This case illustrates GSM in a young man without psychosis, highlighting rapid-onset GD and detransition risks. GSM should be considered not only surgically and psychiatrically but also ethically.
In a review of 173 GSM cases, Veeder and Leo (8) reported schizophrenia (49%), substance use (18.5%), personality disorders (15.9%), and GD (15.3%) as major associations.
Thus, GD, though less common, is a significant risk factor. Our patient experienced childhood bullying, expressed female identity wishes in adolescence, amputated his genitalia, then regretted it and sought male identity restoration.
Rapid-onset gender dysphoria (ROGD) is not a diagnostic entity in DSM classification and remains a controversial and hypothesized construct. It has been proposed to describe cases in which gender dysphoria emerges or intensifies during adolescence in association with psychosocial and environmental influences. However, in the present case, the patient reported gender-related concerns extending back to adolescence, which limits the applicability of a strict ROGD framework. Therefore, this case is more appropriately interpreted within the broader spectrum of persistent gender dysphoria with fluctuating intensity rather than a discrete rapid-onset subtype.
Detransition and regret following gender-related interventions or self-directed body modification have been reported in the literature, although reported rates vary significantly across studies and populations. In the present case, the patient re-affirmed his male identity following self-mutilation and expressed a desire for reconstructive procedures, illustrating the potential reversibility of identity-related decisions under extreme distress conditions. This highlights the importance of long-term psychiatric evaluation and stability of decision-making capacity prior to irreversible bodily interventions.
Some reports suggest GD may occur within psychotic episodes, making diagnosis difficult and supporting recommendations to defer irreversible surgery until comprehensive psychiatric evaluation and long observation are complete (9). Our case similarly shows how regret may alter identity goals, emphasizing the importance of delaying irreversible interventions.
A cohort study conducted in Sweden found that some individuals who had completed surgical transition later experienced regret (6). Detransition is particularly more common in rapid-onset GD. In a survey of 100 detransitioners, Littman (7) reported 55% felt inadequately evaluated before transition, many linking their decision to psychological distress. Kettula et al. (10) similarly found high psychiatric comorbidity and childhood trauma among detransitioners. In their study, nine adult individuals who detransitioned all exhibited psychiatric comorbidities, including mood disorders, anxiety, borderline personality disorder, and dissociative disorders. Childhood traumas—such as sexual abuse, bullying, attachment problems, and eating disorders—were reported in 78% of cases. Most participants described their transition process not as a permanent expression of identity but as a consequence of psychological distress. After an average of seven years of hormone therapy and surgical interventions, the majority reported significant regret. Our patient aligns with these findings, as his irreversible self-surgery was followed by regret and re-identification with his male sex.
Complications of GSM often lead to permanent loss (1). Although penile transplantation has been attempted, testicular transplantation is not performed due to technical and ethical issues. Genital transplants remain experimental with donor, surgical, immunologic, and ethical challenges.
Accurate psychiatric assessment is essential. Many GSM patients attempt suicide, and self-mutilation often represents an attempt to relieve distress or externalize overwhelming emotions (1). Early detection of psychiatric illness, thorough evaluation, and long-term follow-up in GD are crucial before irreversible surgery. In GSM with GD, reconstructive or gender-affirming surgery should be delayed, with psychiatric care prioritized (9).
DISCUSSION
This case illustrates GSM in a young man without psychosis, highlighting rapid-onset GD and detransition risks. GSM should be considered not only surgically and psychiatrically but also ethically.
In a review of 173 GSM cases, Veeder and Leo (8) reported schizophrenia (49%), substance use (18.5%), personality disorders (15.9%), and GD (15.3%) as major associations.
Thus, GD, though less common, is a significant risk factor. Our patient experienced childhood bullying, expressed female identity wishes in adolescence, amputated his genitalia, then regretted it and sought male identity restoration.
Rapid-onset gender dysphoria (ROGD) is not a diagnostic entity in DSM classification and remains a controversial and hypothesized construct. It has been proposed to describe cases in which gender dysphoria emerges or intensifies during adolescence in association with psychosocial and environmental influences. However, in the present case, the patient reported gender-related concerns extending back to adolescence, which limits the applicability of a strict ROGD framework. Therefore, this case is more appropriately interpreted within the broader spectrum of persistent gender dysphoria with fluctuating intensity rather than a discrete rapid-onset subtype.
Detransition and regret following gender-related interventions or self-directed body modification have been reported in the literature, although reported rates vary significantly across studies and populations. In the present case, the patient re-affirmed his male identity following self-mutilation and expressed a desire for reconstructive procedures, illustrating the potential reversibility of identity-related decisions under extreme distress conditions. This highlights the importance of long-term psychiatric evaluation and stability of decision-making capacity prior to irreversible bodily interventions.
Some reports suggest GD may occur within psychotic episodes, making diagnosis difficult and supporting recommendations to defer irreversible surgery until comprehensive psychiatric evaluation and long observation are complete (9). Our case similarly shows how regret may alter identity goals, emphasizing the importance of delaying irreversible interventions.
A cohort study conducted in Sweden found that some individuals who had completed surgical transition later experienced regret (6). Detransition is particularly more common in rapid-onset GD. In a survey of 100 detransitioners, Littman (7) reported 55% felt inadequately evaluated before transition, many linking their decision to psychological distress. Kettula et al. (10) similarly found high psychiatric comorbidity and childhood trauma among detransitioners. In their study, nine adult individuals who detransitioned all exhibited psychiatric comorbidities, including mood disorders, anxiety, borderline personality disorder, and dissociative disorders. Childhood traumas—such as sexual abuse, bullying, attachment problems, and eating disorders—were reported in 78% of cases. Most participants described their transition process not as a permanent expression of identity but as a consequence of psychological distress. After an average of seven years of hormone therapy and surgical interventions, the majority reported significant regret. Our patient aligns with these findings, as his irreversible self-surgery was followed by regret and re-identification with his male sex.
Complications of GSM often lead to permanent loss (1). Although penile transplantation has been attempted, testicular transplantation is not performed due to technical and ethical issues. Genital transplants remain experimental with donor, surgical, immunologic, and ethical challenges.
Accurate psychiatric assessment is essential. Many GSM patients attempt suicide, and self-mutilation often represents an attempt to relieve distress or externalize overwhelming emotions (1). Early detection of psychiatric illness, thorough evaluation, and long-term follow-up in GD are crucial before irreversible surgery. In GSM with GD, reconstructive or gender-affirming surgery should be delayed, with psychiatric care prioritized (9).