It can affect both men and women, and makes sufferers excessively self-conscious. They tend to check their appearance repeatedly and try to camouflage or alter the defects they see, often undergoing needless cosmetic treatments. Onlookers are frequently perplexed because they can see nothing out of the ordinary, but BDD causes devastating distress.’
Speaking as someone who once spent £3000+ to correct my (perfectly normal) nose because I could not stop thinking about its ‘hideous deformity’, BDD can be horrible to live with. Sufferers absolutely deserve all your care, help and compassion to recover from their symptoms, and re-develop a more realistic self-image.
Body alterations such as cosmetic surgery are also not generally recommended for treating BDD. One study on cosmetic surgery procedures on BDD patients found that a shocking 98% of surgeries did not reduce the severity of BDD symptoms in the long term. It’s true that small studies occasionally find contrary results to this (cosmetic genital surgery performed on cisgender females with BDD appears to improve psychological wellbeing in some cases, for example). More research is needed. The factors at work are complex here. As it currently stands, though, the overall medical consensus is that cosmetic surgery is a poor treatment for BDD. Most doctors agree that the root of the disorder lies in the mental perception of a flaw, not an actual flaw. A BDD sufferer holding the quasi-delusional belief that literally everyone in the street is staring at the mole on his cheek (when actually nobody has noticed it, and nobody cares) is unlikely to feel better in the long run if doctors ‘play along’ with his false belief. He may feel temporarily better after cosmetic surgery (speaking as a former BDD sufferer, I know I did). But typically, a sufferer who manages to get their original ‘defect’ ‘corrected’ will remain afflicted with BDD symptoms, and simply go on to obsess about a different body part (or in my case, develop full-blown OCD and start obsessing about other topics).
Taking all this into account, it’s important to make sure that a person suffering from BDD isn’t misdiagnosed as having a different condition. Confusing a BDD sufferer with an actual LGBTQI+ individual would be problematic. Offering surgery to someone with BDD might seem like the obvious solution, but as the scientific evidence currently stands, there’s no guarantee this surgery will truly improve their wellbeing.
4) Detransitioned trans individuals seem to have an above-average likelihood of OCD symptoms.
In an informal 2016 survey of detransitioned women (i.e. women who formerly identified as trans in some way), an astonishing 20% of survey responders said they suffered from OCD. Bear in mind that the number of OCD sufferers in the general population is only 1–2%. This, therefore, represents a surprising number of OCD sufferers amongst formerly trans-identified people; much higher than in the general population. Qualitative responses to this survey included comments such as: ‘Obsessive thoughts were part of what drove my transition, completing the actions felt the same as fulfilling other compulsions I had’
Another respondent described how intrusive, unwanted mental pictures of herself as a man had driven her to try to present herself as a man — even though she later found she was not trans — in a compulsive attempt to lessen the distress these unwanted mental pictures caused her. The respondent adds that these intrusive thoughts have now waned, since she has treated her OCD, and she identifies as a butch lesbian woman.
This survey, based on a sample of 211 females, is an informally-done piece, not a peer-reviewed piece from a scientific journal. It’s thus important to take it with a pinch of salt until further evidence comes to light. Additionally, the focus in this article is on OCD alone, so no claims are here made as to the study’s accuracy with regards to any other mental health condition or medical advice. Anecdotally, though, it fits with what OCD advocates are seeing within the community.
If You Are Experiencing Suspected Symptoms of OCD (or BDD):
Please seek a professional diagnosis ASAP. Find a mental health specialist near you or via Skype, preferably one who has direct experience of dealing with OCD (a full directory of practitioners knowledgeable about OCD is available at the International OCD Foundation website). Be honest with the doctors about your symptoms, even if some of them seem bizarre, sexual or embarrassing. OCD doctors are used to hearing weird things, believe me.
If a professional confirms you haven’t got OCD, that’s brilliant news (and lucky you, seriously!). You still did the right thing by getting checked out. Mental health services may be overstrained at the moment, but never let anyone tell you that mental health isn’t important.
The approved methods for fixing OCD are certain medications, a type of CBT therapy called ‘Exposure and Response Prevention Therapy’, and (in extreme cases) brain surgery. If you end up on a long waiting list for therapeutic help, try getting a professional book on OCD recovery techniques in the meantime. David Veale and Rob Willson’s ‘Overcoming Obsessive Compulsive Disorder’ or Dr. Fiona Challacombe and Dr. Victorian Bream Oldfield’s ‘Break Free from OCD’ are both highly recommended and inexpensive.
The number one piece of ‘mental health first aid’ to know, as soon as you understand that you have OCD is: try not to keep doing your compulsions. Compulsions make obsessions worse. The more you do, the worse your OCD gets, the harder it is to recover. No-one is the exception. However much your OCD may try to convince you that you ‘need’ to do a compulsion again or that you’ll be able to ‘finally figure it out’ if you check one more time, resist. OCD is lying to you. Resist. As difficult as it is, try.
Whatever theme of OCD a sufferer ends up getting, whether it’s gender, harm, sexuality, contamination, morality or anything else, know that OCD sufferers can significantly recover from OCD symptoms, and get their life back. In some cases, they even end up symptom-free. So stay positive, and remember: the brain is an organ, flesh and blood, like any other — and like any other, it can break down. More importantly, it can heal.