A. BANERJEE et al. and early developmental history was uneventful. He had passed his intermediate examation. Al school, he used to play games like hockey, football, kabaddi, and khokho. He was, however, always assigned the feminine role in plays. He often preferred to do house­ hold chores e.g.. cleaning the house, washing clothes and working in the kitchen. The patient started mas­ turbation around the age of 13. After an initial het­ erosexual experience, he had homosexual contacts with several partners, especially one regular partner who had given him feminine name. The patient had no guilt feelings regarding these acts. His masturba- tory fantasies were of young men. On general physical examination he was found to be 5'8" tall, with a body weight of 65 Kg. Exami­ nation of genitalia and secondary sexual characteris­ tics revealed no abnormality. There was no evidence of any endocrinopathy. No abnormalities were de­ tected on a detailed neurological and neuropsycholocical examination. Routine investiga­ tions and EEG were normal. The sperm count was found to be low. 35 million/ml (N = 60-130 million/ ml) with 15% abnormal forms, and 70% motility af­ ter 1 hour. The patient continued to show significant cross dressing behaviour, remained homosexually active and distressed by his condition till last seen in Sep- tember'95. DISCUSSION The index case showed some preference for cross-sex roles and dressing during childhood, which was not persistent. The patient's adolescent sexual orientation was definitely homosexual and his gen­ der dysphoria first manifested and increased mainfold following a brief psychotic episode after he reached adulthood. To the authors' knowledge this is the first report of such an occurrence. In the cases of symp­ tomatic transsexualism described so far in the litera­ ture, the childhood developmental history was not knowan(Akhtar and Thompson, 1980: Commander 77 and Dean, 1990), and moreover, in the second case, the patient's orientation was heterosexual and mani­ fest gender dysphoria was not present. The patient's symptoms during his psychosis were suggestive of made act and delusion of con­ trol, and in the setting of marked emotional turmoil, would qualify for a diagnosis of polymorphic acute and transient psychosis with schizophrenia like symp­ toms. It could be that the psychosis was coincidental and had a strong reactive element to it, with the patient's conflict about his gender identity becoming more acute once he received his call to join the State Police. However, the sudden onset of intense gender dysphoria following the psychosis remains to be ex­ plained. Recent theories on the aetiology of gender identity disorder of the homosexual subtype, espe­ cially in males, have taken on an increasingly bio­ logical basis, assuming a developmental continuity with homosexuality (Green and Blanchard. 1995). The hypothalamus has become the focus for the search for structures that might be related to prob­ lems of sexual orientation and gender identity (Swaab andHofman, 1995). These anatomical manifestations would be the final pathway through which the con­ ditions are expressed. That a variety of genetic fac­ tors may still be involved, is indicated by the fact that 5 cases of 47, XYY individuals with transsexualism have been reported in the literature (Taneja et al., 1992). It is possible that a subset of transsexuals share a common genotypic vulnerabil­ ity with psychotic disorders. The psychosis results in neurotransmitter-mediated alteration in neuronal gene expression in the brain, which changes the way indi­ vidual neurons process information and changes com­ munication among multicellular networks, resulting in changes in manifestation of transsexual behaviour, as occurring in the present case. The developmental and sexual history of adult onset "symptomatic" transsexuals, needs to be gone into more detail for any likelihood of an earlier age of onset of transsexual feelings and homosexual ori* entation.