Abstract
Lindsay Manderson, Lakeland Health, Rotorua, New Zealand, and Shailesh Kumar, Division of Psychiatry, Auckland University School of Medicine, Auckland, New Zealand:
Gender identity disorder (GID) is defined in DSM-IV [1] as a heterogenous group of disorders characterised by a strong and persistent cross-gender identification and persistent discomfort with one's current gender. Rates of prevalence for GID, sometimes referred to as transsexualism, are cited as 1 in 10 000 to 1 in 100 000 [2, 3]. With an accepted 1% prevalence of schizophrenia, the combination of the two disorders is an interesting rarity. Clinicians need to be aware of the co-occurrence of these two disorders given the fact that prior to recommending hormonal or surgical intervention for GID any underlying psychotic illnesses must be excluded. We present a case of GID in a woman with schizophrenia.
AT, a 35-year-old Maori woman with a 15-year history of paranoid schizophrenia, was admitted in relapse following refusal of her usual antipsychotic (flupenthixol decanoate, 100 mg weekly). Dressed in men's clothes with closely cropped hair she was agitated and spoke in a loud, pressured voice. She stated that she was born male but had given birth to four babies 4 months previously.
AT believed she was born a boy but that her mother cut her penis off at birth or shortly afterwards and injected hormones to make her female. Since her mother'sdeath 6 years ago she had been ‘reverting back to being a man’ and finally, 3 years ago she started dressing as a man. She even cited the bible in support of her transformation to being a man, that she was the King of Israel who was prophesied to have a baby. AT expressed a sexual preference for women as opposed to men and based it onher ‘aversion to homosexuality’. Her community mental health nurse and general practitioner confirmed that even though she preferred to dress as a man while well she rarely reported discomfort with her female gender and had never sought sex change.
AT described an unhappy childhood, with few friends, suffering prejudice being both a Maori and a transvestite. She spoke of a multitude of sexual, physical and emotional abuses by her mother and sexual abuse by her father and brother. School reports described her a loner, poor achiever, exhibiting behavioural problems including truancy. While pregnant, aged 18, she experienced her first psychotic episode.
AT spent 28 days as a voluntary patient. With the reintroduction of her usual antipsychotic medication her mental state improved. Parallel to this her delusion encapsulated and her GID became less apparent.
AT's belief that her transformation to being a man had begun, and would continue without medical or surgical intervention, was delusional because people with GID understand that sex reversal does not occur spontaneously. Furthermore, this belief and her recollection of events were prominent only when she was unwell. The delusion responded to treatment, becoming encapsulated as her mental state improved.
AT had a traumatic childhood but did not fulfil the diagnostic criteria for posttraumatic stress disorder according to DSM-IV [1]. It has been hypothesized that an atypical gender identity is formed as a psychological coping strategy in relation to trauma and abuse in childhood, and that the earlier the trauma occurs, the more rigid and unchanging the belief will be [4]. These factors along with the experiences of relationship difficulties with parents and peers, depression/misery, social sensitivity and victimization, all described as significant in the development of GID, were significant in this case [4].
To conclude, even though AT's GID existed prior to her acute deterioration, the delusion of GID paralleled the course of schizophrenia, becoming prominent with the relapse and diminishing in response to treatment. For her, GID was a manifestation of schizophrenia which is a rarity.