Abstract
Gender identity disorder (GID) affects around 1 in 11 900 males and 1 in 30 400 females [1]. An increasing number seek hormone therapy with or without gender reassignment surgery. With increasing evidence emerging in the literature of the role of oestrogen as a psycho-protective agent [2], the potential psychiatric adverse effects of hormone manipulation with, or without gender reassignment surgery has not been well studied, or reported in the literature.
We report a case of a 48 year old transgender female to male who was diagnosed with GID 12 years previously. Since the age of 38, he has received exogenous testosterone 250 mg IMI three-weekly. He underwent a bilateral mastectomy at age 45 without a hysterectomy or bilateral salpingo-oophrectomy. Prior to his initial presentation to hospital with a schizophreniform psychosis at age 47, he was generally stable. Organic factors to explain the psychosis were excluded and there was no noted genetic predisposition. The patient's psychosis progressed to a treatment resistant state after several antipsychotic trials within a short time frame of several months after the initial diagnosis. His psychosis is in partial remission on 30 mg of olanzapine.
It is thought that oestrogen has a protective effect against the onset of schizophrenia based on epidemiological and clinical studies. The epidemiological evidence shows that young women are less likely to develop schizophrenia than men at an early age. Women are more likely to develop late onset schizophrenia after menopause due to diminishing oestrogen concentrations. Clinical studies have also demonstrated higher rates of psychotic symptoms in peri-menopausal women [2,3]. This psycho-protective effect of oestrogen is hypothesized to be due to its ability to reduce dopamine levels, receptor quantity and receptor sensitivity in the striatum [4]. There are no reports in the literature of exogenous testosterone causing psychosis.
In the case of our patient, the psychosis emerged in later life, age 47 around the time of onset of peri-menopausal symptoms (irregular menstruation). Therefore, based on a review of the literature we hypothesize that diminishing oestrogen levels in the patient and not the effects of exogenous testosterone was a significant aetiological factor in the onset of his psychosis.
Several clinical trials have shown the antipsychotic benefit of oestrogen therapy in addition to antipsychotic medications in psychotic female patients with physiologically low oestrogen levels [4,5]. Using oestrogen in such cases can lead to lower required doses of antipsychotics [3,4]. Our patient declined an empirical trial of oestrogen because of its potential feminizing effects.
In a transgender female to male, the consideration of adding oestrogen with potential feminizing effects raised ethical questions. The option of reducing testosterone had limited antipsychotic evidence and potential negative psychological effects for the patient. This case could also be approached as a generic treatment-resistant psychosis where clozapine was indicated.
This case of late onset treatment resistant psychosis with the potential clinical and psychological considerations highlights the ethical and management challenges potentially facing clinicians working in the transgender area.