A 40-year-old man with a long history of schizophrenia was admitted to hospital after another relapse. He had stopped taking his medication and was behaving oddly – he was paranoid, agitated, self-neglected and had ideas of being controlled. He had two previous admissions with similar presentations. Interestingly, one of the early indicators of his relapse was his conviction of being of the opposite sex and tendency to dress as a female. He initially started wearing a wig with tights and a skirt, but with the worsening of his condition he ended up wearing a full female outfit with make-up. Before the admission he bought oestrogen tablets over the internet to develop secondary sexual characteristics. He even insisted on being admitted into a female ward.

During his stay as an in-patient, he expressed persistent discomfort with his gender and talked at length about different ways to change it. On each admission, the degree of his cross-dressing coincided with the severity of his primary illness. The more he looked like a female the more ill he was. Therefore, it became a useful indicator of his overall mental well-being. He was routinely treated with oral amisulpiride along with haloperidol depot, to which he always responded quite well. Once recovered, his gender dysphoria also disappeared.

Delusions of gender change have been noted among patients with schizophrenia (Reference Borras, Huguelet and EytanBorras et al, 2007); also, transsexualism could be a rare manifestation of schizophrenia (Reference Manderson and KumarManderson & Kumar, 2001) and very rarely schizophrenia leads to secondary transsexualism (Reference Caldwell and KeshavanCaldwell & Keshavan, 1991). To avoid diagnostic confusion, one must understand the relationship between such sexual manifestations and schizophrenia as it has implications for management and prognosis.