A Case Report on Suicidality in a Gender Non-confirming Bisexual Person Presenting with Depression

Introduction

Gender identity and sexual orientation are independent components of a person’s sexuality. Although these dimensions are most often in harmony with an individual’s sexual phenotypic characteristics, sometimes they vary. Gender identity is the internal and individual sense of gender, which can be the same as the assigned sex or different in the gender spectrum, including but not limited to transgender, bigender, and agender. It is a socially constructed identity that differs from biological sex as well as its associated attributes. ¹ On the other hand, sexual orientation is the persistent pattern of romantic, emotional and/or sexual attraction to men, women, or both sexes ² endured by the prime four components comprising self-reported sexual feelings, genital or brain responses, actual sexual behaviour and self-identified labels affecting both human functioning and sexual behaviour. ³

Though gender has been perceived as an age-old binary figure, non-binary gender (NBG) is an unexplored area that encompasses individuals whose gender is not confined to concrete male and female identities. ⁴ The estimated proportion of gender-diverse individuals (those who are not cis-gender) varies between 0.1% and 2% of the population, depending on the inclusion criteria and where the studies were held. ⁵ Suicide rates are higher in those who identify themselves as transgender or gender non-conforming (TGNC) compared to the overall population ⁶ with lifetime suicide attempt rates between 30% and 81%.^7–10 Unfortunately, 50% of the gender incongruent persons has attempted suicide at least once before their 20th birthday. ¹¹ Also, the exact prevalence of suicide among gender incongruent persons in India is undocumented owing to a lack of research in the specific context.

As per our knowledge, there are no case reports highlighting the suicidality among gender non-confirming persons identifying themselves as bisexuals in the Indian subcontinent. Hence, this case report aims to aid in the early diagnosis as well as management of such debilitating scenarios.

Case Report

On 24th June, at 2:30 pm, a patient was brought into the medical emergency room with left arm cellulitis. A thorough medical history revealed an attempt at suicide, which was attempted by injecting air into the patient’s left cubital vein, which was then managed by immediate surgical intervention (left arm fasciotomy surgery). The patient was then referred to the psychiatry department for further management owing to persistent suicidal thoughts and crying spells. After a detailed investigation, the patient revealed that the suicidal attempt was due to the recent breakup with a man with whom the patient was in an intimate romantic relationship. Verbal consent was witnessed and formally recorded. The client prefers the pronouns they/them/their, and therefore they will be addressed as such.

The client in discussion is a 26-year-old, educated, unmarried software engineer who was born out of a non-consanguineous marriage with no past history or family history of psychiatric illness. They were born into a middle-class family, and their birth was at full term with the clear cut anatomical sex of a male child. There was no confusion about sex assignment at birth. Since 5 years of age, the client has reported being perceived as female. During childhood, they preferred not only to play as well as spend time with girls; they also mentioned keenness in playing with dolls as well as kitchen items with disinterest in outdoor sports. They felt comfortable in female dresses and attire such as frocks, skirts and braided hairs. During school hours, they used to spend the majority of their time in the classroom, as they reported feeling anxious to be around male peers. They confined the feeling to themselves this entire time, with the exception of their best friend, out of being perceived differently by the society, which might expose them to stigma, discrimination and bullying.

They reported getting sexually attracted to boys of the same age after puberty. These sexual traits were embarrassing and unwelcoming at that age until they moved to a bigger city for higher studies. This shift paved a new path for their sexual as well as gender identity exploration, which led their innate feelings of gender to change over time. They felt comfortable wearing female attire at home while at the same time wearing male attire outside the house. In several instances, they reveal that they didn’t fit into any definite gender categories, as they felt like a woman and a man at different points in time. They considered themselves to be bisexual owing to their sexual relationships with multiple partners, including both men and women. At 25 years of age, the notion of unacceptance of their sexuality and immense pressure for marriage from his family evoked huge mental pressure, which led them to attempt suicide multiple times.

The mental status examination of the patient revealed ideas of hopelessness, helplessness and worthlessness. They reported severe guilt, low mood, loss of energy, disturbances in sleep and appetite, as well as suicidal thoughts. They scored 22 on the Hamilton Depression Rating Scale, ¹² which is an indicator of severe depression. A detailed clinical history revealed their intense internal conflicts with sexuality. Upon examination with Kinsey’s heterosexual to homosexual rating scale, ¹³ they scored three, which are described as equally heterosexual as well as homosexual. The possibility of paraphilias and other disorders of sexual preference was ruled out. Their laboratory investigations (endocrine status) and electro-encephalogram were reported to be normal. A psychometric assessment was done, and their intelligence quotient (IQ) was found to be 100, which is average. Rorschach’s inkblot test ¹⁴ also revealed depressive symptoms with no other significant finding. A sentence completion test reported the presence of “depressive cognition” and “gender identity issues.” Their interpersonal adjustment was disturbed, and he scored high on the “depression” and “anxiety” sub-scales of the multidimensional personality questionnaire. ¹⁵

They were prescribed Escitalopram 10 mg (a selective serotonin re-uptake inhibitor) once daily in the morning and Lorazepam 2 mg (a benzodiazepine) at night, oral route. Supportive as well as grief-work psychotherapy was initiated for the management of depressive ideas. Psychosocial interventions were given to family members to clarify the doubts and issues regarding the client’s gender identity and sexual orientation. With supportive psychosocial intervention, they came out to their family as bisexual and a gender non-confirming person. The psychotherapeutic interventions were continued for the next 12 weeks. With the rigorous and effective interventional modalities and the patient’s apt compliance, the depressive cognitions as well as suicidal ideations were managed, resulting in the improvement of their overall socio-occupational functioning.

Discussion

In our case, the client was presented with left arm cellulitis as an implication of a suicidal attempt, which was effectively treated by surgical interventions. The client also exhibited severe episodes of depression with low mood, loss of energy, disturbance in sleep, appetite, and suicidal thoughts, which were intervened with and promptly managed with psychotherapeutic modalities. The precipitating factors were relationship issues with their partner as well as the notion of societal acceptance of his sexuality and gender non-conformity.

Sexual differentiation of the genitals takes place before sexual differentiation of the brain, making it possible that they are not always congruent. ¹⁶ The leading biological theory of sexual orientation in humans, as in animals, draws on the application of the organizational theory of sexual differentiation, the fraternal birth order (FBO) effect. ¹⁷ Research has demonstrated that sexual orientation ranges along a continuum, and people have little or no sense of choice about their sexual orientation. There is no scientifically proven research to show that conversion therapy aimed at changing someone’s sexual orientation works. ¹⁸ Individuals with gender incongruence are prone to serious distress related to emotional distress, depression, social rejection, isolation or worse, become suicidal, become suicidal. ¹⁹ The distress is not inherent due to cross-gender identity but rather a result of social rejection and discrimination. ²⁰ The prevalence of suicide-associated mortalities among the gender non-conforming population in the Indian hemisphere is not well known. One cross-sectional study done among 120 gender-incongruent adults in India showed 25.8% reported at least one suicidal attempt in the past. ²¹

The prime factor in our client’s suicide attempt was the relationship issue and eventual breakup with their male partner. Strikingly, the ending of a relationship initiated by the partner has been considered to be an important triggering factor in the act of suicide among transgender persons in India. ²² The patient was fearful regarding the social acceptance from his family as well as friends towards their sexuality, which turned out to be a major stressor for the past several years. This is supported by the fact that transgender people face poor family as well as social support in the Indian hemisphere, with 62% having no support and being compelled to live away from their families. ¹¹ Many studies have shown that those with gender incongruence who do present for treatment develop additional, secondary diagnoses. ²³ Our client developed secondary depression, which led to their eventual suicidal behaviour. Also, our client and their family have been following up for 12 weeks for pharmacological and psychological treatments, which have been very effective in smoothing social transition as a family. This shows how an empathetic psychotherapeutic approach taken at a pace at which the client is comfortable leads to positive mental health outcomes.

We believe that mental health professionals (psychiatrist, psychologist and psychiatric social worker) as a part of the multidisciplinary team need to be thorough with their clinical skills and knowledge of psychosexual medicine. They also need to be able to screen for any co-morbid psychiatric conditions and psychosocial vulnerabilities to be able to identify high-risk factors for self-harm and suicide. Clients must be provided with all the treatment options available (hormones and/or gender affirmative surgeries) and weigh their risks and benefits.

Conclusion

Gender is not only a complex biopsychosocial phenomenon; it’s also an expression of one’s self. In India, medical professionals need to be well trained in the diagnosis and management of a variety of problems faced by people with gender incongruence and other sexual minorities to alleviate similar scenarios in the future. More relevant case reports and case series highlighting such scenarios should be published, which would pave the way for a positive attitude towards same-sex relationships and associated sexual attitudes as well as behaviours. In today’s world, as a contemporary civilized society, we should move to a place where gender does not define a person, but the person defines the gender. Sexual rights have significantly gained acceptance in the human rights community. People who identify themselves in any group of sexual diversities should be entitled to equal human rights devoid of discrimination, as stated in Article 1 of the Universal Declaration of Human Rights: “All human beings are born free and equal in dignity and rights.” ²⁴