(216) Gender Dysphoria in the Context of Severe Psychiatric Disorder

Abstract Introduction Gender dysphoria (GD) may occur as an independent condition or emerge in the context of other psychiatric disorders. In patients with schizophrenia spectrum disorders, neurodevelopmental conditions, and some personality disorders, the assessment and management of gender identity can be challenging. Psychotic disorganization, cognitive rigidity, and impaired self-concept may obscure genuine gender incongruence, while social immaturity and emotional instability may compromise engagement with care. Distinguishing between psychopathology and authentic gender identity is essential to ensure appropriate and ethical clinical management. Objective To present a complex clinical case of persistent gender dysphoria in a patient with multiple psychiatric and neurodevelopmental comorbidities, highlighting the diagnostic, therapeutic, and ethical challenges involved. Methods Longitudinal clinical observation of a young adult assigned male at birth, followed in a psychiatric outpatient setting. Data were obtained through serial clinical interviews and collateral information from family members. All data were anonymized in accordance with ethical standards. Results The patient, assigned male at birth, displayed early behavioural difficulties, motor tics, and poor social reciprocity from childhood. Family history was significant for autism spectrum disorder (ASD) in a first-degree relative. Since adolescence, the patient demonstrated marked social naivety, difficulty recognizing interpersonal boundaries, and impulsive behaviours placing them at personal and sexual risk. Over time, the patient exhibited clinical features consistent with autism spectrum disorder comorbid with schizophrenia and dysfunctional personality traits, including affective instability and identity diffusion. Despite chronic psychiatric instability and mistrust of healthcare services, the patient has consistently expressed discomfort with their assigned sex and a desire to live in another gender role, fulfilling criteria for persistent gender dysphoria. However, repeated missed appointments and lack of sustained engagement have hindered a full sexological assessment or transition-related interventions. Conclusions This case illustrates the complexity of addressing persistent gender dysphoria in individuals with overlapping psychiatric and neurodevelopmental disorders. Chronic instability, poor social judgment, and identity diffusion may heighten vulnerability and interfere with access to appropriate care. A trauma-informed, multidisciplinary, and highly individualized approach, integrating psychiatry, psychology, and specialized sexology, is essential to ensure safety, continuity of care, and ethical support of gender affirmation in this vulnerable population. Disclosure No