Obsessive compulsive disorder with gender identity related obsessions: a diagnostic challenge in an adolescent

Abstract

Background: Obsessive compulsive disorder (OCD) can present with a wide range of symptom dimensions, including less commonly recognized taboo obsessions related to sexual orientation and gender identity. These presentations may lead to diagnostic confusion, particularly with gender dysphoria, especially in adolescents.

Case description: We report the case of a 17-year-old male who presented with a 4-year history of intrusive, distressing doubts about being transgender. The thoughts were ego dystonic, repetitive, and associated with significant anxiety and functional impairment. The patient engaged in multiple compulsive behaviors, including mirror checking, genital checking, mental review of past behaviors, and repeated reassurance seeking. Mental status examination revealed preserved insight and absence of psychotic features. Careful clinical evaluation helped differentiate OCD-related gender identity obsessions from gender dysphoria.

Management and outcome: The patient was treated with fluoxetine, titrated up to 60 mg/day, along with cognitive behavioral therapy (CBT) incorporating exposure and response prevention. Over 12 weeks, there was a significant reduction in symptom severity, with improvement in functioning and a decrease in Yale Brown Obsessive Compulsive Scale (YBOCS) score from 22 to 14.

Conclusion: This case highlights the importance of recognizing gender identity-related obsessions as a subtype of OCD and differentiating them from gender dysphoria. Early identification and appropriate treatment can lead to favorable outcomes and prevent unnecessary interventions.