- Screening for psychopathology essential for psychosocial mgt
Since morbid jealousy is seen in the context of gender dysphoria, screening for such psychopathology is essential for comprehensive psychosocial management.
This finding and recommendation was made in a case report on "Gender dysphoria and morbid sexual jealousy in an adolescent" which was authored by L.C. Rathnayake (attached to the National Institute of Mental Health), C. Kuruppuarachchi (attached to the General Sir John Kotelawala Defence University), M. Abeyrathne (attached to the Colombo North Teaching Hospital in Ragama), P.K.D.H.J.L. De Silva Rajaratne (attached to the Lady Ridgeway Hospital for Children), and M. Chandradasa and K.A.L.A. Kuruppuarachchi (both attached to the Ragama Teaching Hospital and the Kelaniya University's Medical Faculty's Psychiatry Department) and published in the second issue of the 31st Volume of the Sri Lanka Journal of Medicine in December 2022.
Gender identity could be described as a person’s self perception of being female, male, a varying combination of both or neither. B.F. Palmer and D.J. Clegg's "A universally accepted definition of gender will positively impact societal understanding, acceptance, and appropriateness of health care" elaborates that gender dysphoria is the psychological distress that occurs when an individual’s biologically determined sex and gender identity do not align. D. Dèttore, J. Ristori and P. Antonelli's "Gender dysphoria in children and adolescents: A review of recent research" shows that gender dysphoria in the young is far more common than anticipated by physicians. A study in the Netherlands noted that referrals to certain specialised services in European nations have increased by 20 fold from the 1980s to the present (2015-2018). K.J. Zucker's "Epidemiology of gender dysphoria and transgender identity" shows that self-reported transgender identity in young people and adults ranges from 0.5-1.3%.
In Sri Lanka, W. Gunarathna, N. Sandamali and P. Pathiraja's "Personal characteristics, treatment methods, and prevalence of mental disorders among individuals with gender dysphoria who receive treatment at the National Hospital" which was a study conducted among 163 attendees of a clinic managing gender dysphoria, found that the mean age of the participants was 26 years, the female to male gender transition was common (68%), 69% were heterosexual, most (98%) had undergone lifestyle modification and physical interventions to change their anatomical gender identity, and that depression (16.6%), deliberate self harm (14.7%), and suicidal ideation (16%) were reported.
Jealousy in a relationship could be defined as a resentful suspicion that one’s partner is attracted to or stated to be involved with someone else. M. Kingham and H. Gordon's "Aspects of morbid jealousy" points out that the belief of rivalry is the cornerstone of psychopathology, whether or not such an issue truly exists. Usually, an individual may become jealous in an intimate relationship in response to certain evidence. However, the belief will be modified as new information becomes available. S.K. Singh, S.S. Bhandari and P.K. Singh's "Phenomenology and predisposing factors of morbid jealousy in a psychiatric outdoor: A cross sectional, descriptive study" notes on the other hand that a morbidly jealous person would refuse to consider contradictory evidence, and that jealousy could present as an obsession, overvalued idea, or delusion.
A Brazilian study observed that jealousy is likely to occur in any form of intimate partnership, whether it is heterosexual or any other, and that there is no evidence that jealousy would be less in same gender relationships, although reproductive outcomes were not at risk. A Brazilian and Portuguese study noted that jealousy in a relationship is affected by socio-cultural variables, masculinity, and femininity.
G. Rao and B. Aparna's "A case report of gender dysphoria with morbid jealousy in a natal female" reported a 24-year-old natal adult female with gender dysphoria and morbid jealousy.
A Spanish study found that young adolescents perform and suffer more jealous behaviour than in adult relationships, and that exploring morbid jealousy in this age category would therefore be necessary for the psychological management of teen relationship related conflicts.
Case report
An 18-year-old General Certificate of Education Advanced Level (GCE A/L) student, an assigned female at birth, presented with a strong desire to be a male from her childhood.
The teenager met the criteria for gender dysphoria as per the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5). The DSM-5 criteria for gender dysphoria in adolescents and adults includes a marked incongruence between one’s experienced gender and assigned gender of at least six months duration, as manifested by at least two of the following: a marked incongruence between one’s experienced gender and primary and/or secondary sex characteristics; a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced gender; a strong desire for the primary and/or secondary sex characteristics of the other gender; a strong desire to be of the other gender; a strong desire to be treated as the other gender; and/or a strong conviction that one has the typical feelings and reactions of the other gender. According to the DSM-5, the condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.
The adolescent preferred to dress in typical male suits and usually bought shirts and trousers from the men’s section in clothing shops. Growing up as an assigned girl, in adolescence, the teen started to get attracted to women.
The teen constantly felt trapped in the wrong physical body and helpless due to being unable to lead a normal life.
Six months ago, the teenager commenced an intimate relationship with a 21-year-old female university student whom he had met online. The teen considered it a heterosexual relationship and identified the teen's self as male, while the partner considered herself to be heterosexual and had identified herself as the ‘girl’ in the couple. The teen had a strongly held belief that the partner had sexual relationships with multiple men, and this thought in turn led to severe distress. This person followed the partner while travelling to the university and demanded to delete her social media profiles, fearing that men would contact her online. Whenever they met physically, the adolescent demanded to hand over the partner’s phone and checked all the available text messages and call history for indications of connections with males. Innocuous behaviour, such as a colourful dress, a new hairstyle, or perfume, led to incessant interrogation about meeting other men.
The adolescent was not on any hormonal treatment during this period. There was no family history of psychiatric disorder, recent head injury, or psychoactive substance use. In the mental status examination conducted by a consultant child and adolescent psychiatrist, emotional distress and delusional infidelity were detected. Speech, perceptions, and cognitions did not reveal any abnormalities. There was no suicidal ideation, hostile or homicidal ideation, obsessions, overvalued ideas, other delusions and hallucinations, but the insight was impaired with the complete denial of the possible psychological causation for the symptoms. The assessment of intelligence found the scores lying in the normal range. Biochemical and endocrinological investigations were normal, including the thyroid, liver, renal, and glycaemic values, and neuroimaging was not conducted. Gender dysphoria and delusional disorder were diagnosed according to the DSM-5 criteria.
The teenager was managed with psycho-education, supportive psychotherapy, and an atypical antipsychotic for delusional jealousy. The adolescent was treated as an outpatient and responded well within a few weeks, while management for gender dysphoria was continued, and an endocrinology referral was done.
C. Kapugama, C. Suraweera, W. Kotalawala, V. Wijesiri, M. Dalpatadu and R. Hanwella's "Prevalence of morbid jealousy among inpatients in a psychiatry unit in Sri Lanka" revealed that morbid jealousy was detected among 17.1%, with more than half having overvalued ideas and 30.7% suffering from delusional jealousy. An Indian study noted that among delusional disorders, jealousy is considered the commonest type, and that more than half respond well to antipsychotic treatment. The described patient had a delusional disorder of the jealousy based type and responded well to an atypical antipsychotic, which is, per K. Kulkarni, R. Arasappa. K. Prasad, A. Zutshi, P.K. Chand, P. Murthy, M. Philip and K. Muralidharan's "Risperidone (atypical antipsychotic) versus olanzapine (atypical antipsychotic) in the acute treatment of persistent delusional disorder: A retrospective analysis", effective in adults.
D. Bhugra's "Cross cultural aspects of jealousy" points out that the causality of morbid jealousy is likely to be multifactorial, with socio-cultural and neurobiological contributory factors. P. Strålin and J. Hetta's "First episode psychosis and co-morbid attention deficit hyperactivity disorder, autism and intellectual disability" observes that the presence of neuro-developmental disorders such as autism spectrum disorder has been associated with the diagnosis of delusional disorder. However, the described teenager showed typical development.
J.A. Easton, L.D. Schipper and T.K. Shackelford's "Morbid jealousy from an evolutionary psychological perspective" emphasises that in evolutionary psychology, it is hypothesised that men with morbid jealousy are more worried about the sexual infidelity of their female partner while women are more focused on emotional infidelity. The described adolescent, an assigned female at birth, seemed more worried about the sexual infidelity of the female partner, and that this might be related to the self perception of masculinity.
K.A.L.A. Kuruppuarachchi and A.N. Seneviratne's "Organic causation of morbid jealousy" notes that morbid jealousy due to organic causes such as head injury and meningioma (a primary central nervous system tumour) has been reported from Sri Lanka. However, there was no such history in this adolescent.
J. Todd, J.R. Mackie and K. Dewhurst's "Real or imaginary hypophallism (the belief that the penis is unusually small): A cause of inferiority feelings and morbid sexual jealousy" elaborates that sexual dysfunction and hypophallism have been associated with morbid jealousy.
The described adolescent, an assigned female at birth, has not yet undergone hormonal treatment or gender reassignment surgery, and therefore, the perceived deficits in this context are likely to have contributed to the morbid jealousy.
R. Jayasinghe, U. Jayarajah and S. Seneviratne's "Overview of the medical management of transgender men: Perspectives from Sri Lanka" opines that compared to regional countries, better acceptance of gender dysphoria is seen in Sri Lanka. However, M. Chandradasa and L. Champika's “Sub-specialisation in postgraduate psychiatry and implications for a resource limited specialised child and adolescent mental health service” explains that the structure of the health system and limited adolescent mental health services may hinder adolescents with gender dysphoria from seeking appropriate care.
L.D. de Freitas, G. Léda-Rêgo, S. Bezerra-Filho and A. Miranda-Scippa's "Psychiatric disorders in individuals diagnosed with gender dysphoria: A systematic review" found that among 577 individuals, 53% had presented with at least one mental disorder in their lifetime, and mood disorders (42.1%), followed by anxiety disorders (26.8%), and substance use disorders (14.7%). K. Başar, G. Öz and J. Karakaya's “Perceived discrimination, social support, and quality of life in gender dysphoria” observes that persons with gender dysphoria experience perceived discrimination in multiple settings, and that therefore, social support from loved ones have a central role in their resilience.
L. Littman's “Individuals treated for gender dysphoria with medical and/or surgical transition who subsequently detransitioned: A survey of 100 detransitioners” found that the reasons cited for detransitioning were the discrimination experienced, becoming comfortable with the natal sex, worries about medical complications, and understanding that their dysphoria was caused by either trauma, abuse, or a mental health disorder. These results show the changeability of the decision of gender change which could be even more prominent in adolescence. Gender fluidity is the change in a person’s gender expression and/or gender identity during a period. Harvard Health's "Gender fluidity: What it means and why support matters" states that both the expression and identity of gender might change individually or together.
In morbid jealousy, the socio-cultural expectations of masculine and feminine roles play a significant role in the development of psychopathology. Gender dysphoria is a unique entity where gender attributions are ever changing with the ongoing management. Hence, Rathnayake et al. concluded that a comprehensive clinical assessment is required in order to understand the deeper psychosocial connotations.