As therapists, we know that people with OCD tend to experience symptoms around things that are important to them. This is why obsessions often fall into themes like morality, harm, religion, and health. Even obsessions that seem neutral, like worrying about what color shoes to wear, are usually related to larger self-concepts such as a desire to make perfect decisions, prevent negative outcomes, or minimize future regrets.
It’s no surprise that OCD can latch on to something as personal and important as one’s identity. Both sexual orientation OCD (SO-OCD) and gender related OCD do just that; these symptoms undermine a person’s sense of who they are and who they’re attracted to. Further, they leave in their wake a trail of maybes, what-ifs, and doubts.
What if I’m not really gay (or straight or bi or asexual or queer, etc)? How can I be sure that I’m not transgender (or cisgender or nonbinary, etc)?
While SO-OCD has been discussed in the OCD literature for years, it has gone by different names over time. You may have heard it referred to as H-OCD or homosexual OCD, both terms that have fallen out of favor due to their lack of accuracy and inclusiveness. That is, H-OCD was initially used only to describe heterosexual people who have obsessions about possibly being gay/lesbian. While this is a very common (and valid!) manifestation of SO-OCD, it is by no means the only way that SO-OCD manifests. People of all sexual orientations are subject to obsessions about this aspect of identity. And in true OCD fashion, it can feel like no amount of seeking certainty turns down the volume on these doubts. It is estimated that between 10-15% of people with OCD have experienced SO-OCD.
Gender-related OCD refers to obsessions and compulsions pertaining to one’s gender identity. This can look like someone doubting that they are cisgender (the same gender as the one assigned at birth) even though they’ve identified as such their whole life. These thoughts are not associated with pleasure or curiosity but are regarded with anxiety and confusion. This can also look like a transgender or nonbinary person wondering if they are really cisgender even though this thought is not consistent with how they see themselves. Gender-related OCD used to be referred to as Trans OCD or T-OCD, but because this was an inaccurate and stigmatizing portrayal of true scope of symptoms, these terms are no longer used. There’s not as much research on gender-related OCD as there is for SO-OCD, but please know that if you’ve experienced this, you’re not the only one.
Symptoms that attack one’s identity can be painful for the people experiencing them because they touch on a core fear of inauthenticity. If the obsessive fears were true, this could lead to shake-ups in romantic and family relationships, increased discrimination, and other possible changes in daily life. Questions about identity can morph into ones like Will I have to end my relationship?, What will my employer think? and Should I move to a different city?
And while having SO-OCD or gender-related OCD doesn’t mean that someone is homophobic, transphobic, or otherwise prejudiced, having negative beliefs about LGBTQ+ people can complicate the experience of these themes. Religious beliefs can also affect the expression of symptoms, leading people not only to fear inauthenticity but also to fear damnation or rejection.
The most common question that we get from clients with SO-OCD and gender-related OCD is about how to distinguish between true aspects of identity and symptoms of OCD. Put another way, am I having these thoughts because they’re true or is it only OCD? While it’s understandable to want to know this, there are no shortcut answers to this question that are likely to give the sort of certainty that OCD demands. In fact, many of the ways that people with OCD attempt to clarify their sexuality or gender (compulsions) actually make things muddier! And things that are used as “evidence” for one’s sexuality and gender are usually based on misinformation. Let’s look at some examples.
People with identity symptoms may find themselves constantly checking to determine their sexuality or gender identity. For SO-OCD, this can include looking at pictures of same-gender or different-gender people to check for attraction or viewing pornography to assess for arousal. Checking can become more involved as well, such as when people go on dates or seek out sexual contact with others to test their levels of attraction. For gender related OCD, it can include trying on more traditionally masculine or feminine clothing to see what feels more authentic or testing one’s feelings of connectedness when hanging out with people of varying genders. These kinds of behaviors don’t actually yield the information that the person with OCD is seeking. In fact, arousal can occur after any exposure to sexual content, regardless of the level of true desire. Moreover, admiring people isn’t necessarily equal to desiring them OR desiring to be more like them.
Comparison is another compulsion often used to check one’s sexuality or gender. Comparing one’s clothing, appearance, behavior, interests, and more to others in a group can give the illusion of providing information to answer OCD’s burning questions. Maybe if I relate more to my gay friends than my straight ones, that means that I’m a lesbian. Or if I have more in common with my cisgender friends, I’m not trans. But again, these are not helpful metrics to attain the certainty that OCD wants. They may seem to provide answers for a moment before the doubts swirl back in.
Sometimes compulsive behaviors focus not on real-time stimuli but instead involve reviewing past events compulsively. Playing doctor with friends as a child can be used as a reason to suspect a new sexual orientation (even though it’s irrelevant information). Someone who was called a tomboy in their youth might wonder if this means that they are transgender. But combing one’s past for evidence for or against OCD’s claims doesn’t usually uncover anything to answer your questions. Plus doing so can distort the very memories that we want to uncover! The more you try to remember, the less certain you may become about those events.
Our clients often ask questions about their sexuality or gender outright and with an air of urgency, a compulsion that we call reassurance seeking. While we need to be certain not to lump all questions into the reassurance bucket, some questions are better left untouched. For example, someone who doesn’t know about arousal non-concordance (the lack of connection between one’s physical sexual response and actual desire) may do well to get education about this. Once. However, if people with SO-OCD or gender related OCD ask repetitive questions to seek a soothing answer, this may be an unhelpful compulsion. And like other compulsions, it doesn’t ultimately provide the 100% sure answers that OCD demands.
In contrast to those who seek clarity with compulsions, some people with SO-OCD or gender-related OCD are so worried about finding out the truth about their sexual orientation or gender that they avoid things that may provoke intrusive thoughts or unwanted feelings. For SO-OCD, this can show up as avoiding any media depicting sexual/romantic relationships of the feared orientation or discontinuing valued behaviors for fear of being triggered. This can also look like avoidance of media or triggers that would disconfirm OCD’s fears on the off event that there’s not enough disconfirmation! That is, someone who’s afraid of being asexual may avoid anything remotely sexual because if they don’t respond with arousal, they feel that it’s “proof” of their asexuality. Further, people may avoid dating and intimacy altogether.
Even though it’s tough to hear that compulsions won’t get you the certainty that OCD demands, treatment helps people move toward recognizing that they can be sure enough in their identity to live authentically. Exposure and Response Prevention (ERP) teaches people resilience by moving toward difficult things without relying on compulsions. Acceptance and Commitment Therapy (ACT) ensures that you aren’t skimping out on the important parts of life or becoming too fused with your thoughts along the way. Inference-based CBT helps people recognize the role of doubts and imagination in your symptoms, and self compassion infuses treatment with empathy. A well rounded OCD provider can use multiple tools to help you in your journey to reduce symptoms and get you back to living the life you want!
