Indian J. Psychiat., 1997, 39 (1) 76-78 TRANSSEXUALISM : ONSET AFTER AN ACTUE PSYCHOTIC EPISODE A. BANERJEE, S.H. NIZAMIE, V.K. CHOPRA & D.J. BAGCHI ABSTRACT Transsexualism is a rare disorder with an uncertain aetiology. Recently, biological factors have been considered to be important in its occurrence. The relationship of transsexualism with psychosis is not known; in most cases no specific relationship exists, though few cases of symptomatic transsexualism have been reported. In the following case, cross dressing and homosexual orientation was present from an early age, but gender dysphoria became manifest only after the onset of an acute psychotic episode. The implications of such a finding are discussed. Key words: Transsexualism, psychosis. Sixty percent of male to female transsexuals and 95% of female to male transsexuals are oriented sexually towards their own sex (Swaab and Hofman, 1995). There seems to be general agreement that transsexual feelings start in childhood (Tsoie, 1990), and most gender dysphoric adults of the homosexual subtype would qualify for a diagnosis of gender iden­ tity disorder in childhood, with their adult behaviour simply being a continuation oftheir childhood disor­ der (Green and Blachard, 1995). In the following case report, cross-dressing behaviour and homosexual orientation was present earlier, but gender dysphoria manifested suddenly during an acute psychotic episode after the patient became an adult and continued to intensify after­ wards, with increase in cross-dressing behaviour and homosexual activity. CASE REPORT Mr. S.R.. a 20 years old unmarried male of rural, lower socio-economic background presented with the complaints of feeling weak and feminine, believing he was a girl and wanting to marry a man for a period of one year. The symptoms started sud­ denly in November'93, when after receiving a call for joining the State Police, the patient became dis­ ruptive, violent and felt he was being influenced by nearby people. He felt objects were deliberately be­ ing kept in places, so that he was forced to break them; when her sister was moving her hands, the patient was forced to move and turn, and felt he would give birth to children. The patient was kept restrained for five days and faith healing treatment was tried. The patient started feeling a puckering sensation in his anus, and though his violence and disruption disappeared after a few days, the patient became con­ vinced after this episode that he was a female. He started dressing like a female, started mixing with young men, and expressed his desire to marry one of them; he started referring to himself in the feminine gender; all along he realized his genitalia were that of a male, expressed great distress and a desire for proper treatment. The patient had a history of a couple of febrile convulsions in his childhood for which he received temporary treatment, but no details were available. The patient was the youngest of 6 sibs. with 4 elder sisters. The patient's mother died when he was 14, and his father remarried after a couple of years. No family history of psychiatric illness was present. Birth 76