How big is the risk of schizophrenic delusion being mistaken for true gender dysphoria? What implications might this risk have?

Question

I'm no expert, but below are some premises I've gleaned from my independent research.

• Schizophrenia usually does not manifest until a person's 20s. The onset is often gradual, during which time the person will have symptoms that can fly under the radar for years before rising to a level warranting a diagnosis.
• I have read mixed reports about the prevalence of gender dysphoria-like delusions among schizophrenics, but it appears that it does happen.
• Gender-affirming medical care, like hormone therapy and surgery, is sometimes provided to teenagers, the rationale being that earlier affirming care improves mental health outcomes.

I presume that gender-affirming medical professionals are aware of and on the lookout for other potential causes of gender dysphoria, including confounding mental health issues. But if schizophrenia usually cannot be diagnosed until adulthood, doesn't this mean there's a risk of a young person presenting with gender dysphoria, ultimately receiving irreversible gender-affirming care, later being diagnosed and treated for schizophrenia, then finding that the gender dysphoria was actually a delusion caused by the schizophrenia, and finally regretting their transition? This is, in fact, exactly what is described here.

So, how big of a risk is this? Is it a big enough risk to justify delaying medical transition until the patient is older? Might it justify the use of antipsychotic drugs as a test to weed out those who are likely to regret their transition later?

(I realize this question might sound like I'm fishing for a justification for medical discrimination against trans people since two of the questions in the above paragraph look an awful lot like gatekeeping, and the exploratory antipsychotics idea sounds particularly unethical to me. I assure you that's not where this is coming from. I am a trans ally and this question arose out of my various interactions with gender-critical types who often argue some variation of "transgender people are mentally ill and gender dysphoria is nothing more than a delusion.)

Answer 1

Pre-syndrome schizophrenia still shows cognitive difficulties, social difficulties, etc. Perhaps the most essential characteristic of schizophrenia is cognitive difficulty, which manifests much earlier than late adolescence and schizophrenia diagnosis.

This paper: "Elvevag, B. & Goldberg, T. E. Cognitive impairment in schizophrenia is the core of the disorder. Crit. Rev. Neurobiol. 14, 1–21 (2000) is behind this reasoning."

So here is a paper that look at children who later develop schizophrenia "*Childhood intellectual differences between schizophrenic adults and their siblings. https://psycnet.apa.org/record/2013-39739-017*" and shows that even as a child, cognitive difficulties and characteristics of schizophrenia show up.

There is a lot of active research being done on UHR (ultra-high risk) individuals for psychosis, and those are pre-diagnosis but are at very high risk of descending into full-blown schizophrenia. Many studies cover this, yet there is still no reliable way to figure out who will have schizophrenia and who will not. So, in part to answer your question, we can tell who is at risk for schizophrenia pretty early on but cannot yet say for sure who will.

So if someone comes with gender delusions, one can check for cognitive difficulties and see if they're at risk for schizophrenia, but there's no way of telling, especially very early. Besides, people can have both gender delusions and schizophrenia, or a host of delusions without schizophrenia, or even hear voices and be completely healthy. In human health, you can get any combination of things and be perfectly healthy or be very ill and it's often hard to tell which you will be! This paper even looks at people who hear voices and are healthy in the sense that they do not need any medical care:

"Toh WL, Thomas N, Robertson M, Rossell SL. Characteristics of non-clinical hallucinations: A mixed-methods analysis of auditory, visual, tactile and olfactory hallucinations in a primary voice-hearing cohort. Psychiatry Res. 2020 Jul;289:112987. doi: 10.1016/j.psychres.2020.112987. Epub 2020 May 19. PMID: 32446007."

In summary, the reason that gender delusions are not (usually) immediately schizophrenia is that there needs to be cognitive impairments and other changes, even when a child, to go with delusions to be at risk for schizophrenia. And we can only say 'at risk' because we do not know enough to tell. Really, as of now, we can only truly say who is schizophrenic and who is not upon full-blown manifestation, usually in late adolescence.

A good psychiatrist would explore all possible disorders and take preventive measures for all disorders the person is at risk for at each stage of development. Nutritional supplements, lifestyle changes, and better social support can help prevent a lot of mental illness at each stage of life.

Answer 2

Gender dysphoria is characterized by a persistent discomfort with one's assigned gender and a strong desire to be of another gender. Schizophrenia, on the other hand, is a severe mental disorder characterized by delusions, hallucinations, disorganized thinking, and impaired cognitive function.

But NOT JUST delusions. And that's what many people don't get.

A diagnosis of schizophrenia requires the presence of certain core symptoms, with careful consideration of their duration, frequency, and impact on the individual's daily life. The symptoms are categorized into positive and negative symptoms.

https://en.wikipedia.org/wiki/Positive_and_Negative_Syndrome_Scale

Positive Symptoms: These symptoms involve an excess or distortion of normal functions.

• Hallucinations: False perceptions that are not based on external stimuli. Auditory hallucinations (hearing voices) are common, but visual and other sensory hallucinations can also occur.

• Delusions: Strongly held false beliefs that are not influenced by reasoning or evidence to the contrary. Delusions can be paranoid (believing others are plotting against them), grandiose (believing in exceptional abilities), or bizarre (implausible and not based in reality).

• Disorganized Thinking: Individuals may have difficulty organizing their thoughts, leading to incoherent speech and difficulty expressing themselves logically.

• Disorganized or Abnormal Motor Behavior: This can manifest as unpredictable and inappropriate movements, agitation, catatonia (lack of movement or response), or repetitive actions.

Negative Symptoms: These symptoms involve a decrease or loss of normal functions. They include:

• Affective Flattening: Reduced emotional expression and responsiveness.

• Alogia: Poverty of speech; difficulty or inability to maintain normal conversation.

• Anhedonia: Reduced ability to experience pleasure from activities previously enjoyed.

• Avolition: Decreased motivation and difficulty initiating and sustaining purposeful activities.

• Social Withdrawal: Reduced interest in social interactions and a preference for isolation.

So it's not just some delusion. Otherwise you can claim 99% of human population being schizofrenic on their beliefs.