Case Report


Sreeja Sreekumar1, TP Subhalakshmi2, P Joseph Varghese3
1Junior Resident, 2Assistant Professor, 3Professor and HOD,
Dept. of Psychiatry, MOSC Medical College, Kolenchery, Kerala.
Correspondence: Dept. of Psychiatry, MOSC Medical College, Kolenchery, Kerala. E-mail:


Schizophrenia presents in many curious ways. Here we report a 42-year-old, married lady brought with history of wearing gents’ clothes for the past three months, attributed to a desire to become a church priest. Though Gender Identity Disorder was suspected at first contact in the Emergency Room, collection of detailed history after admission revealed that for the past 25 years she had reduced social interaction, impaired personal care and functioning, and increased religiosity. MSE revealed delusions of persecution, grandeur and control. She was diagnosed with Paranoid Schizophrenia and treated with antipsychotics, following which she improved and gradually returned to wearing ladies’ clothes.

Keywords: schizophrenia, gender identity disorder


Viola is the heroine and protagonist of the play Twelfth Night, written by William Shakespeare, who dresses up like a male to find her missing brother, by working for the Duke, which she could not accomplish as a female.

Gender identity disorder (GID), renamed as “gender dysphoria” in DSM 5, is a rare condition of incongruity between the experienced/expressed gender and the assigned gender, causing significant distress or impairment in the person.1 Prevalence of GID is low and is estimated to be around 1 in 10,154 for male-to-female and less than 1 in 27,668 for female-to-male GID.2 The co-occurrence of GID and schizophrenia would be rare, as the prevalence estimates for schizophrenia in developing countries is in the range of 1.4 to 6.8 per 1,000 population at risk.3

However, clinical evidence points to higher rates of incidence of schizophrenia and schizophrenia-like traits in patients with GID compared to general population.4 There are documented evidences in history, of patients with schizophrenia harbouring beliefs or ideas related to gender change. One such documented patient is Daniel Paul Schreber, a schizophrenia patient of Freud, who believed that he would be transformed into a woman as a part of his mission to redeem the world.5 Richard von Krafft-Ebing described a condition, metamorphosis paranoica sexualis or the “final possible stage” of the “disease”, where the individuals suffer from psychological “delusion of the transformation of the sex” and identify themselves as belonging to the opposite gender and behave accordingly.2,6 According to him, due to the distress experienced related to their biological sex, such psychotic individuals frequently express a desire to change their gender by hormonal or surgical means.

There are several reports of persons brought for psychiatric treatment with delusion of sex change and behaviour like that of the opposite gender and improvement with antipsychotic medication.7

Schizophrenia-linked personality traits may be more common in men with GID who did not seek gender reassignment surgery.4 Female-to-male transsexuals who received testosterone therapy showed a significant reduction in psychotic symptoms.8

In schizophrenia, feminization/de-masculinization of brain processing in male patients and masculinization/de-feminization of female patients is partly due to the altered interaction between gonadal hormones and brain function.9

Awareness regarding the co-occurrence of these two disorders is important in that, prior to recommending hormonal or surgical intervention for GID, any psychiatric illnesses must be excluded.


We report a 42-year-old, Mrs. M, a housewife and mother of two, from a lower socioeconomic class family who presented to Emergency Room with history of wearing gents’ clothes for the past 3 months. She wore gents’ clothes, with hair cut short in male pattern. Her relatives reported that she claimed that except for her face, she had the body of a male. Being a lady, she could not achieve her desire of conducting prayers in church. To her, male gender was associated with positive energy and female gender with house work, responsibilities of children, and monthly menstrual cycles which again prevented her from going to church on certain days. A possibility of GID was suspected and she was admitted.

Detailed history and serial MSE revealed a different picture. She refused nonvegetarian food for herself and her children, as she believed it amounted to committing a sin and would cause menstrual bleeding. For three months, she had been sleeping in sitting position, as lying down on bed made a person slave to it. She had been keeping to herself and had stopped taking care of household matters.

MSE revealed a middle aged lady with short hair, no accessories, wearing a loose gents’ shirt and pants. She was poorly kempt, and had normal psychomotor activity and speech. Mood was dysphoric, restricted in range and congruent to thought. She believed that she had been blessed by God with two powers, Grace and Mercy, as she was born on the same day as Mother Mary. Grace was a positive energy seen in males and Mercy was the fluid power, like rain and menstrual bleeding, which made people weak. She wanted to conduct prayers in church, but could not do so as the priest was causing her to menstruate on the previous day through a wireless connection from a computer in his room. She believed the priest was trying to prevent her from taking over his post. She revealed no sexual arousal or gratification on wearing gents’ clothes. MSE and history revealed delusion of control and persecution for more than three months. Based on this and other findings, we made a diagnosis of schizophrenia.

She was treated with Tab. Risperidone 6mg/day and given supportive management. Her psychopathology improved after two weeks, and at the time of discharge she had gone back to wearing ladies’ clothes.


The possibility of GID was considered initially because the patient wore clothes of the opposite gender to achieve what only males could do in the church. Neither was there any sexual motivation for the cross dressing nor did she want a permanent change to opposite gender.


From the late 1960s to the early 1980s, several studies have contributed to the knowledge of relationship between gender identity and schizophrenia. Most studies indicate some degree of impairment in gender role or gender identity in people with schizophrenia, and suggest that both the disorders are neurodevelopmental disorders sharing common causal mechanisms and risk factors.10


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