Nuances of Gender Identity for a Transgender Patient Receiving Inpatient Treatment for Paranoid Schizophrenia: A Case...

Nearly one-fourth of individuals diagnosed with schizophrenia may experience symptoms of gender dysphoria. Patients may identify with a gender other than the gender assigned at birth before or after psychotic disorder onset. In either case, the presence of both psychosis and gender dysphoria may complicate evaluation and treatment.

We present the case of a 45-year-old patient with a past psychiatric history of paranoid schizophrenia who was assigned male at birth and began to identify as a woman in her youth around the age when her psychosis first developed. During the admission discussed in this report, the patient identified as a man during a period with frank psychotic symptoms but preferred feminine clothing and structured the clothes to create the appearance of female anatomy. Later in admission, as psychosis resolved with pharmacologic treatment, the patient began to identify as a woman and adopted a traditionally feminine name and female-coded dress. Psychiatric assessment, record-gathering, and psychological assessment were completed to better understand her perspective on self and others and the historical context of her symptoms and gender identity.

This case highlights the risk of assessing gender identity in patients with active thought disorders. Patients' perspectives on gender and presentation may shift during periods of psychosis compared to periods of remission. Assessment and treatment of gender dysphoria is possible and beneficial in patients with psychotic disorders, but physicians must be cautious about diagnosing and treating gender dysphoria during active psychosis.