Clinical case of gender dysphoria in a patient with a procedural disease

Relevance

The problem of gender dysphoria in recent years has become increasingly relevant and resonant. A few decades ago, this topic was restricted professional. Especially the Soviet Union should be noted, where studies, associated, as it seemed then, with sexual deviations, were not welcomed. Only during the period of perestroika and glasnost, this problem began to be covered more actively by mass media, which were primarily attracted by the exotic nature of the subject. As evidenced by a number of publications describing this disorder in historical figures in ancient times, the desire of some people to reassign their gender goes back centuries. Nemirovsky (1993) in “Myths and Legends of the Ancient East” describes the mythological Indian deity Bshihmu, who refused to fight the mighty warrior Shikhandi, since the latter was born a girl and subsequently reassigned his gender. Fedorova in her book “Imperial Rome in Persons” (1979) describes the biography of the emperor of Rome Varius Avitus Bassianus, which resembles a description of transsexualism. He went down in history under the name Heliogabalus (Elagabalus). During the four years of his reign, he gained notoriety for his dressing up as a woman. After “marrying” a male slave, he promised half of the empire to the healers if they could turn him into a woman [1]. However, this problem attracted the attention of scientists not so long ago. For the first time, a scientific description of clinical cases of an irresistible desire to wear clothes of the opposite sex was presented in the works of Frenkemi in 1870 and Westphal in 1870 [2]. For a long time, there was no terminological certainty in the name of this disorder. Therefore, in different years, the following terms were used: “metamorphosis sexualis paranoica” [3], “mental hermaphroditism” [4], “perverse sense of one’s gender”, “sexo-aesthetic inversion”, or “eonism” [5-7]. The latest history begins with the monograph by Benjamin (1953) "The Transsexual Phenomenon". Over the past time, the clinical picture of transsexualism has been described phenomenologically, and its heterogeneity has been shown. Along with the classic cases of transsexualism, in which its main manifestation is the phenomenon of gender rejection, which was the most completely described in the works by Bukhanovsky in 1994, the same type of conviction in the need to reassign gender takes place in transvestic disorder as one of the adolescent manifestations of sex-role violations, but without violation of gender identity [8], as well as in masochistic automonosexual transvestism [9], in “asexual” transvestism [10], which, according to Bukhanvosky and Perekhov [11], is the final stage of fetishistic transvestism with sex rejection syndrome, and in nuclear homosexuality. Therefore, a long-term study of this problem has confirmed the heterogeneity of the group of mental disorders, which are characterized by symptoms of cross-dressing and the mindset to reassign gender, which was also mentioned at the Second International Conference on Sexology in 1976, where the term “gender dysphoria syndrome” (sex rejection syndrome), proposed by Walker, was adopted. This group included transsexualism, transvestism, effeminate homosexuality, and virilized lesbianism [12]. Moreover, Money [13] noted the comorbidity of paraphilias with temporal lobe epilepsy, since there was a clear similarity between perverse cases of sexual behavior and nonconvulsive epileptic seizures [14]. Rejection of one's own gender also occurs in various forms of schizophrenia: in a paroxysmal course – as periodic delusional effeminization or masculinization, in a continuous course – at the stage of paraphrenization [15], in a low progression course – as a variant of the pretentiousness of the emotional-volitional sphere or an absurd worldview [16]. However, only in persons with transsexualism, the gender reassignment mindset finds its full development, being one of the main manifestations of the psychosocial maladjustment of this suffering, competing with suicidal behavior [11]. In view of the foregoing, it becomes understandable that there has been an increase in the number of requests for gender reassignment to medical centers in recent years. Considering the trend toward depathologization of gender dysphoria issues that has emerged in recent years, a large number of patients suffering from certain mental disorders perceive information in the mass media as a guide to action and consider gender reassignment to be a panacea in solving their problems [17].

Description of the clinical case

A 14-year-old patient G. applied to the Medical and Rehabilitation Scientific Center Phoenix in March 2021. During the examination, a hereditary burden was revealed along both lines: the maternal great-grandmother at an advanced age suffered from dementia accompanied by aggressive behavior at that time. The maternal uncle, presumably, suffered from an affective pathology (for six months “he lay, did not get up, was not interested in anything until therapy was prescribed”). The maternal aunt, according to relatives, had “psychosomatic pains”. The patient's mother had a depressive disorder (revealed after her daughter's illness), a history of jitteriness accompanied by panic attacks. The patient's father suffered from chronic ethylism, but did not admit that he had an alcohol addiction. In a stressful situation, the father began to stutter. Heredity was somatically burdened on both lines: the paternal grandmother suffered from atrial fibrillation, and the paternal grandfather suffered from arrhythmia and died of oncopathology (throat cancer). The maternal uncle had a thyroid disorder. The maternal aunt was diagnosed with pituitary adenoma and obesity.

The patient, accompanied by her parents, came to the medical center with a desire to reassign her gender.

Medical history

The patient was born from the first pregnancy, which occurred when her mother was 27 years old; the father at that time was 29 years old. The pregnancy proceeded against the background of a threat of miscarriage (uterine hypertonicity), taking hormonal drugs (duphaston), anemia, fetal hypoxia, oligohydramnios, and tight triple entanglement of the umbilical cord around the fetal neck. She was delivered at term by cesarean section. The birth weight was 2,950 g. The patient was breastfed for up to three months, and then she was transferred to artificial feeding due to hypogalactia in the mother. Until the age of one, she was a calm child. Early psychophysical development corresponded to age standards: she began to sit at 6 months, did not crawl; according to her mother, due to hypotension diagnosed by a neurologist, she began to walk at 12 months, the revival complex was developed satisfactorily, there were stages of cooing and babbling, phrasal speech developed at the age of 1.5 years. Convergent strabismus was diagnosed after one year of age, the treatment of which was successfully completed after some time. The patient was also diagnosed with platypodia. When the patient was three years old, she fell from a chair (without signs of concussion) and began stuttering after that. She received neurological treatment, and was also “treated with folk remedies”, regularly studied with a speech pathologist. Stuttering was completely cured by the age of 7. From an early age, fears of spiders, bees, and wasps were noted. The patient attended kindergarten from the age of 3, quickly adapted to it. She grew as a sociable, open, self-confident, inquisitive, “developed beyond her age” person. According to her mother, she was emotional, empathic, affectionate, loving tactile contacts. She was interested in detective games (scouts, spies), from toys she preferred only soft toys in the form of any animals. Since childhood, she loved pets (cats, dogs) very much. The patient played with both girls and boys, quickly became a leader. At preschool age, she liked listening to her mother reading books. She herself became interested in unassisted reading from the age of 8. Since childhood, she preferred more “practical”, sporty outfits, and later she chose business attire. When the patient was between 5 and 7 years old, she visited the pool. When the patient was 7 years old, a stepfather appeared in the family, with whom she immediately developed trusting and warm relations. Indulgent overprotection was the prevailing form of family upbringing. While the proband got older, more categoricalness began to appear in her character, she could throw “a tantrum if something did not go according to her plan”. She went to school at the age of 7 and quickly adapted to elementary school. Studying was easy for the patient due to her abilities. However, she did not have enough patience and perseverance; therefore, the academic progress varied, which often led to misunderstandings with her stepfather, who controlled her studies. The patient took part in olympiads and was an active student in the class. According to the mother, the daughter’s position was authoritative in the class, but at the same time, the daughter never had close friends: “She always had many acquaintances, friends, but she never had a close friend.” From the age of 7, she became interested in playing games on consoles, collecting 3D puzzles, and constructing Lego. Outwardly, she was a tall, slender girl with long hair, which she did not allow to cut, she asked her mother to braid her pigtails. From the 4th grade, she went to school with her hair untressed. She preferred to wear modest clothing to school: a suit (trousers/skirt and jacket), a tight-fitting shirt, a brooch on her jacket. She wore jewelry: earrings, nonbright hairpins. The patient preferred practical (sporty, comfortable) shoes but did not refuse to wear low-heel shoes. From the age of 11, she began to consciously engage in studying English and currently has a good command of it. In 2016, when the patient was at the age of 10, a second child was born in the family; and on the whole, she reacted well to the birth of a child but still showed jealousy. The patient began to spend more time with her brother when he grew a little. In the 5th grade, all the students were differentiated depending on the level of their abilities and academic performance, the patient was included in the “strong” class. According to the mother, the patient’s adaptation to such differentiation was more difficult than at an earlier age but developed “quite smoothly”. Academic performance remained at the same level. From the age of 11–12, certain interests periodically began to arise: for example, there was an interest in Japanese culture. She could imitate heroes or “transform” into one or another hero. Then she became interested in music (hard rock, metal), spent a lot of time in headphones fully “plunging into the music”. Since that time, she “began to pay attention to numbers, giving them special meanings”. The patient believed that since the age of 12–13, she had become more emotional, impulsive, and irritable. In the same period, she began to conflict with her stepfather. She considered that this was due to the fact that until the age of 12, she did not have her own opinion, and after that, she began to defend her point of view. From about the age of 12–13, she began to get involved in books on psychology, anti-utopias, medicine, and read a lot. From the age of 13, she began to stoop more (“in order to hide her breasts”), for the same reason she did not want to attend physical education. From the age of 13, the mother began to notice mood swings in her daughter, but did not attach much importance to this, since the daughter was always very emotional, impulsive, and associated the changes in her mood with the onset of adolescence. Later, the mother began to notice that the patient was periodically less active, and after a while, on the contrary, there were periods of “overexcitation” and activity. In the spring of 2019, the patient had a scheduled examination by a cardiologist-arrhythmologist, who spoke incompetently about the predictions of the existing cardiac problem. The patient reacted very aggressively right in the doctor's office, which had never been noted before. Since that period, “fear for her health” has appeared in the patient, outbreaks of aggression have become more frequent. In the summer of 2019, the patient became interested in programming, but her interest did not last long (according to her mother, it was superficial). According to the patient, in the summer of 2019, she first felt sympathy for a girl in the form of platonic love. In August 2019, she was on a trip with her parents and younger brother to the Crimea, where she swam in a bathing suit, was not shy about her appearance, walked with her hair down, her mood was good. Upon returning from the trip, against the background of worries about the health of her younger brother, she herself fell ill with a sore throat, which proceeded in a severe form. After that, the patient began episodically experience sleep disturbances in the form of insomnia. She also awakened from “panic attacks” that she did not tell her parents about: “an incredibly strong feeling of fear, lack of air, the need to find the coldest place in the house”. In the 7th grade (September, 2019), according to her mother, the patient went to a school assembly with bows on her head. At the same time, the patient herself, already from that period, described her behavior and style as more “masculine” or “close to unisex”, because of which conflicts with peers periodically arose at school. However, after that, the patient's friendship with the main “hooligan of the school” took place, which, in her words, protected her from attacks of girls. She continued to be passionately fond of music, which, in her words, “later pulled her out of her depression”. The patient noted that during that period, the mood worsened, and tearfulness, irritability, and episodic “compulsive overeating” appeared. In the same autumn period, she began to inflict cuts on her hands and body due to conflicts with her parents about her studies in order to facilitate her moral well-being. The patient repeatedly asked her parents to contact a psychologist/psychotherapist. Since January 2020, after going to school, she noted that there were difficulties with the assimilation of the studied material (“it became harder to study and to think”), due to which academic performance decreased, her mood was mostly depressed (parents during that period neither noticed her low mood nor saw emotional fluctuations). From this period, the patient began to talk about herself in the company of her peers using masculine pronouns. She realized that this made her feel more comfortable. At the end of February 2020, according to the patient, an imaginary friend “Mike” appeared whom the patient saw and heard. Then she began to see nightmares, where she killed people, including loved ones. The patient did not understand what was happening to her, she became interested in forensic science, read a lot of information about maniacs and their sophisticated methods of murder. Then she created her own telegram channel in which she posted the studied information. In the spring of 2020, she began to wear a sweatshirt with a jacket in order to hide her breasts. Since the spring of 2020, according to the mother, the daughter began to preach tolerance towards minority communities. However, then she still “actively lived the life of the class”, consulted with her mother. She complained to her mother about difficulties with falling asleep, and began taking persen but without much effect. The patient had repetitive, bloody dreams and began to notice quite often episodes of deja vu. In the same period, for the first time, she shared with her mother the story of the daughter of a famous actress undergoing hormone therapy in order to reassign her gender. Having not received support from her mother, she became dissatisfied, irritable, rude, depressed, and did not make contact with relatives. In April 2020, the patient told her mother about an imaginary friend who became her best friend, who supported and understood her, hugged and stroked her head, came to her every day but only when she was alone in the room. They turned to a psychotherapist, depression with psychotic symptoms was diagnosed in the patient, and the therapy was prescribed (hydroxyzine hydrochloride, risperidone, glycine forte, sertraline). Two weeks later, the patient told the doctor that she did not feel like a girl. During therapy, there was a positive trend: the mood was getting better, the “imaginary friend” did not appear anymore, sleep became better, and appetite was the same. At the next meeting, she told the doctor about her plans: about moving to another country, where the attitude toward the issues of transgender identity was more tolerant and where it would be easier to make the “transition”. The doses of risperidone and sertraline were increased. After that, the parents began to notice that the patient became more irritable, began to talk too much (“there was a lot of talking”). At the end of April 2020, she cut her hair: “I was tired of my hair, I wanted to change.” This act was very alarming for the parents, since the daughter was always sensitive to this issue, but they agreed. In the same period, the patient took off her cross pendant, stopped wearing earrings and jewelry. In May 2020, she began to change her behavior: she changed her style of clothing, began to lower her voice and stoop even more, while her mood was somewhat upbeat, as she was pleased with her external changes. Since the end of spring 2020, the patient began to introduce herself on social networks as Boris Povlyakovsky (“I read Shcheglov and got inspired”). In the summer of 2020, she got a job as a runner in her stepfather's restaurant, where she went with great pleasure. At that time, she worked hard, her sleep was reduced, she did not get tired, “ran to work with pleasure”, easily met people, quickly memorized information, and was fond of various musical styles. The patient spent free time with friends, riding a bike. She became interested in playing the guitar and began to visit a tutor to learn how to play. The patient bought the e-book reader. Menarche was in August 2020, the cycle has become regular. In the same period, a family sea trip to Crimea took place. There the patient self-inflicted injuries with a kitchen knife because of a minor conflict with the relatives. During the trip, she wore only large-size T-shirts (5XL), sports shorts, and unisex clothing. When the patient went to the sea, she put on shorts over a one-piece swimsuit, and after swimming, a T-shirt. Upon returning from Crimea, the patient began to apply Androgel to her body, but after a week she stopped, as she was worried that this would harm her and interfere with hormone therapy in the future. In addition, she was worried that the gel, having a strong alcohol smell, could be noticed by relatives. In September 2020, she attended school without desire (“Why? Why is this necessary?”). At first, the patient bought the school uniform on her own in menswear stores but could not choose the right size. At that time, the patient confessed her feelings to the girl but she refused; being not despaired, the patient began to meet with another girl. Then the patient’s appetite increased, there were frequent awakenings in the middle of the night, she did not feel rested after sleep, and self-inflicted injuries (“it seemed to her that life was over, parents did not accept her”). The patient wondered about the meaning of life. At the beginning of October 2020, she categorically demanded that her parents called her Sasha: “You hate me if you can’t do it.” She stated that she did not like everything feminine. There were sharp mood swings, irritability, tearfulness, and disturbed sleep. The patient began carrying a knife with her when walking. According to the mother, there were two or three episodes when the daughter was anergic and very pale in the morning, had inappropriate behavior, slurred speech, unsteady gait, and hypotension (60/40 mm Hg); therefore, they turned to a cardiologist. Later, the patient confessed to her mother that she took phenazepam up to 6 tablets a day “in order to go blank”. The patient also wanted to take No-Shpa, because she found out that this drug should not be taken when there was an AV blockade – she wanted to die. On October 14, she came to school in men's shorts, a jacket, and black jeans, and felt “pronounced self-confidence”. After returning from school, she made an unsuccessful suicide attempt by “taking medication”. The patient was hospitalized in intensive care, where her behavior was inadequate: she screamed, cursed obscenely, was disinhibited, many self-inflicted cut injuries were found on her arm. Then the patient was admitted to the psychiatric department of the Federal State Budgetary Scientific Institution Scientific Center for Mental Health, where she was from October 15, 2020 to November 24, 2020 with a diagnosis of “Other schizoaffective disorders F25.8”. The mental status at admission was as follows: “The patient willingly takes part in the conversation, sits down on the proposed chair. The patient is oriented all around. The mood background is uplifted. The patient has a hypomimic face, facial expressions are devoid of childish liveliness. Eye contact is unstable. The patient talks in monologue, tells about herself; clarifying questions are unnecessary. Statements are inconsistent, ambivalent. She speaks of herself in the masculine gender, calls herself Sasha in honor of her father, Boris, ‘trans person’; she openly says that she came ‘with a sock in her shorts’, without it she experiences ‘gender dysphoria’; confidentially reports that she secretly from parents takes testosterone. The patient promptly announces personal interests, being engulfed by the topic of serial killers, repeats the name of Jeffrey Dahmer several times, ‘sex psychology as a deviation considers what maniacs do … and I'm interested in those who killed men, this is abnormal, and it means that it is interesting to me’. The patient plans to create a Telegram channel on the relevant topics. She is enthusiastic about hospitalization, dreams of meeting people with similar interests. The patient confusedly describes the circumstances that led to the suicide attempt, expresses various reasons: ‘I wanted to die, but first I had to hallucinate due to taking phenazepam, but they didn’t bring phenazepam’, ‘I didn’t want to die, just get partially poisoned’. She confirms the presence of suicidal ideas: ‘I must definitely die’; at the same time, she declares: ‘I don’t want to die ahead of time, I want to grow a beard first’. The patient also says: ‘It seems to me that I have two personalities, and they are in contact with each other: Emerson and Boris, Emerson + Boris = Sasha’, ‘previously there was an imaginary friend Mike, but he was removed by rispolept’. No criticism of the present state is revealed”. In the hospital, she introduced herself as Sasha, and in social networks – as Alexander Fedorov. She was discharged as planned, due to the stabilization of her condition. It was recommended to continue treatment: haloperidol 9 mg/day, biperiden 6 mg/day. The drugs were taken regularly, under the supervision of parents. After discharge, she began to quickly deplete after communication, the previous state returned: mood swings, irritability, and the relevance of the gender reassignment idea did not change. Appetite sharply increased in the patient, she gained weight. The patient began to study remotely (“I won’t go to school, I feel bad there”), without much initiative. She had conflicts with her stepfather over studies, and there were conflicts over domestic disagreements with other family members. The patient spent most of her time at home, on social networks; she stopped going out, did not communicate with anyone, became withdrawn, very shy. The patient planned to study Chinese. She started going to the gym after much persuasion. After a while, she liked doing it. She perceived any phrases addressed to her in a “narrowly focused way”, believing that people did not treat her that way.

Somatic status

The patient was of normosthenic type with increased nutrition. The skin and visible mucous membranes were pale pink. There were multiple cut marks on the forearms of both hands, including several keloid scars. Breathing in the lungs was vesicular, without wheezing. The respiratory rate was 18 br/min. Cardiac tones were clear and rhythmical. The cardiac rate was 80 bpm. Blood pressure was 96/65 mm Hg. The tongue was moist, clean, and pink. The abdomen was soft and painless. The liver was at the edge of the costal arch, painless on palpation. Murphy’s punch sign in the lumbar region was negative on both sides. Stool was with a tendency to fecal retention. Urination was free and painless.

Neurological status

The gait was stable. Cranial nerves functioning: disseminated microorganic symptoms. The pupils normally responded to light, consensual pupillary response was normal, D = S. Pathologies in the sensitive and motor areas were not revealed. Romberg’s pose showed a slight staggering of gait. Coordination tests were performed with a slight overshoot on both sides.

Mental status

The patient entered the doctor’s consulting room at the invitation, accompanied by her mother. Outwardly, she was dressed neatly but she looked untidy. Her hair was short and tousled. The patient wore plus size, sporty, unisex clothing. She avoided prolonged eye contact with the doctor. There was no makeup on the patient’s face. Speech was slurred. She said that her parents did not understand her, because she wanted to change her gender to male: “I want to reassign the gender, I consider myself a man, I have male psychology, male hobbies, I like girls”. The patient believed that lack of self-confidence lay in the “female gender”. In her opinion, the concept of gender reassignment included hormone therapy, removal of the mammary glands. The patient planned to remove her mammary glands, cut her hair short, change the timbre of her voice, “grow hair on the body”, and buy men's clothing. She had not yet decided on phalloplasty, since her transgender acquaintance “does not think that this is necessary”. She was dissatisfied with her face (“it’s feminine”), her legs (“they have cellulite, but men don’t have it on their legs”), and her voice (“it’s high”). The patient complained of apathy, laziness, unwillingness to do anything, low mood, fatigue, drowsiness, retardation. She implemented hygiene measures with difficulty and irregularly. She was convinced that she no longer had feelings for her parents and relatives. The patient confirmed that she had suicidal thoughts from time to time. She also felt uncomfortable on the street because of the glances of people: “It seems that people perceive me strangely, that I am a freak, not only outwardly, but also a moral freak”. Criticism of her condition was significantly reduced, while she agreed to treatment at the Medical and Rehabilitation Scientific Center Phoenix.

Conclusion based on the results of a pathopsychological examination (dated April 2, 2021)

As a result of an experimental psychological study, a decrease in sensorimotor performance with a tendency to exhaustion, a significant decrease in the selectivity and concentration of attention in conditions of overload of the visual analyzer due to distortion of the motivational sphere, signs of a violation of the operational side of thinking in the form of a distortion of the generalization process through the actualization of nonessential properties had been revealed. Particular attention should be paid to the affective-personal sphere, where a clinically significant level of both anxiety and depressive symptoms had been found; signs of emotional and personal disintegration had been revealed. In the characterological picture, sensitive-schizoid traits came to the fore, and femininity traits predominated in the system of relations. The absence of clearly separated ideas about the gender differences between the male and female roles had been revealed; in the gender-role profile, not the predominance of gender-stereotypical features but androgyny had been found. “Intellectualization” had been the main mechanism of psychological defense. The leading coping strategy “Escape-avoidance” was conditionally maladaptive. Based on the anamnestic information and data obtained during the study, signs of development of a schizophrenic pathopsychological symptom complex had been revealed.

Electroencephalography (dated March 26, 2021): the main rhythm corresponded to the age norm. Slight diffuse changes in the bioelectrical activity of the brain were found. During the entire study, no significant interhemispheric asymmetry, typical epileptiform activity, patterns of epileptic seizures, or epileptic seizures were registered.

Electrocardiogram (dated March 19, 2021): sinus rhythm with a cardiac rate of 96 bpm. Solitary supraventricular extrasystole with aberrant conduction was revealed.

Complete blood count (dated July 28, 2021): Lymphocytes 38.9 (above reference values); all other parameters were within the normal range.

Hormonal and biochemical blood tests were performed, which did not reveal any pathology according to multiple indicators.

Ultrasound investigation of the thyroid and parathyroid gland: (dated April 7, 2021): small cysts in both lobes of the thyroid gland were found.

The following treatment was performed:

1. Detoxification therapy – sodium thiosulfate, reamberin.
2. Metabolic, nootropic, antioxidant therapy – neurox, cardionate, panangin, cytoflavin, picamilon.
3. Antipsychotics – haloperidol (up to 4.5 mg/day), quetiapine (up to 850 mg/day), trifluperazine (up to 8.75 mg/day), cariprazine (up to 6 mg/day).
4. Normotimics – lithium carbonate (up to 750 mg/day).
5. Correctors of extrapyramidal symptoms – biperiden (up to 6 mg/day).
6. Tranquilizers – diazepam (2.0 ml/day via IV drip), clonazepam (up to 0.5 mg/day), hydroxyzine hydrochloride (up to 43.75 mg/day).

Treatment results

Against the background of the therapy, a significant positive trend was achieved: the mood returned to euthymic; irritability, tearfulness, proneness to conflict, aggressiveness, and suicidal thoughts disappeared. Anxiety, obsession with numbers, and other fears that disturbed the patient were leveled. The patient again returned to learning languages, new hobbies appeared, she became more sociable and self-confident. The patient started speaking of herself in the feminine gender; in social networks and in life, she appeared to be female. Outwardly, she became neat and tidy, took care of her appearance, and visited regularly a beauty salon. Criticism of her illness had been formed.

Clinical analysis

Based on the patient's complaints, anamnestic information, and using a clinical and psychopathological method, a hereditary burden was revealed (the maternal great-grandmother suffered from dementia at an advanced age; the maternal uncle, presumably, suffered from an affective pathology; the patient's mother suffered from a depressive disorder, and the patient’s father — from chronic alcoholism). Despite mild perinatal pathology, early psychophysical development corresponded to age standards. During the premorbid phase, the patient was characterized by sociability, activity, amphiphilia and amphisociality, she was quite empathic, but did not build deep friendly relations. From an early age, behavior conformed to standard feminine criteria. The disease started developing with the onset of puberty when along with a set of standard adolescent reactions, separate abstract ideational symptoms began to be noted (“I began to pay attention to numbers, giving them special meanings”). Approximately from the age of 13, clinically defined dysmorphomanic symptoms appeared (she slouched, hid her breasts, avoided attending physical education classes, and wore loose clothes). Protest behavior and opposition had sharpened. The emerging neurosis-like symptoms were polymorphic in nature (sleep disturbances with homicidal experiences, transient panic attacks, self-harm, and compulsive overeating occurred). After the objectification of affective symptoms and revealing of dysthymia, quasipsychotic episodes started appearing in the structure of the disease. Further affective symptoms occurred in a phased manner with subsequent inversion toward hypomania, and then a mixed state. Increasing maladaptation was manifested in overeating, self-harm, and parasuicidal attempts. As a result, on the basis of dysmorphomanic symptoms, signs of gender dysphoria appeared and a transsexual mindset started developing as gender reassignment was considered by the patient as the only way to resolve her “psychological” problems and was part of the hypercompensation reaction. The sex-role cross-dressing was manifested in a somewhat exaggerated way. The declaration of a transgender mindset was vague and indefinite. The emerging personality-characterological drift toward sensitive-schizoid traits should be particularly noted. The conducted experimental psychological study revealed specific structural mental disorders in the form of a distortion of the generalization process through the actualization of nonessential properties. At the same time, there were no clearly separated ideas about the gender differences between the male and female roles in the gender-role profile.

Therefore, taking into account the above syndromokinesis, it is possible to conclude that in this clinical case, within the framework of the nosological approach, the schizoaffective variant of shift-like schizophrenia, in which the pseudotranssexual setting was optional, had been revealed. However, according to the ICD-10, there was not enough clinical evidence to establish a diagnosis of schizophrenia or schizoaffective disorder. In the dimensional classification paradigm, there were grounds for establishing a diagnosis of schizotypal disorder combined with bipolar affective disorder.

The performed psychopharmacotherapy stabilized the patient's condition and, as a result, the transsexual mindset to gender reassignment was completely reduced.

Conclusion

This clinical case demonstrates that patients seeking medical help for gender reassignment require a thorough clinical, psychological, and paraclinical examination. Otherwise, a diagnostic error can lead to irreversible consequences and aggravate the course of the underlying mental disorder.