A clinical review: schizophrenia, transsexualism or their combination?

Introduction

The change in the position of transsexualism in the new ICD and the heated discussion about the psychopathological structure of this phenomenon and its connection with other mental disorders [1] require the accumulation of disparate clinical cases, their systematization, and identification of possible connections, as well as determine the relevance of considering the following clinical case.

Description of the clinical case

Patient M., aged 34, applied for permission for gender reassignment surgery.

Of the close relatives, she had only a sister, who was extremely negative about the patient's behavior, the desire to reassign gender, and categorically refused to communicate with doctors. The patient told that her mother died at the age of 43 from “severe diabetes” and characterized her as “kind, affectionate, caring, sympathetic”. The father died at the age of 52 from a “genitourinary infection” (no more details available), and the patient characterized him as “always drunk, aggressive”. The elder sister was “obsessive, oppressive, stubborn”.

She was born from a second pregnancy, a second delivery, information about which, as well as about early development, was not available. The first memory of childhood was associated with intrafamily conflicts, “the constantly drunk and aggressive father chasing her mother with an ax”. As the elder sister told the patient, during the first year of her life she “was very weak, healthless, could not hold her head for a long time, did not sit, did not walk”. At the age of about one year, she suffered a “critical condition” with respiratory arrest (“turned blue”), her parents tried to perform “artificial respiration”, she was hospitalized by ambulance, the hospital “performed a complete blood transfusion”, after which she “soon began to walk”.

For the first few years of her life, she suffered from chronic pneumonia, and “her parents treated her with small doses of alcohol, more often beer”.

At preschool age, the patient was active, mobile, “naughty”, demanding, vindictive, persistent, always bringing “everything to the end”. She attended a kindergarten, where she “did not like the fact that she had to fulfill the requirements of the regime when she was completely immersed in the games”. She preferred outdoor games in mixed company (when there were more boys). As a child, she preferred “boyish” toys (cars, weapons, soldiers) and games. When playing house, the patient always chose the role of a man.

The patient went willingly to school at the age of 7. Without protest, she wore a female school uniform. She always resisted tying bows and braiding, as “they were inconvenient”, she preferred a short haircut. Both at school and in the preschool period, among friends she named more girls but “very mobile and active ones — tomboys; among favorite games was the war, and also liked to put light bulbs on the tram rails”.

In primary school, the patient was prone to fantasizing. She often fantasized that “the ability to understand the language of plants and animals woke up in her”. She had a mental dialogue with a willow that grew near the house for a long time, and imagined its answers. The patient’s mother, when knowing about this, asked the daughter not to tell anyone about it and explained that “no one would understand these fantasies of hers”.

Until the age of 8–9 years, there was an occasional urge to urinate, sometimes, not having time to get to the toilet, she passed urine, and therefore she was ridiculed by her peers.

The patient studied well at school and was a “quick learner”. Preference was given to humanitarian subjects. STEM subjects caused difficulties, especially those associated with spatial representation (geometry, stereometry). The patient was left-handed, retrained to write with her right hand.

Menarche was at the age of 12. Menstruation had always been accompanied by severe pain (which often required an ambulance call), as well as by vomiting and diarrhea, and sometimes fainting.

Until the age of 14, the main hobby of the patient was reading. She preferred science fiction (Wells, Belyaev). She read quickly and willingly; she had to be “pitched out for a walk, but if she went for a walk, then it was difficult to get her in home”. When going out for a walk, the patient always wore neutral sportswear (“unisex” clothing). At the age of 14, a hobby appeared, “which determined life for many years ahead”. Since the moment the patient came to the hippodrome, she became interested in horses, began to spend a lot of time at the hippodrome, caring for the horses and helping the grooms. At that age, she was called “Marina”; surrounding people treated her like a girl, which did not cause discomfort to the patient. She preferred, as before, a predominantly male company. Being part of this company, the patient began to smoke at the age of 14 in accordance with the mechanisms of imitation. She categorically rejected offers to meet with young people; there was an attraction to girls. At the age of 15, she was “in love” with a woman, a hippodrome veterinarian. The patient fantasized about sexual themes, “kissed horses to relieve sexual excitement”. In general, the situation was “surprising and incomprehensible” for the patient, she could not explain what was happening to her.

She graduated from the eighth grade of the school at the age of 15 and after that, she “disappeared at the hippodrome” for a year, where at the age of 16 she got a job as a groom. She “loved horses so much that even with a fever of about 40 degrees” she went to work. At the age of 17, she successfully graduated from an evening school (all grades were “excellent”), then she studied extramurally zoo engineering at the Agricultural Institute.

When the patient was 22 years old, her mother died. For about six months, a severe grief reaction was noted, in which the “participation and care” of her friends helped.

At the age of 23, the patient learned about transsexualism from magazines and immediately realized that “in fact, she was a male, not a lesbian, as she thought before”, that this explained all the insoluble problems in her life: attraction to women, the desire to wear men's clothing, and a short haircut. Then the patient for the first time applied to the medical center for permission for gender reassignment surgery. An examination was offered to her but she declined to perform it for financial reasons.

At that time, she was in love with a girl, made her an offer, and explained that she was actually a man but the girl replied that she “did not know men and, therefore, she was attracted to women”. The girl’s reply was convincing to the patient and she tried three times to have sexual intercourse with random men. The foreplay of sexual intercourse aroused in the patient “only curiosity”; she “did not remember” whether the intercourse itself took place or not, since all three times “at the most crucial moment she lost consciousness, turned blue, her breathing and heart function were disturbed”, which led to her partner’s “evasion”.

At the age of 26, the patient’s “life has changed significantly”. On the night of January 6–7, 1993, she suddenly heard the voice of God who congratulated her on her birth. The voice “confirmed she was a man”. She was “informed that her real name was Sergey in honor of the second son of God and Jesus’ half-brother”. The voice sounded inside the patient’s head. Immediately after this monologue, “the patient saw people in white floating in the air who took her with them on a journey. During this journey, they showed to the patient the whole history of mankind: she saw and touched a dinosaur, she saw the creation of the Earth, a storehouse of souls, in which she found the soul of her mother; these people in white showed her first steps, told her about her whole life, taught her the language of the animal and plant worlds. Everything she saw was voluminous, real – the same as it was in everyday life. The purpose of the journey, as she understood it, was the message that she was the master of all living things”. The patient claimed that she spent a whole week on this trip which she “realized by comparing the dates”.

It was not possible to detect either subjectively or objectively any changes in the patient's mental activity in the period preceding the described one.

 After the “journey”, the patient preserved the contact with God, and it became permanent. She heard his phrases in her head and understood that it was God, according to the special “tone of his voice”. Due to her “extrasensory perceptions”, she began active actions to reassign her gender. She turned to psychics who soon enough began to say to her directly that she was a “schizophrenic”. The patient soon realized that psychics were uniting against her and her connection with God. They tried to “silence the voice of God, reduce the Power that God endowed her with”. At that time, she often began to notice psychics around her, including those who came from Moscow and were associated with the Federal Security Service. According to the patient, since that time “God sometimes left her, but psychics – never”. Psychics tried to “destroy her male part and strengthen the female one”. Using “ion weapons”, they made it so that her mammary glands “suddenly and rapidly grew”. Under the influence of these weapons, they “burned with fire”; episodically “she physically felt psychic rape by a man”, while on the “screen” that appeared before her eyes, she saw the image of a psychic. However, messages from God began to appear on the same screen, allowing or forbidding the use of her Power. Psychics “rejoiced” during periods of her menstruation, when “she was especially vulnerable”, “sent such pain to her that she had to go to the doctors”. There was a period when psychics “drove astral nails into her hands, crucifying her, she physically felt the blood that flowed down her hands, and only after praying in the church did she feel free again”.

At the age of 26, the patient performed the first cunnilingus (before that, from the age of 16, there were cases of episodic superficial petting; the patient created an “alibi” in advance, drinking alcohol and artificially demonstrating a greater degree of intoxication than she really had). She believed that it was after this that a male pattern of hair distribution developed in her (“a rare, slowly growing straggly beard”).

During the described period, the patient was “active, energetic, frank, she tried to tell everyone she met about the Miracle that happened to her”, then she realized that “she had to be secretive so as not to harm herself.” Since that time, the patient changed her job profile: if before this year, she performed work mainly related to animal science (groom, laboratory assistant, animal technician), then after that she preferred to perform the work of a locksmith, loader, electric welder, cleaner, carpenter. She easily coped with “male” jobs, her muscles developed quite quickly, and she did not concede to the men she worked with, she easily joined their company, “understanding them”. At all places of work, the patient visited the women's toilet, but only if there were cubicles, if there were none, she “preferred to endure”.

 Sometimes she “succumbed to the persuasion of psychics”, she reconciled herself to the fact that she was Marina, refused active attempts to reassign gender (“she just calmly waited for the rebirth that God promised her”), put on women’s clothing (“which looked so ridiculous on her, that those around her shied away”). However, even during these periods, “she was not left alone by psychics. She was constantly monitored, all her actions and thoughts were recorded on a computer”. She was “astrally offered” images of beautiful girls with whom she entered into sexual relations. After a short time, the patient met these girls in the everyday world, tried several times to talk on the topic “How did you like it last time?” but it caused scandals. The patient psychically “mastered all the skills of sex, becoming the best lover in the world – Casanova”. Enemies spread information about this side of her life in order to discredit her: “as soon as she got a job, some person with a computer appeared, installed something, and then she began to notice sidelong glances on herself”.

She was raped once by a man (at about the age of 30), while losing consciousness from pain and disgust.

The patient turned to a professor of surgery, who recommended her to apply for surgery permission to a psychiatrist. A urologist diagnosed hermaphroditism in the patient.

In order to obtain permission for gender reassignment surgery, she applied for psychiatric help.

The patient’s only friend has known “Sergey” for about 10 years. Before meeting, she heard about the patient that “this was a girl who identified herself as a guy”, so she was not surprised when Marina “upon meeting asked to call her Sergey, spoke of herself in the masculine gender, looked (behavioral style, clothing) like a man”. At first, they rarely saw each other, but for the last 5–6 years they became good friends. “Sergey” often came to visit her with a desire to consult, to talk about herself. Most often, “Sergey” complained about the misunderstanding of others, about problems in relations with girls, about the inability to get a job due to a discrepancy between the appearance and passport data. For all 10 years, the patient said that she would definitely achieve gender reassignment surgery. Attractive qualities of “Sergey” were honesty, directness, lack of meanness and quarrelsomeness.

 The friend knew that “Sergey” had intimate relationships with women, with one of whom she lived together, in fact in a civil marriage, for about one year. They lived in the patient’s apartment; the cohabitant called the patient “Marik”. The common-law wife used drugs and often drank, and for this reason (at the initiative of “Sergey”), the relationship ended.

 “Sergey” had “a rather attractive appearance, which was spoiled by the teeth malalignment”. Two years ago, the patient underwent prosthodontic treatment and aligned the teeth.

The friend quite rarely heard from “Sergey” unusual statements about the witchcraft of psychics, the voice of God, understanding the language of the animal and plant world, and perceived this as an eccentricity and demanded to “stop talking nonsense”, after which the patient immediately fell silent and did not return to these topics anymore; the patient’s behavior did not follow from the content of these statements.

A few years ago, there was a period of about a year when the patient wore women's clothing (always sports clothing, but still with a feminine arrangement of buttons and locks). The patient still considered herself a man, she said that she was “tired of fighting and proving to society”. Perhaps this was due to the job that she wanted to keep, where the job condition was that the appearance matched the passport gender, but she did not remember exactly.

In order to hide her breasts, she always wore “camouflage clothing: a tight shirt, a sweater”. “I have never seen Sergey in a tight t-shirt”, noted the friend.

The patient lived in a “typically male bachelor apartment where it was dirty, dusty”. However, the bed was always fresh, clothes were clean and neat. She did not know how to cook and did not like to cook. The patient liked to walk, often alone, and in general, her company was extremely small. The year before last, the patient went to a gay club but did not enter into sexual relations with anyone, saying that “easy, accessible, without feelings, sex did not attract her”.

As far as the friend knows, “Sergey’ never got into hospitals in general and psychiatric ones in particular. There was no outrageous behavior. Some neighbors considered the patient “crazy” but only because of her desire to reassign gender. The patient’s individual unusual statements were rare and did not affect her behavior. She believed that after the gender reassignment surgery, “she would turn out to be a great man” and asked for assistance in obtaining permission.

Somatic status

The patient had a normosthenic body type. Her weight was 65 kg, height – 173 cm. The pelvis was wider than the shoulders. The muscles of the shoulder girdle and arms were developed. The skin was clean, with traces of healed acne vulgaris. Hair growth of the chin and areolas of correctly formed mammary glands were noted. Breathing in the lungs was vesicular. Cardiac tones were clear and rhythmical. The abdomen was soft, moderately painful in the right flank, right hypochondrium, and hypogastrium. Murphy’s punch sign was negative. The external genitalia were formed according to the female type; the clitoris was enlarged to 1.5–2 cm.

Neurological status

The patient’s gait was stable in classical and sensitized Romberg's tests. Coordination tests were accurately performed. Asymmetry of the face when baring teeth (the left side was lower than the right one) was defined in the patient. A normal range of eye movement, without nystagmus, was determined. Tendon reflexes were symmetrical, brisk. Pathological reflexes and sensory disturbances were not determined. Fine movements were difficult. With significant difficulty, she performed Ozeretsky's tests for the dynamic organization of a motor act.

Mental status

The patient had clear consciousness. She came to talks willingly, without delay. The patient sat freely, in an uninhibited position. Facial expressions and pantomime were lively. The eyes were often squinted, looked wary, “frowningly”. The speech was slightly accelerated in pace; there were noticeable violations of purposeful thinking, which hampered understanding of the patient's narrative. The voice of the patient was emotional, well-modulated; despite repeated reprimands, she abundantly used obscene words, which she explained by “a habit developed in a male company”, exaggeratingly emphasizing “belonging to the circle of men”. At the same time, after a conversation with a friend of the patient, who clarified that she had never heard a swear word from the patient, she was embarrassed and agreed that she wanted to “demonstrate her masculine soul” in this way. The patient called herself in the masculine gender (when she suddenly used feminine gender, she immediately corrected it). She warned in advance that upon addressing her as “Marina”, she could be “aggressive”.

The purpose of contacting a psychiatrist was to obtain permission to perform gender reassignment surgery (remove the uterus, which she “hated” and called “viper”, and make the penis large) and change documents; the patient considered herself mentally healthy and had self-diagnosed transsexualism.

The patient talked about the fact that “she was a man, she felt this way internally and always knew this, and God, in his appeal to her about 10 years ago, confirmed this, saying that her name was Sergey. God told her that Jesus Christ was her half-brother. God gave her the Power with which she could kill or heal. The Power was maximum for the first time after the conversion, then gradually weakened, but never completely disappeared. In order to use the Power, God's permission was needed, and he gave her this information either with his voice, sounding inside her head, or with messages that often appeared on the screen in front of her face, she perceived this screen not with her eyes, but in some other way, at this time Enlightenment appeared in her eyes”.

When questioned, she noted that she considered herself “a hermaphrodite with a female and male part”, “saw these parts on the same screen”. The patient talked about how “male and female energy circulated through special tracts in her body” (which she depicted in the diagram and showed on the body). The “masculine principle” was concentrated on the right side, and the “feminine principle” was concentrated in the hypogastrium. All her actions were aimed at eliminating the “female” as much as possible and developing the “male”, becoming a full-fledged man. This could be achieved in the following three ways:

1. Psychic influence: “unrealistic, since psychics had united against her, drowned out the voice of God, strengthened the feminine principle”.
2. “Rebirth: indulge in sex with a man, die afterwards, and be reborn as a man. It did not work”.
3. Obtaining permission from psychiatrists, surgery, changing documents – “the most realistic way”.

The patient had decided to follow the third way. She was sure of success, because “if they refuse here, there was Moscow”, and the Father (God) would help. The patient was surprised by the message that the surgery treatment performed after obtaining permission was difficult, multistage, and not always successful. After a pause of confusion, the patient said that “then, at least according to the documents, she would be a man”. This had to be achieved, since “living in the state in which she was then was worse than death” (the patient cried, trying to hide her tears). The patient declared the desire to be a full-fledged man, to have “normal sex and children”. She believed that even before obtaining surgery permission, surgery treatment and changing documents, she had to “behave like a man – in behavior, speech, clothes”. The patient urinated half-sitting: “urinating while standing was impossible, and urinating while sitting was disgusting”. The patient said with a smile that “they did not understand her: she swam in the river like a man in the summer, in swimming trunks and without a bra, which shocked onlookers”. When questioned about this situation later, the patient said with pain in her voice that “she was so tired of her position that she wanted to somehow draw God’s attention to what was happening to her and decided that the collective emotion would reach God faster than her single one”. When asked about the smiles that accompanied these topics being clearly significant for the patient, she said that she “did not want to demonstrate to others her extremely difficult situation, to arouse pity”.

One of the confirmations of her belonging to the male gender the patient called “the eruption of the penis: 7–8 years ago she was in love with a girl, felt a powerful attraction, constantly thought about her, and, in order not to attack the girl, she mounted a horse without a saddle and galloped for a long time to reduce sexual excitement. Suddenly she felt blood flow and experienced pain. Later, the patient discovered a cylindrical structure near the clitoris, which was clearly a penis, although ill-wishers tried to convince her that this was an ordinary cyst”. One of the obvious ill-wishers – the elder sister (the patient called her exclusively by her last name) – “constantly moved from the camp of enemies to the camp of friends and back”.

The patient talked about being lonely. She named with effort one person (girl) with whom she had friendly relations and who could consult upon different issues.

The patient said that “she had a lot of time to solve this problem, she stopped aging from the time she heard the voice of God and would be generally immortal when she became a man”. At the same time, when asked by a doctor about how her life would turn out if the council decided negatively, she answered that “fog would come to the earth, but she would no longer be on this earth”.

The patient interpreted everything that happened during the examination in a special way: “it is good that they did magnetic resonance imaging, the study drove away the devil”, which covered her back, she “saw a receding black cloud”; when having hormone load testing (with folliculin injection), “for some reason the male part was suppressed, the erection disappeared, the excitement subsided, and pain appeared the same as during menstruation”.

In a conversation after a multidisciplinary team meeting, at which a decision was made on the need to terminate the attack and reconsider the issue of gender reassignment, the patient accepted the news of a discovered mental disorder without resistance, agreed to treatment, which was dictated more by “the belief that after the disappearance of the disorder found during the examination, she would finally receive surgery permission”. The patient wondered whether she would stop communicating with God as a result of treatment and, without waiting for an answer, she said that she agreed to everything to achieve the final goal. There was no criticism.

Psychologist's conclusion

Contact with the patient was easily established. The patient was sociable. When asked how it would be better to address her (Marina or Sergey), she replied that she did not care, but soon clarified that it would be better to address her as a man. The patient directly reported the reasons for contacting the Center. The patient demonstrated a willingness to openly share her experiences and impressions related to the “presence” of signs of both sexes in her body, spoke of a desire to understand this, agreed to the hermaphroditism diagnosis. However, during the conversation, it was revealed that it was the mental level of living “bisexuality”, which the subject sought to resolve by means of gender reassignment surgery (“to become a man”).

Joint activities were organized without difficulty, since the subject was focused on the examination, which could bring her closer to the main goal – to obtain permission for the surgery.

The study of thinking allowed revealing distinct violations of the personality-motivational and operational spheres in the form of distortions in the processes of generalization, diversity, derailment, specific reasoning, and a decrease in criticality. So, in the subject classification, the patient immediately singled out a large group and called it “planet Earth and all flesh”, including there, first of all, a globe, and then animals, plants, and people, and not all of them but only a doctor, a cleaner, and a child; a sailor and a blacksmith were referred to technology (transport). The subject paid a lot of attention to this group, said that she was fond of wildlife, while the inanimate world did not interest her much. The order of the cards should be noted, to which the patient attached a special meaning (“people should go first, then predators, according to the tickets purchased, then herbivores, then birds, then a lower class (fish, beetles, and butterflies) and at the end of this chain should be plants as the most sinless creatures on planet Earth”). Despite the tendency to hyper-generalize, the patient did not combine all inanimate into one group at the second stage, leaving them separate. In the “fourth superfluous” test, against the background of correct generalizations, the patient gave situational or subjective interpretations (“the hut needs to be removed, since you cannot hang a lock there”, “I do not know where the shelves for books should be, I do not have such ones in my room”, “a butterfly cannot drink from a bucket”, etc.). The interpretation of proverbs revealed a tendency to tangentiality, violations of the harmony of thinking, and pretentious associations. The proverb “You cannot make an omelette without breaking eggs” was, for example, explained by the patient as follows: “cases are resolved to such an extent that there are always guilty people who become in charge of these cases, the conclusion is that you do not have to meddle there”, etc.

MMPI test. The Welsh code profile was 468"520'1379. The profile had a “positive” slope, indicating a high risk of behavioral reactions. Pathological changes were revealed, manifested by the rise of the profile above the limits of the normal range. The revealed pathological changes did not have syndromic specificity.

Therefore, the psychological examination allowed revealing structural thought disorders (distortions of generalizations, diversity, tangentiality), a decrease in criticality, specific disorders of voluntary attention, which indicated the presence of a schizophrenic pathopsychological symptom complex (according to I. A. Kudryavtsev, 1988), as well as inadequate gender identity.

Results of additional studies

Magnetic resonance imaging of the brain. In the frontal areas, multiple small convolutions were visualized, characterized by a thickened layer of gray matter. Focal brain lesions changes were not revealed, myelination was not disturbed. The differentiation of gray and white matter was reduced. Convexital subarachnoid fissures, cortical sulci, and ventricular system were moderately evenly expanded. Basal cisterns were not changed. The pituitary gland was oval in shape and 1.5 × 1.8 × 1.0 cm in size. The posterior lobe was differentiated. The pituitary stalk was expressed, not displaced. The suprasellar cistern was free. The optic tract courses were not disturbed. The craniovertebral junction was normally formed, the arteries of the base of the brain were of normal shape and size. Paranasal sinuses were airy, without inflammatory changes. Conclusion: signs of neuronal migration and cerebral cortical malformation – bilateral frontal polymicrogyria. Mild ventricular dilatation, diffuse atrophic changes in the hemispheres. Posterior pituitary hyperplasia without distinct focal changes.

Electroencephalogram. The torpidity of the alpha rhythm, interregional asymmetry represented by an increase in slow waves in the anterior parts of the brain, i.e., signs of a diffuse organic lesion had been revealed. All these violations were of mild severity.

Ultrasound of the pelvic organs (transabdominal scanning). Moderate diffuse changes in the myometrium structure, as well as pronounced diffuse changes and cysts of both ovaries, were revealed.

Consultations by specialists

Urologist. During the examination of the external genitalia, typical female anatomy was revealed. An increase in the clitoris was noted, but there were no signs of hermaphroditism.

Neuroendocrinologist. The response to the hormone load test was typical for a woman, which allowed concluding that the hypothalamic-pituitary system was differentiated according to the “female” type.

Clinical analysis

The clinical method characteristic of domestic psychiatry had been applied. Compliance with the methodological principles of diagnosing mental disorders presupposed certain stages. At the first stage (sensory perception of the disease phenomenon), various signs of the disorder were identified and described. At the second stage (clinical analysis), clinical information was summarized, and terminological typing of the previously identified signs was performed, i.e., they were designated as symptoms, and their systematization implied the combination of symptoms into psychopathological syndromes. At the final stage (diagnostic conclusion about the nosological form), a clinical and dynamic model of the disease was built, which demonstrated the features of the dynamics of syndromes (syndromogenesis and syndromokinesis), the patterns of interconnection, turnover and transformation of various syndromic formations (syndromotaxis), and was combined with all available medical information, including those obtained from paraclinical and experimental studies. All these data in total allowed forming the basis for diagnosis. This approach allowed combining the phenomenological, statistical, and dynamic principles of psychiatry and establishing an individual diagnosis.

The entire history of psychiatry is evidence that only the phenomenological approach provides the most valuable information. That is why the analysis of the case began with an assessment of the phenomenon of the disease, and there was no doubt that the patient was mentally ill. The disease phenomenon is always one and indivisible, but in the given case, it clearly had two components.

The first component implied the patient's statements about God communicating with her, whose voice she heard inside her head, which had to be typed as verbal pseudohallucinations with the hallucinatory informing effect; ideas of a special origin, messianism, protectorate, as well as antagonistic ideas, ideas of manipulation, mental automatisms allowed defining a paraphrenic syndrome. Considering the relatively small proportion of ideas of persecution, manipulation, automatisms, as well as the patient’s behavior that did not suffer grossly (which was confirmed both by observation during the examination and by an objective medical history, as well as by the maintenance of the patient’s workplace), a clinical variant of systematized paraphrenia could be determined.

The second component of the disease phenomenon involved hatred of the patient to her body, especially sexual characteristics; the desire to conceal sexual characteristics (the so-called “mimicry”); a distinct psychosocial maladjustment associated with gender rejection; self-destructive behavior (the desire to perform a mutilating surgery).

The totality of these features allowed determining the presence of gender rejection syndrome [2].

Conclusion

The patient's condition was determined by two syndromes related to different types of mental disorders. It was fundamentally important to understand whether they were caused by a single (and which) or different diseases. Can schizophrenia develop in transsexual patients? Does a transsexual patient, who satisfies the indications for gender reassignment tactics and later develops schizophrenia, have the right to gender reassignment surgery? How to implement this right?

It is possible to answer the questions posed only using a structural-dynamic analysis of the case, i.e., by performing the third stage of the diagnostic process.

Five points should be noted when considering predisposition. First, in the family history, the father's abuse of alcohol, probably with explosive forms of intoxication, attracts attention. Second, the early period of the patient's life is characterized by developmental delay and frequent infectious diseases. Third, the imperative urge to urinate up to primary school age, reflecting the dissonance between the processes of excitation and inhibition, is noted. Fourth, the anatomical features of the central nervous system found on the MRI scan are signs of neuronal migration and cerebral cortical malformation (bilateral frontal polymicrogyria leading to dysontogenesis).

At preschool and primary school age, the behavioral features that were previously described as characteristic of the early (presexual) stage of transsexualism development were already noted in the patient: heterosociality (preference for toys and games characteristic of boys; if the patient took part in a girl's game, she performed a male role in it), amphiphilia (tendency to communicate with peers of her own and the opposite sex), tomboyism (behavior of a “tomboy”), the initial manifestations of crossdressing (dressing in clothes of the opposite sex).

In the puberty period, the gender identity inversion and reactions of grouping with peers (preference for the company of boys) intensified, clear formation of crossdressing was noted, an inverse psychosexual orientation developed, which at this stage had a romantic-platonic character, and transsexual conflicts formed. By the end of the pubertal period, which passed with a delay and algodysmenorrhea, signs of inverse gender identity and psychosexual orientation were fixed and began to determine the entire style and behavior of the patient: petting with persons of the same biological and passport sex, which, however, was perceived as “natural” in her perception; constant crossdressing; frequent transsexual conflicts accompanied by growing psychosocial maladjustment and the emergence of antivital experiences. The slow formation of an inverse gender identity (the patient continued to consider herself “a woman, but not quite ordinary, with lesbian inclinations”) led to the late and situational emergence of a transsexual mindset to gender reassignment. Only at the age of 23, having received information about the possibility of a situation where the “passport” sex does not correspond to the “mental” gender, she immediately correlated it with herself and applied for permission for surgical treatment and changing documents. The primary examination did not reveal signs of another mental (psychotic) disorder “competing” with the gender rejection syndrome.

The sharpened multiple complex transsexual conflicts and the growing psychosocial maladaptation led to the formation of compensatory behavior, in particular, sexual contacts with men. They were accompanied by extremely difficult experiences and were assessed as morally unacceptable.

All of the above allows assuming that by the age of 25–26, such pathological condition as transsexualism had been fully manifested in the patient M. It was against the background of this disorder that the patient developed acute paraphrenic psychosis at the age of 26. According to the mechanisms of sanogenesis, the severity of the condition decreased without medical assistance, but the patient did not leave the psychotic state. Paraphrenic psychosis, in fact, had not undergone any special dynamics for 10 years, remaining at the level of the initial syndromic formation. Features of the onset and dynamics of psychosis (acute development, absence of signs of syndromotaxis characteristic of continuous schizophrenia) allowed attributing it to a variant of a protracted attack of shift-like schizophrenia.

It should be noted that after the onset of psychosis, the stereotype of the development of gender rejection syndrome did not undergo significant changes: the formation of crossdressing, inverse psychosexual identity (oral sexual contacts appeared), inverse gender identity (long-term stable relationship – a year in a civil marriage; job implied predominantly being in men's groups) had finally been completed; mimicry reactions became bright, self-destructive tendencies began to appear more and more clearly, and the patient applied for permission to gender reassignment.

The patient's condition was assessed as a combination of two independent disorders – female transsexualism (F64.0 code according to ICD-10: transsexualism) and shift-like moderately progressive schizophrenia, unbroken chronic paraphrenic attack (F 20.01 code according to ICD-10: paranoid schizophrenia with episodic–progressive course with increasing defect).

In the described situation, the primary task was to stop an attack of schizophrenia; in solving this problem, the development of a program of secondary prevention and rehabilitation will acquire special significance. Formally, the patient does not have the right to reassign gender since she suffers from schizophrenia, which is a contraindication for gender reassignment; in a state of psychosis, the patient essentially loses her civil procedural capacity. Informally, the issue remains relevant.