Gender Dysphoria Secondary to Delusion: A Case Report
Corresponding Author: Biplab Konwar, Department of Psychiatry, Assam Medical College, Dibrugarh, Assam, India, Phone: +91 7002450517, e-mail: email@example.com
How to cite this article: Bhuyan D, Konwar B. Gender Dysphoria Secondary to Delusion: A Case Report. Ind J Priv Psychiatry 2023;17(2):101–102.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Received on: 30 December 2022; Accepted on: 24 January 2023; Published on: 14 June 2023
Gender dysphoria (GD) may appear in individuals with schizophrenia either as the consequence of a delusional change in gender identity or it may appear separately from psychotic symptoms. Differentiating between these scenarios is not only a difficult task from a diagnostic standpoint, but it also has an impact on treatment choices. People with GD should undergo detailed psychiatric and psychosocial evaluation as unnecessary hormone replacement therapy and sex reassignment surgery could be avoided in cases where it is secondary to a primary psychiatric illness. When both illnesses co-occur, it is imperative to analyze the occurrence and progression of each symptom, their consistency (across time), the patient’s feedback, and their reaction to antipsychotic medication.
Keywords: Gender roles, Schizophrenia, Sex assignment surgery.
Though GD is not a new notion, it has become a topic of interest because of the rise in new cases and global public awareness of the condition in recent years. A survey of the literature reveals that roughly one-fourth of schizophrenia patients experience various delusional ideas about being of a different gender, anatomy, or alterations to the genitalia.1 People with a clear discrepancy between their stated or experienced gender and the gender they were given at birth are said to have GD.2 Persons with GD express their discontent with their assigned sex as a desire to have the body of the other sex or to be regarded socially as a person of the other sex.3
As a result, there may be significant impairment in one’s ability to operate in occupational, economic, social, and other aspects of functioning. Data on the prevalence of GD are few since it is difficult to identify the target group, primarily because people hide their identities due to the stigma attached to them. However, experts estimate that 1 in 11,000 people who identify as male and 1 in 30,000 people who identify as female have gender dysphoria as adults in Europe.3 According to DSM-5, the prevalence rate for persons who were designated as male ranged from 0.005 to 0.014%, and for those who were assigned as female ranged from 0.002 to 0.003%.2
There are few data that are unique to India, particularly in Assam. The available literature is primarily based on the patients’ reports. As a result, we describe a case of gender dysphoria brought on by delusion.
A 25-year-old male who has passed B.Com from a middle-class rural background visited the outpatient Department of Psychiatry for detailed psychiatric evaluation to undergo sex reassignment surgery. Therefore he was admitted to the psychiatric ward for detailed evaluation. On further evaluation it was found that he had a history of irritability, aggressive behavior, hearing voices not heard by others, and suspiciousness for the duration of 6 months.
He also believed that everyone talked evil about him and he was ill-treated; everyone in society blamed him for anything he did and anything that went wrong in society. He also believed that his family members did black magic on him to cause harm but could not specify the reason behind it according to him people did not like him as well as criticized him everywhere for certain acts which were not done by him. According to him, no one blames females and they are more well treated for every work although those activities did not help society. So, he started believing that he should not have been born as a male and started having discomfort in his assigned role as a male. So he wanted to change his gender as according to him if he would become a woman then no one would have blamed him.
He started behaving like a woman, dressing like a female and speaking with a feminine voice so that no one could recognize him as male which would subsequently help him from keeping away from criticisms from society. Hence he approached the department of psychiatry to have a proper psychiatric assessment to undergo sex reassignment surgery.
There was no prior history of mental illness. He had a history of bronchial asthma in the past. The patient’s family history reveals no history of mental illness. There was no history of delayed attainment of developmental milestones. There was no history of alcohol or other drug abuse. He was admitted to the department of psychiatry and on detailed evaluation, he was found to have the delusion of reference, a delusion of persecution, and commanding auditory hallucination. His social and professional functioning was extremely poor during this time. He was given a schizophrenia diagnosis as a result. There were no abnormalities found in any of the studies, including the hormonal estimation, computed tomography of the brain, and electroencephalogram.
He was initially given the antipsychotic drug Risperidone 6 mg along with Trihexyphenidyl 4 mg orally in two divided dosages. Though there was some improvement in terms of presenting symptoms still was having suspiciousness. Hence tablet Aripiprazole 20 mg in two divided dosages was added following which his symptoms decreased. Gender dysphoria due to his delusional belief had significantly improved.
Gender dysphoria in schizophrenia patients can be challenging to diagnose. Usually, gender dysphoria presents with a desire to change gender. Every patient must undergo detailed psychiatric and psychosocial evaluation before coming to the proper diagnosis. Gender dysphoria in schizophrenia patients is a rare symptom, but it is seen more frequently than in the general population.4 Less than 1 in 10,000 adult natal males and 1 in 30,000 adult natal females, according to prevalence surveys, although these numbers can vary greatly.2
Today, the possibility of co-occurring schizophrenia and gender dysphoria is acknowledged.5 According to Baltieri and De Andrade, schizophrenia can alter the trajectory of prior gender dysphoria.5 The desire to make sex reassignment or the subjective sense of belonging to the opposite sex in schizophrenia does not always have to be a symptom of the illness.5 Patients are subjected to extensive and permanent modifications when the distinction between a delusion of sex change and gender dysphoria is improperly made.6
In a study of 359 gender dysphoria cases, 270 cases (75%), were interpreted as secondary to other psychiatric illnesses.7 Similarly in our case also gender dysphoria was secondary. Ours was a case of 25-year-old schizophrenia patient, who had developed gender dysphoria secondary to delusional belief. Men with schizophrenia have reportedly had their gender dysphoria incorrectly diagnosed, leading to the inappropriate prescription of female hormones that, among other things, cause genital atrophy and breast growth,7 and even undergo sex reassignment surgery.6
The treatment and understanding of the connection between gender dysphoria and schizophrenia are affected by the prompt diagnosis of a primary psychotic disorder in patients exhibiting it. People with gender dysphoria should undergo detailed psychiatric and psychosocial evaluation as unnecessary hormone replacement therapy and sex reassignment surgery could be avoided in cases where it is secondary to a primary psychiatric illness. This case study aims to fill a gap in the literature on schizophrenia patient’s secondary gender dysphoria caused by delusion.
2. Arlington VA. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. American Psychiatric Association 2013;(1):451–452. DOI: https://doi.org/10.1176/appi.books.9780890425596.
3. Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry, Eleventh edition. Wolters Kluwer Health 2015;600–601.
7. à Campo J, Nijman H, Merckelbach H, Evers C. Psychiatric comorbidity of gender identity disorders: A survey among Dutch psychiatrists. Am J Psychiatry 2003;160(7):1332–1336. DOI: 10.1176/appi.ajp.160.7.1332.
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