Transsexuality OCD, social context and Superego.

Increase in the Incidence of Transsexuality OCD

For many years, as the methodology of IPITIA was being developed, and over the past ten years of specific therapeutic experience with OCD, we have been able to observe and increasingly understand the relationships between the types of obsessions presented by patients and the social context in which they emerge.

Recently, we have noticed a considerable increase in therapy requests related to Transsexuality OCD (or Gender Identity OCD), something that had only occurred sporadically in previous years. Although we do not have sufficient numbers for a study with firmly generalizable results, we believe that this increase in our Center is related to the changes in the perception of gender identity occurring at a social level in certain contexts. This article discusses this hypothesis.

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OCD at IPITIA

As readers of this blog or those familiar with our therapeutic work with OCD may already know, at IPITIA we focus on reducing trait anxiety, which is responsible for obsessive symptoms. We consider these symptoms to be a mere manifestation of such anxiety. We do not work on symptoms directly and repetitively to teach patients to control and live with them. Instead, we work on the anxiety that generates them to promote their gradual reduction and, in many cases, their disappearance.

This anxiety is often the product of the patient’s internal conflicts (neurosis) derived from childhood/adolescence traumas, the progressive installation of fear in the nervous system, and an excessive submission/adaptation (often unconscious) to external circumstances or imposed ways of thinking and living dictated by family, society, or the dominant culture of their place of origin.

Thus, while we do not consider it functional to address symptoms directly, it is important to understand their origin, meaning, and function within the patient’s organism. To do so, it is impossible to disregard the social context in which they begin to manifest.

Superego and Social Norms

According to many psychologists, the term neurosis generically refers to the internal conflicts of a patient and the emotional and behavioral consequences derived from them. But conflicts between what elements? While there is an extensive literature on the subject that could be debated for hours, in this article, we will focus specifically on the conflict that can arise between the basic drives of the human being, their primary nature, and the norms internalized by the individual—that is, what much of the psychological literature defines as the Superego.

When a child is born, they are a cauldron of basic impulses. They do not have an extensive perception of the external context nor an idea of what is right or wrong according to the people around them. As they grow, through interaction with parents, their reactions, language, other reference figures appearing in their life/consciousness, the culture of their place of origin, and its moral, ethical, and religious norms, the child forms an idea of how they should think, feel, and behave to be loved, accepted, and cared for in their social context, which at that moment signifies survival for their developing nervous system.

That idea is the Superego.

Explaining the close relationship between the formation of the Superego and the social context, we can now focus on its interaction with OCD.

Superego, Personality, and Pathology

According to the theoretical framework we refer to in our work at IPITIA, the interaction between an individual’s basic drives and the Superego determines a large part of a person’s personality, behaviors, and level of well-being. Broadly speaking, and with inevitable exceptions, we can affirm that a person dominated at all times by their impulses and instincts without a Superego capable of balancing and channeling them will likely tend towards impulse control issues, dispersion, or personalities lacking empathy or limits, such as histrionic, narcissistic, or borderline personalities. Conversely, a person whose impulses are constantly repressed and judged by a rigid, punitive Superego that conflicts with their true essence will likely tend towards issues related to excessive restraint, somatization, passive-aggressiveness, and all types of anxiety disorders, including OCD.

Obsessions, therefore, represent the symptom of this internal friction.

Social Context and Types of Obsessions

Now that we have clarified the relationships between social context, the formation of the Superego, and its role in generating Obsessive Disorders, it will be easier to understand how different social contexts and the cultural changes occurring over time can modify the probability of one type of obsession over another.

Although we are extremely aware of the need to treat each case with absolute specificity and of the overgeneralization we would incur if we did not delve deeply into each case, we would like to propose some examples of the relationship between social context and types of obsessions.

In our experience, Homosexual OCD (in men) tends to occur more frequently in contexts where a very primary idea of masculinity, linked to bravery and strength, dominates, and where the patient feels they have failed to meet this standard. Religious OCD is more common in contexts where the idea of sin is highly present, where the conception of God is that of an omnipresent judge of every action, thought, or impulse of the individual. Aggressive OCD is seen in contexts where adherence to family, social, and moral norms becomes so dominant and suffocating that it generates a feeling of extreme containment in the patient. Pedophilia OCD has a higher incidence in contexts where social norms required children to become adults too soon, without giving them the opportunity to integrate the concept of childhood.

As we can see, different environments interfere in various ways with the formation of a Superego that responds to the real needs of the person and their essence, generating a neurosis that results in the emergence of specific intrusive thoughts (obsessions).

We now proceed to describe Transsexuality OCD and the contexts in which it tends to develop more frequently, according to our experience.

Transsexuality OCD

We already know that when we talk about OCD, we are referring to a complex condition that manifests as intrusive thoughts and repetitive behaviors aimed at relieving the anxiety generated by those thoughts. However, when mentioning Transsexuality OCD, it is important to approach the topic with an even more nuanced, respectful, inclusive, and deeply human perspective.

We could define Transsexuality OCD as a situation in which a person experiences an obsessive and anxiety-inducing concern regarding their gender identity or their sex assigned at birth by their own biology. This concern can lead to a compulsive search for answers, external validation, or repetitive behaviors related to gender transition, with the goal of alleviating the anxiety caused by uncertainty about their identity. It is a problem that often coexists with other anxiety symptoms and is considered a disorder when it begins to affect overall well-being, as well as normal daily, social, and professional functioning.

Just like Homosexual OCD, Transsexuality OCD is often mistakenly confused with the legitimate process of gender identity exploration by trans individuals. However, the key distinction lies in the fact that, while gender identity exploration is a healthy and often necessary process of self-understanding, OCD is characterized by extreme anxiety, emotional paralysis, and a lack of resolution, regardless of the authenticity of gender identity.

Concept of Gender and Current Context

The current connotation of the word “gender” has relatively recent origins. Many sociologists trace its beginnings to the 1950s in the field of American psychiatry, where the physician and psychiatrist John Money was one of its most relevant exponents. From that point on, parts of feminist movements began to embrace these ideas with the initial goal of liberating women and the homosexual community from the gender roles imposed by society at the time. However, we could consider that it was not until the Fourth World Conference on Women, held in Beijing in 1995, that a significant turning point was marked for the global political and social agenda regarding this concept.

From that moment on, both academic and social discussions gradually and more forcefully shifted from the conception of gender roles to that of gender identity.

Broadly speaking, the difference—which is psychologically very relevant—is that the first view argues that biological sex or sexual orientation should not define a particular gender role in society, while the second asserts that gender itself is actually a social construct that does not depend on biological sex and is therefore subject to one’s self-perception. In this view, gender is not necessarily stable and requires individuals to autonomously and continuously decide, without external influences, how they want to define themselves based on what they feel is true at that moment.

Obviously, these ideas have different degrees of acceptance in society depending on the context, but there is no doubt that, especially in major European and Western cities, these concepts are increasingly confronting children, adolescents, and the general population with challenges, thoughts, and emotions different from those of the past—challenges of a current context that psychologists have a duty to understand in order to grasp the origins of certain psychological issues.

Current Context and Transsexuality OCD

As should already be clear, our intention is not to judge or express opinions on the aforementioned societal changes but rather to understand their possible role in the development of the Superego and, consequently, certain neuroses that, in some cases, may become obsessive.

What is important to understand is that, on a psychological level, this is a delicate topic and that changes in society’s perception of gender identity also entail significant shifts in identity development in general. Without oversimplifying, it is essential to recognize the significant psychological difference between feeling free to choose what kind of man or woman one wants to be in life and questioning whether one is truly a man or a woman. The depth of the question—and therefore the self-doubt—is much greater in the second case. And the level of implication for a person’s identity is also much greater.

We must consider that identity—and consequently personality—is also shaped by limits that a child wishes to explore and often challenge as they grow, and through this struggle, they define themselves. As previously discussed, the Superego is built through interaction with the environment, which therefore also serves as a boundary against which we define our own identity. In other words, initially, we do what our parents say is right, and then gradually, in a healthy development, we determine what we think is worth keeping and what we feel we want to transgress and change. Through this ongoing struggle with boundaries, identity is formed, balancing our drives with a healthy Superego that respects them to an appropriate degree.

It thus becomes evident that we are discussing a contrast between limits and freedom, which must reach a healthy balance to ensure emotional well-being. As analyzed in the article, Liquid Modernity and Neurosis, referring to Polish philosopher Zygmunt Bauman, the excess of fluidity and lack of certainty in many aspects of modernity can contribute to the creation of a neurotic society, and neurosis is precisely the foundation of OCD.

In other words, just as repressive societies can instill limiting Superegos and foster certain types of obsessions, environments that lack boundaries on what can be questioned also risk triggering a different type of obsession—such is the case with Transsexuality OCD.

Based on reports from various patients, in certain sectors of society, questioning one’s assigned gender at birth is considered a moral duty, a sign of progress and respect, something to aspire to. And there is no doubt that for many people, this is indeed a positive change, as they finally feel validated in their identities and no longer marginalized.

However, every social change, no matter how beneficial it is for some, necessarily brings consequences for others. One of the trends observed at our center is that in this new social paradigm, individuals with high levels of anxiety and uncertainty begin to doubt something they would never have questioned before: their gender identity.

OCD is the illness of doubt—the “what if…?” disorder—the inability to perceive almost anything with absolute certainty, the difficulty in making decisions. If the social environment introduces a new doubt about identity, if gender becomes a choice, and fear and guilt are already ingrained in the nervous system, having to self-define gender becomes fertile ground for the development of new obsessions.

What has meant a shift toward freedom of expression for many people has resulted in anxiety for others, as it offers new opportunities for uncertainty and doubt.

In a significant number of cases at our center, we have observed how the lack of space for drives or behaviors historically more frequently associated with the opposite sex used to generate the obsessive doubt, Am I homosexual? However, little by little, when faced with the same internal stimuli, the new social paradigm pushes toward the obsessive question, Am I really a man or a woman?

If a person’s Superego is rigid and judgmental, fueled by guilt and fear, it constantly needs to classify reality into dichotomies to achieve a false and unattainable sense of control. This new social paradigm regarding gender identity represents a new possible dichotomy that generates types of obsessions that, until a few years ago, we did not frequently observe in therapy.

To make it absolutely clear, we reaffirm an essential concept: OCD arises from the interaction between an individual’s biology and the traumatic circumstances experienced throughout childhood and adolescence.

The social context helps determine the type and content of obsessions, as, for many people, their relationship with it can be a trauma in itself, dysfunctionally shaping the formation of the Superego.

The Superego feeds on the external context to generate the content of obsessions, but the real problem lies in the fear and guilt that have been created. Therefore, therapeutic work should not be directed at criticizing the context but at seeking an internal security based on the individual’s true drives.

Thus, as should now be clear, this article is not at all intended as a critique of the current social context but rather as a hypothesis on how it may be related to the emergence of new contents in the types of obsessions we have observed more frequently in recent years.

How to Treat Transgender OCD Therapeutically

In this section, we will provide a brief synthesis (not exhaustive) of the key concepts of the procedure we successfully use at IPITIA to address this specific issue and OCD in general.

PITIA has developed an integrative therapeutic approach that stands out for its sensitivity to the complexities of gender identity and its individualized care. Working with individuals experiencing Transgender OCD requires a deeply empathetic, respectful, and de-pathologizing approach to effectively meet both the emotional and cognitive needs of the patient.

In our Analytical-Experiential approach, the key concepts presented below are not followed in a strictly sequential manner. Instead, they represent elements that our psychologists take into account throughout the entire process to reduce internal anxiety, which is responsible for obsessions and compulsions.

Diagnosis
Anamnesis
Analysis of past and present contexts
Identification of the causes and sustaining factors of OCD
Evaluation of possible pharmacological intervention
Defocusing from the symptom
Instinct activation
Instinct focus: significant lifestyle changes
Relapse prevention

Diagnosis. First and foremost, it is important to establish a correct diagnosis. As we previously mentioned, it is essential not to confuse Transgender OCD with the legitimate process of gender identity exploration. For an experienced psychologist—like all those working at IPITIA—this differentiation is not difficult to make. This is especially true because individuals with OCD have often gone through various obsessive themes throughout their lives, experiencing high levels of anxiety in different contexts. However, to summarize, the main symptoms of Trasgender OCD are:

– Obsessions about gender identity. The person feels a constant and repetitive need to reassess their gender identity, persistently questioning whether they are truly trans or whether their feelings of dysphoria are “strong enough” to justify a transition. These thoughts are recurrent, often uncontrollable, and generate high levels of distress.

– Compulsive search for answers (compulsions). To relieve the anxiety triggered by their obsessions, the person may engage in compulsive behaviors, such as constantly consulting therapists, compulsively reading about transgender issues, spending excessive hours following trans people on social media and comparing their experiences, or frequently taking “tests” about their gender identity—seeking definitive confirmation that never comes.

– Avoidance of gender dysphoria triggers. People with Transgender OCD may avoid situations that trigger anxiety related to their gender identity, such as avoiding mirrors, avoiding discussions about their identity, or refraining from dressing in ways that align with the gender they identify with. This avoidance seeks to reduce discomfort but ultimately increases anxiety over time.

– Persistent doubts about transitioning. While some transgender individuals may take time to decide about transitioning, those with Transgender OCD experience chronic doubt and an inability to make definitive decisions due to extreme anxiety—rather than a genuine lack of clarity about their gender identity.

– Broad anxiety symptoms. Individuals with Transgender OCD often report experiencing previous obsessive themes unrelated to gender identity and have experienced high levels of anxiety in various life situations.

It is therefore crucial to understand that while transgender individuals may experience doubts or legitimate questions about their identity and transition, Transgender OCD is characterized by the repetitive nature and extreme interference of these thoughts and actions in daily well-being and self-understanding.

Anamnesis. Anamnesis involves a deep exploration of the person’s history, both clinically and in terms of personal and family background. Significant life events that contributed to personality patterns, fear, guilt, and the current symptoms are thoroughly analyzed.A good anamnesis is fundamental to identifying aspects of a person’s essence that were not allowed to be expressed in the past—leading to the formation of a neurotic conflict.

3. Analysis of Past and Present Contexts. As previously discussed, the social environment plays a determining role in shaping a dysfunctional and repressive Superego. Thus, it is essential to understand which environmental factors contributed to this in the past and which of these factors the individual continues to reproduce in their present life

4. Identifying the Causes and Sustaining Factors of OCD. Los tres puntos anteriores conducen de forma natural a la identificación de aquello de lo que la persona tendrá inevitablemente que distanciarse, de aquello que será imprescindible empezar a cambiar para superar el TOC, y de las partes de su esencia (pulsiones, instintos) que al no haber tenido suficiente expresión en el pasado tendrán necesariamente que encontrar espacio a lo largo del proceso terapéutico y de la vida en general. Repetimos que cuando hablamos de Esencia versus Superyó no hablamos simplemente de metáforas, sino de una falta de expresión de la misma biología del individuo en su hábitat.

5. Evaluation of the possibility of pharmacological intervention.Not only in the case of Transsexuality OCD but in any type of anxiety disorder, it is important to assess whether a pharmacological intervention should accompany psychological therapy, a task that must be carried out by a specialized psychiatrist.

At IPITIA, in cases where it is required, we consider the role of pharmacology important, not as a curative element in itself but as a tool that, in some cases, facilitates the implementation of the necessary life changes to overcome OCD more effectively or with greater serenity during the process.

6. Defocusing from the symptom. Transsexuality OCD, like other types with different contents, represents only the tip of a much deeper iceberg. The symptoms are what we can observe, but they stem from the internal conflicts mentioned earlier. In our opinion, it is therefore useless to spend a large number of sessions talking repeatedly about the symptoms and proposing constant exposure to them, as this would only reproduce the obsessive dynamic. The IPITIA methodology, besides, of course, depathologizing Transsexuality itself, aims to progressively direct all energies and attention toward what the person truly desires to achieve and what genuinely represents them, far beyond gender identity. In other words, defocusing from the symptom to activate the real identity. This way, the internal conflict is reduced, and with it, the symptoms.

Pulsional activation.This is one of the core aspects of our methodology. In order to reduce the influence of the Superego based on fear and guilt, we proceed to reactivate the instinctive and pulsional part of the individual, and ultimately, their biology. It is about living life again instead of just thinking about it. Therapist and patient therefore agree on external activities that will be essential and an integral part of therapy. These activities defocus from the symptom and require a high level of engagement. Additionally, aspects of the self identified as blocked or deficient (assertiveness, firmness, decision-making, sexuality, sensuality, aggressiveness, creativity, spontaneity…) are activated through a wide variety of stimuli and exercises proposed by the therapist. By activating impulses and vital instincts that were repressed due to experiences of fear, normal anxiety regulation in the patient is facilitated, leading to a gradual reduction of obsessive and compulsive symptoms. This happens because when a strong identity is activated, all types of obsessive doubts decrease in intensity, including those pathologically related to gender identity, allowing the true nature of the individual to emerge, whatever it may be.
Pulsional focus: significant lifestyle changes:The previously described activation of drives, instincts, and the individual’s biology is the essential foundation for what will be most important in a second phase: a lifestyle change. Every person who has overcome or significantly reduced an obsessive disorder knows that this was achieved by identifying and accomplishing personally meaningful challenges. Once activated, the individual’s pulsional nature must be focused on creating a new lifestyle that aligns with their true essence. This involves identifying and maintaining the aspects of life that are truly authentic and resonate with them while simultaneously developing the courage to modify those aspects that were built based on fear, guilt, and over-adaptation due to a dysfunctional Superego (Job? Place of residence? Family relationships? Romantic relationships? Friend group? Etc.).
Relapse prevention.Once OCD has been significantly reduced or, as in many cases, completely overcome, it is important for the person to understand why this occurred in order to stay firm and not fall back into making decisions based on guilt and fear. If the patient returns to over-adapting to the external environment and adopts a passive attitude toward life, obsessive symptoms are likely to return, sometimes with a different content as the context will have changed. It is therefore essential to work with the therapist to firmly integrate the achieved results, understand their logic, and develop sufficient self-awareness to detect genuine life needs as they arise over time.

Conclusion on Transgender OCD

The neurotic conflict between a dysfunctional Superego and basic human drives is responsible for OCD formation.

Since the Superego is shaped by social context, it can influence the content of obsessions. Recent societal shifts in the perception of gender identity likely contribute to the increasing cases of Transgender OCD we have observed.

Beyond the necessary depathologization of transgender identity and the natural process of gender exploration, overcoming OCD requires activating and focusing on instincts that were suppressed by fear, guilt, and over-adaptation.

By doing so, the true essence of the individual can emerge—reducing neurotic conflicts and obsessive symptoms, including those related to gender identity.

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