Phenomenology of ideas of gender change in patients with schizotypic disorder

Introduction

Definitions of gender dysphoria existing in the ICD-10 (transsexualism) and ICD-11 (gender incongruence) include the desire to belong to or acquire the characteristics of another sex. However, this desire can be considered as a separate phenomenon, independently acquiring different psychopathological saturation. DSM-5 notes that ideas of gender reassignment should not be regarded as a manifestation of delusional disorders. Long-term experience of working with patients shows that in some cases, the existing gender dysphoria does not lead to the idea of ​​ gender reassignment, and the desire for gender reassignment is not necessarily associated with the severity of gender dysphoria, but has its own dynamics.

Some studies indicated schizotypal disorders in adults who, when being adolescents, were treated for sexual and gender identity disorders and the coexistence of gender dysphoria and schizoid personality [1]; some mechanisms of gender dysphoria in such patients were described [2]; difficulties in diagnosing such conditions were noted [3]; however, no studies highlighting the ideas of gender reassignment in terms of psychopathological analysis were found.

Materials and methods

Thirty-eight patients (27 women, 9 men) with schizotypal disorder (F21 according to ICD-10), who applied for gender reassignment during the period of 2015–2021, were examined. The average age was 23.8 years. Thirteen women whose mental state did not allow giving an unambiguous psychopathological qualification of the variants of gender reassignment ideas were excluded from the sample. The methods used were clinical-psychopathological and sexological. A specially designed questionnaire was used to assess the sexual sphere and identify the motivation for gender reassignment and plans for the future.

Results

In two patients (one woman, one man), the ideas of gender reassignment were of an obsessive nature, as well as accompanied by a struggle and the development of coping strategies while maintaining criticism of them. They were anancastic, characterized by alien content, the presence of resistance, persistence and resistance of obsession to autocorrection, accompanied by an emotional reaction in the form of a painful feeling to the fact of the emergence and manifestation of the phenomenon of obsession [4]. In these cases, being in anxiety-depressive states, patients sought not treatment, but advice on what to do in such a situation. These patients agreed to treatment, which led to the deactivation of such ideas, they did not have a direct impact on the behavior of the patient. In the sexual history, there was a delay in psychosexual development without gender-role violations, and avoidance of sexual contacts.

In four cases (one man, three women), it was possible to reveal fixed ideas [5], which were characterized by a “frozen piece of logic”, which indicated an area in which a person did not perceive (there was a certain blockage), i.e., a person did not realize that he or she had chosen these ideas that guided him/her in various life situations, ideas that a person considered true without thinking about it, and never checked them and accepted them unconsciously. For such patients, the preservation of formal criticism turned out to be inherent not to the ideas themselves, but to the possible consequences of their implementation for patients’ condition and position in society. Such persons tended to postpone gender reassignment for the future and agreed to long-term observation by a doctor in order to clarify the diagnosis. They dressed and talked about themselves according to their passport gender, and in response to a doctor's question about the reason for this, they explained that they had postponed the peculiarities of their behavior for the period after the change of passport gender. Specific thought process disorders in the form of tangentiality and paralogicality were intensified or even revealed only when describing experiences associated with a sense of sexual identity. Such persons refused treatment and outwardly agreed with the doctor and the premature realization of the desire to change the passport gender. They critically assessed the impact of external circumstances on the decision to change the passport gender, expressed concern about the side effects of hormones, and postponed the decision on surgical correction until later. They showed signs of a delay in psychosexual development, a weakly expressed sexual desire, which was realized mainly through masturbation (2 cases), or were generally asexual, also postponing the onset of sexual activity for the period after changing their passport gender.

 In six cases (three men, two women), patients had dominant ideas which “periodically assumed a dominant role in the mind of a person; as well as were accompanied by a positive emotional charge; obeyed the will of the bearer of these ideas; were limited by the content of the experience; yielded to autocorrection; critical evaluation of ideas was preserved” [4]. Such persons had pronounced autochthonous fluctuations in the affective background; in hypomanic states, they actively visited the doctor, required examination to change their passport gender; such conditions lasted up to 1–2 months followed by the disappearance of patients from the doctor's field of vision for a period of up to 1.5–2 years, after which they appeared again in a similar condition. When explaining their long absence, patients referred to external circumstances. In contrast to the definition of Rybalskiy, in patients with schizotypal disorder, criticism of experiences was of a formal nature, which manifested itself in external agreement with the words of the doctor about the necessary examination and observation for a certain period of time while maintaining the conviction of the need to change the passport gender. The ability to manage one's emotions arose only against the background of normal affect, which could be judged from the patient's stories about how he or she felt during periods of remission. In one woman, on the contrary, visits to the doctor coincided with periods of subdepression with anxiety. In patients, speech behavior and clothing corresponded to the passport gender, with the exception of one man who, in hypomania, wore women's clothing and spoke of himself in the feminine gender, dressed like a man in remission, and changed accordingly the generic endings in speech. As proof of their belonging to the other gender, they cited such arguments as personal and behavioral characteristics. In the anamnesis of patients in three cases, a delay in psychosexual development was revealed; in sexual contacts, bisexual tendencies were determined in men, homosexual – in women. Autogynephilia was revealed in one man, the corresponding fantasies supported his desire to change gender.

In nine cases (two men, three women), the overvalued ideas of gender reassignment were defined. “Supervaluable ideas arise in connection with real facts and events; are closely connected with beliefs, fixed on desires, based on delusions, are formed in the form of understandable ideas, ideas are recognized as their own (without a sense of alienation) with their unconditional meaningfulness; are characterized by bright affective accompaniment with hyperbolization of internal experiences, and deprived of paralogical constructions; influence the motives and actions of the subjects under examination; there is the possibility of dissuasion” [4]. In this group, in contrast to the cited definition, there was no bright affective accompaniment due to a general decrease in emotionality, really detectable gender-role violations and homosexual orientation were primarily subjected to hyperbolization, the possibility of autocorrection or correction by the doctor was limited, patients stenically sought an immediate solution to their problem, and in case of refusal went to other private clinics. In contrast to the previous group, in response to a doctor's question on how can they prove their belonging to the opposite gender, the patients stated that since they thought so, it did not need proof. At the same time, there was, albeit limited, awareness of the problems associated with changing the passport gender for oneself and others. When asked by a doctor what their life problems could not be solved by gender reassignment, the patients cited their personal or appearance characteristics, though often considering them to be secondary. When asked what they expected from hormone therapy or gender reassignment surgery, patients indicated that they expected to improve their ability to communicate with other people. They were partially aware of the problems of the side effects of hormones and their impact on the sexual sphere; women with experience of homosexual contacts preferred to confine themselves to the removal of the mammary glands; men were set up for a complete surgical correction, declaring the possibility of a complete rejection of sexual contacts, even if there were such earlier. All men demonstrated signs of delayed psychosexual development. In two cases (men), the patients started hormone therapy on their own without a doctor's prescription. In women, an egodystonic form of homosexual orientation was revealed; in one woman, sadistic tendencies were determined against the background of premature psychosexual development, which was expressed in clothes close to men's, while the rest of the patients dressed in “sexless clothes”.

In four patients (one man, three women), the delusional nature of the ideas of gender reassignment was defined. These patients had no criticism of the possible consequences for themselves and those around them, argued that they had no problems that would not be solved by gender reassignment, as well as made life plans that were far from reality after changing their passport gender. The preoccupation with experiences blocked the doctor's correction and autocorrection. They planned hormone therapy, expecting a “complete” transformation of their appearance in the result, as well as “total” surgical correction. In two cases (women), it was possible to trace the mechanism by the type of “insight” in puberty, when thoughts about gender reassignment arose at the peak of the depressive state, which led to the relief of affect and “life was filled with new meaning”. This “insight” was associated with the first acquaintance with literature about transgender people or personal contacts with them. Involvement in such a community obviously facilitated the condition of patients: they noted that in such an environment, addressing them in a desirable field contributed to an improvement in their mental state. Among them, two women identified themselves as “bigender”, and one – as “agender”. In the anamnesis, according to the words of the patients, gender-role violations were revealed, which, however, were not confirmed by the data of an objective anamnesis.

The latter phenomenon was also observed in three patients (two women, one man) who were not included in the above groups. When describing experiences related to gender and psychosexual development, they used stenciled, stamped phrases such as “gender-neutral games” when they were unable to explain their essence. The entire anamnesis outwardly repeated literary descriptions of transsexualism, which were not supported by objective data. The patients could not convincingly explain the reason for this discrepancy, demonstrating disagreement with their parents and even accusing them of a negative attitude toward them. Outwardly, the patients dressed as intersex, spoke about themselves avoiding generic endings or alternating male and female gender. Two women from this group complained that it was difficult for them to imitate the gestures and facial expressions of men, which indicated that they were doing it consciously. The closeness of patients, the inaccessibility of the analysis of their experiences did not allow unambiguously qualifying their condition psychopathologically, although the connection of the ideas of gender reassignment both with external factors (plots on the Internet, entering the transgender community) and with the peculiarities of the mental state at the time of exposure was clearly traced. The pronounced mental infantilism, which facilitated suggestibility, was revealed in these patients. The author of this study qualifies such states as “overvalued ideas” that have arisen by the mechanism of induction.

Discussion

The approach outlined in the study is a deliberate simplification, since the author does not consider the mechanisms of gender dysphoria in the studied groups of patients. It should be noted that for all its debatability, it allows highlighting the main, according to the author, problem for such patients, namely, violations of criticism of their own experiences and behavior, which casts doubt on their ability to adequately assess the situation of gender reassignment and predict its consequences. An analysis of the characteristics of the sexual sphere of the studied groups demonstrated the predominance of delays in psychosexual development and the deactualization of the sexual sphere associated with it. The small number of patients in the groups did not allow revealing any significant relationships between the behavior of patients and the phenomena of gender reassignment ideas, which dictates the need for further research.

Conclusion

The author of this study shares the opinion of Perekhov [6] that this ability should be assessed as a type of capacity, regardless of the nosological nature of the disease, and that previously existing considerations about contraindications to changing the passport gender in patients with mental disorders of the schizophrenic nature need to be revised. It is also necessary to create a new methodology for the psychological study of such patients for a clearer idea of the levels of criticality violation.  

Ethical considerations

The study was conducted in full compliance with the Federal Law of November 21, 2011 No. 323-FZ (as amended on December 28, 2013, as amended on June 4, 2014) “On fundamentals of the protection the citizens’ health in the Russian Federation”, the Law of the Russian Federation dated July 2, 1992 No. 3185-1 (as amended on December 28, 2013, as amended on June 4, 2014) “On psychiatric care and guarantees of the rights of citizens in its provision”; also in accordance with the International Conference on Harmonization, other requirements of the legislation of the Russian Federation and the countries participating in the study, it is consistent with the principles laid down by the Declaration of Helsinki of the World Medical Association (WMA) and the order of the Federal Agency for Technical Regulation and Metrology dated September 27, 2005 No. 232 “National Standard of the Russian Federation "Good Clinical Practice (GCP) GOST R 52379-2005”.