Jaspers described three main conditions for a patient's belief to be categorized as a delusion. These are certainty, incorrigibility, and impossibility. Certainty is where the idea is held with absolute conviction. Incorrigibility is the phenomena wherein the belief is not changeable even after giving convincing counterarguments or evidence to the contrary. Impossibility describes a falsity in which the content is implausible, bizarre, or patently untrue. However, recent research suggests that the beliefs in the patients may fluctuate in intensity and conviction over a period, suggesting that the criteria of certainty and incorrigibility are not an essential part of the delusional belief.[12] We report a rare case of delusion of sex change in a patient with delusional disorder.A 21-year-old male, unmarried, science graduate, currently unemployed, had presented to urologist with the chief complaints of development of breasts and feeling that his penis has become smaller in size. Since external genitals were normal, he was referred to psychiatrist. History given by the patient revealed that he was apparently all right about a month back when he took some Ayurvedic tablets for 15 days to increase his sexual performance after reading an advertisement. He reported an improvement in his sexual performance but started feeling that the tablets have caused a hormonal change in him. He believed that he had the development of breasts and that his penis had started shrinking. He was convinced that his genetics had changed due to the medicines and that he was genetically a female and said that he had XXY chromosomes. These genetic changes were causing all his internal organs to become like that of a female. He started reading online about males who were genetically females and felt that this was his case too and he needed treatment for it. He started feeling that as he had breasts all the people around him are pointing and laughing at his external appearance. He said that his brother has also taken similar medicines to increase sexual performance and he had also become a female as told to him by his brother's wife. Because of these worries, he was not able to carry on with his daily activities. Even after the urologist told him that there is nothing wrong with him, he was not convinced. He felt that the doctor should have done his genetic testing. The patient denied any substance use. No history suggestive of epilepsy, head injury, neuroinfectious disease. No past or family history of any psychiatric disorder. Physical examination: vitals stable. External genitals were normal, and no breast development was observed. On mental status examination, he was kempt, sitting comfortably, cooperative, communicative, well oriented to time place and person. Speech was coherent and relevant. Mood was fearful, affect was reactive and appropriate. He had somatic delusion and delusion of reference. No perceptual abnormality. He lacked insight and judgement was impaired.The patient was counseled and reassured that such changes are not possible, but he was firm on his belief and asked for genetic testing to be done. With a diagnosis of persistent delusional disorder he was started on Risperidone 2 mg at night and uptitarted after a week. On follow-up, the patient reported feeling less anxious, his overall mental condition improved, and delusional convictions decreased but requested on getting a genetic test done. His chromosomal analysis revealed XY chromosomes. He continued the medication, and on review after 4 months, he was symptom-free.Delusions of sex change are reported to be in 20 of patients with schizophrenia and are found more commonly in unmarried male schizophrenia patients.[3] Our patient was also male. “Pseudotranssexual” delusions are of four types namely “delusions of no longer being of one's own sex, delusions of being neuter, delusions of belonging to both sexes simultaneously, and delusions of belonging to the opposite sex.” Our patient belonged to the last category. The delusion of belonging to the opposite sex has received the most attention due to the issue of sex change surgery.[4] Sex change delusions or abnormal genital sensations are usually observed in acute psychotic exacerbations, but they may persist between those episodes.[5] Several occurrences of auto–castration have been described in these subjects, whereas self-castration in the absence of psychosis is rare.[6] A study of 174 patients at a clinic dealing with gender identity revealed that five people were suffering from schizophrenia, signifying that this pattern may be more common than could be described for by chance.[7] Patients who were formerly categorized as transsexuals but later found to fall under the category of psychotic disorders, state that the thoughts pertaining to being transsexual vanished after starting the patients on antipsychotic agents. Moreover, delusions of sex change are possibly more common than it is believed, and in a few patients, the differentiation between psychosis and gender identity disorders may be very challenging. Predominantly, the patient's beliefs which might be considered as “pseudotranssexual” are bizarre in description and do not cause doubts in diagnosis. In some patients; however, symptoms describing gender dysphoria are predominant and symptoms pointing toward psychosis may then be underestimated or even undetected before sex reassignment procedure. Hence, the diagnosis of transsexualism in patients with psychosis should not be made hurriedly.[8]Knowledge of the source of delusions in patients guides us as to what should the clinicians say to establish a good rapport, gain trust of the patient and eventually treat the patient holistically. It should also be kept in mind that prompt treatment with medications helped delay anxiety and get rid of the symptoms so that patient can be put at ease. Hence, helping us manage these cases efficiently.
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The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.