Myth: Pimozide and gender dysphoria (Gender Analysis)

Summary: Transphobes are irresponsibly promoting the idea that trans people should be treated with ineffective antipsychotic drugs. The “evidence” they present is so weak as to be practically nonexistent. Such a claim could only be plausible to those with no knowledge whatsoever of the broad consensus of scientific research: that transitioning is the only effective treatment for gender dysphoria.

There’s a particularly odd belief that’s been popularized by transphobes over the past few years: the claim that the antipsychotic drug pimozide can treat gender dysphoria in trans people by removing their desire to transition. This idea has been promoted in videos like these describing trans people as ‘mentally ill’, some of which have several hundred thousand views:

[08:11] Also echoing the research thus stated are pharmacotherapy studies that are 20 years old that used the drug pimozide on a cross-dressing man with a strong wish to undergo a sex change. The outcome of the study, as far as I know, has never been mentioned in the mainstream media, or at least I’ve never heard about it between the cacophony of how Caitlyn Jenner is so brave and so beautiful. But, “There was an excellent response to pimozide 2 mg daily, with a cessation of both cross-dressing and the wish for sex reassignment. When, after 1 year, the dose was reduced to 1 mg daily, there was a rapid return of the cross-dressing and the wish for sex reassignment. An increase in the dose again led to a remission which has been maintained since then.” And the conclusion was that, “Pharmacotherapy with pimozide should be considered in cases of doubtful gender dysphoria.” But in all reality, this is one of those cases where you don’t really need to appeal to scientific authority, as it’s clear even enough to a layman to come to these conclusions.

[20:03] You know, there was a report of them successfully treating a transsexual case with drugs, a drug called pimozide. But of course you never hear about this.

[07:00] In fact there was an antipsychotic medication known as pimozide that actually showed a huge amount of promise.

This claim has also spread to numerous other venues, such as Reddit, 4chan, and several more imageboards and forums, under threads with names like “Transgender [sic] should be force-fed Pimozide”. A handful of people have even brought this up in my comments section. However, the notion that pimozide is a viable yet understudied alternative treatment for gender dysphoria is fatally flawed on multiple levels. This argument is so erroneous at so many points, it does not even get off the ground.

1. Disregarding evidence of the efficacy of transition

One of the most glaring flaws in this argument is the failure to evaluate the overall body of medical literature properly. These claims regarding pimozide are not being made on the basis of “pharmacological studies”, plural. This is based on one case report – a study of one person (Puri & Singh, 1996). Conversely, the evidence supporting the efficacy of transition does not consist solely of one publication about just one individual. Hundreds of studies throughout several decades, including tens of thousands of patients, have found that the most effective treatment for gender dysphoria is transitioning.

Living as one’s identified gender, receiving cross-sex hormone therapy, and undergoing gender-affirming surgeries have all been found to alleviate gender dysphoria for appropriately diagnosed individuals (de Vries et al., 2014; Fisher et al., 2014; Murad et al., 2010; Smith, van Goozen, & Cohen-Kettenis, 2001; Cohen-Kettenis & van Goozen, 1997). Transitioning is known to reduce psychological issues (Keo-Meier et al., 2015; Meyenburg, Kröger, & Neugebauer, 2015; Ruppin & Pfäfflin, 2015; Davis & Meier, 2014; Heylens, Verroken, De Cock, T’Sjoen, & De Cuypere, 2014; Hori et al., 2014) such as depressive symptoms (Boza & Perry, 2014; Gorin-Lazard et al., 2013), anxiety (Gómez-Gil et al., 2012), stress (Colizzi, Costa, & Todarello, 2014; Colizzi, Costa, Pace, & Todarello, 2013), and suicidal tendencies (Murad et al., 2010; De Cuypere et al., 2006; Kuiper & Cohen-Kettenis, 1988), while increasing overall quality of life (Gómez-Gil, Zubiaurre-Elorza, de Antonio, Guillamon, & Salamero, 2014; Manieri et al., 2014; Gorin-Lazard et al., 2012; Ainsworth & Spiegel, 2010) and general functioning (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011; Pimenoff & Pfäfflin, 2011; Johansson, Sundbom, Höjerback, & Bodlund, 2010; De Cuypere et al., 2006).

For these reasons, transition is recognized by major medical organizations as the most effective treatment for gender dysphoria. A single case report about one person clearly does not constitute evidence of comparable quality.

2. Omission of relevant details of the case report

This claim isn’t just contradicted by an overwhelming amount of high-quality scientific research into the outcomes of transitioning. It’s also based on a misreading of the single case report in question. While those making this argument quote the study’s abstract, none of them appear to have read the report in its entirety. This study was not about a straightforward and uncomplicated case of gender dysphoria. Instead, it describes a patient with a borderline learning disability, a history of disruptive behavior such as aggression and frequent swearing, an intense fixation on the idea of transitioning, but “no insight into what a sex change would entail in practice” (Puri & Singh, 1996).

For this reason, it was suspected that the patient’s desire to transition was a manifestation of a “monosymptomatic delusion” – “an illness characterized by a single … delusion that is sustained over a considerable period”. The patient was then prescribed pimozide, a first-generation ‘typical’ antipsychotic widely used to treat delusional disorders, Tourette’s syndrome, and tic disorders. In the following weeks, they showed a clear reduction in thoughts of transitioning and stopped dressing as a woman.

The study’s authors recognized that the patient’s symptoms were of an ambiguous origin, and they did not provide a conclusive diagnosis. This is what the phrase “doubtful gender dysphoria” was referring to. However, they noted that the response to treatment with pimozide suggested that the apparent gender dysphoria was actually a manifestation of the monosymptomatic delusion, and that the possibility of schizophrenia “cannot be ruled out”. Crucially, the authors did not conclude that pimozide was a promising alternative treatment to transition in cases of uncomplicated gender dysphoria. They instead stated that “whatever the actual diagnosis, this case underlines the importance of recognizing delusions in gender identity clinics”. This admittedly uncertain diagnosis of one individual fails to support the claim that pimozide can broadly serve as a substitute for transitioning in trans people overall.

3. False claims of suppression of the report

The implication that this case report has been widely ignored or deliberately suppressed is plainly false. The American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders, cited this study in a 2012 publication titled “Report of the APA Task Force on Treatment of Gender Identity Disorder” (Byne et al., 2012). The APA’s report is publicly available and can easily be found via Google. This is clearly inconsistent with a supposed intention to suppress awareness of this single case report.

The case has also been cited in many more studies and publications relating to gender dysphoria, delusional symptoms, and intellectual disabilities. These include:

• A 2000 article on the sexuality of men with learning disabilities (Cambridge & Mellan, 2000)
• A 2003 review of the hormonal treatment of gender dysphoria (Tangpricha, Ducharme, Barber, & Chipkin, 2003)
• A 2003 survey of 382 psychiatrists on their clinical experience with gender dysphoria and comorbid psychiatric conditions (Campo, Nijman, Merckelbach, & Evers, 2003)
• A 2005 case report on a patient with gender dysphoria and obsessive-compulsive disorder (Kayahan, Ozan, Atalay, & Mete, 2005)
• A 2006 literature review of gender dysphoric symptoms in cases of intellectual disability (Parkes & Hall, 2006)
• A 2007 book on the management of gender-related disorders (Barrett, 2007)
• A 2008 article on the psychiatric evaluation of gender dysphoric patients (Gorin-Lazard et al., 2008)
• A 2009 article on avoiding misdiagnosis of gender dysphoria in patients with delusions (Urban, 2009)
• A 2009 case report of a patient with schizophrenia and “pseudotranssexual” delusions (Urban & Rabe-Jabłońska, 2009)
• A 2013 case report of a patient with schizophrenia and delusions involving gender dysphoria (Caballero-Atencio, Cortez-Vergara, & Cruzado, 2013)
• A 2014 systematic review of gender-related disorders and learning disability (Wood & Halder, 2014)
• A 2016 newsletter of the Royal College of Psychiatrists on gender dysphoria and intellectual disability (Bevan, 2016)
• A 2016 book on the psychological assessment of sexuality and gender (Brabender & Mihura, 2016)

Mental health professionals, including leading psychiatric organizations, are clearly aware of the case report and do consider it relevant to the diagnosis and treatment of gender dysphoria. This is hardly some well-kept secret.

4. Clinicians are aware of these complex cases

Medical professionals involved in the diagnosis and treatment of gender dysphoria have repeatedly emphasized the importance of distinguishing genuine gender dysphoria from apparent gender dysphoria arising only as a result of delusional or psychotic conditions. This is a recognized phenomenon throughout the literature.

The 2012 report from the APA Task Force makes note of gender clinics which advise that patients with “higher levels of psychopathology, less gender dysphoria and/or more recent onset of their wish for sex reassignment should be followed over a period of time in order to treat the more obvious psychopathology (e.g., depression, psychosis, body dysmorphic disorder) and to see if treatment of the psychopathology will lead to a reduction in the wish to proceed to SRS” (Byne et al., 2012). The report goes on to cite the 1996 pimozide case as one of several “case reports of change in wish for SRS with treatment of comorbid psychopathology”.

A 2003 report on a survey of psychiatrists also cited this case report, explaining (Campo et al., 2003):

The psychiatric literature offers several anecdotal reports of cases in which cross-gender identification disappeared when patients were treated with antipsychotic medication. There are also case descriptions of patients whose cross-gender identification returned after antipsychotic medication was stopped.

A 2008 article on the evaluation of patients with apparent gender dysphoria also cites the 1996 case as one of many examples in the literature of an “episode of delirium with the idea of body transformation”, and further stated (Gorin-Lazard et al., 2008):

Obviously, these conditions require other types of management than SRS. As exposed previously, diagnostic mistakes may lead to regret, which is why a thorough diagnostic assessment by a experienced psychiatrist is essential.

A 2016 case report on a patient with psychotic symptoms, who presented with apparent gender dysphoria following hallucinogenic drug use, made note of this distinction as well (Schwarz et al., 2016):

Delusions about one’s physical appearance and the desire to change the body can be observed in patients with schizophrenia or other psychotic disorders. Therefore, the differential diagnosis between psychotic disorders and GD is crucial for therapeutic planning.

Notably, this patient also went on to continue comfortably living as his assigned sex following treatment with antipsychotic medication.

A 2007 case report on another patient with “among other psychotic symptoms, intrusive gender identity preoccupations” noted that some schizophrenic patients “develop the conviction of belonging to the other sex”, and emphasized that “In GID, there is classically strong and persistent non-delusional cross-gender identification” (Borras, Huguelet, & Eytan, 2007).

It’s plain to see that psychiatrists and other professionals are not only aware of the 1996 pimozide case, but recognize these symptoms as a distinct phenomenon from genuine gender dysphoria, and know that such cases must be treated appropriately. The need for clinicians to exercise judgment in distinguishing these conditions would not exist if gender dysphoria were simply another presentation of psychosis or delusion.

5. Gender dysphoria with delusions, psychosis, or schizophrenia is rare

While patients with delusional or psychotic disorders may sometimes present apparent symptoms of gender dysphoria as a result of this condition, it’s uncommon for trans people themselves to experience delusional or psychotic conditions. The 2007 report on a case of “delusional pseudotranssexualism” notes (Borras et al., 2007):

Twenty percent of all schizophrenic patients experience sexual delusions at some point during the evolution of their illness. Among them, some patients develop the conviction of belonging to the other sex.

The authors go on to state that “true coexistence of schizophrenia and gender identity disorder is rare”. A 2013 study of 140 trans people similarly found that only 1.4% were also currently suffering from any psychotic disorder (Fisher et al., 2013). For comparison, a 2012 literature review concluded that 0.4% of the general population suffers from an active psychotic disorder (Kirkbridge et al., 2012).

Because of the lack of psychotic symptoms exhibited by the overwhelming majority of trans people, “treating” their gender dysphoria with antipsychotics such as pimozide would not be appropriate. The institutionalization of trans people and forced treatment with antipsychotics was disturbingly common in decades past, prescribed by doctors who did not believe that gender dysphoria was a genuine condition rather than a delusion (Burke, 1996). In some places, this still occurs today. A 2015 exposé reported (Sitnikova, 2015):

Due to high levels of corruption in the Russian health system, transgender individuals older than 15 can also be hospitalised against their will: ‘For a bribe, I was locked in the psikhushka [Russia word for mental hospital], and fed with Zyprexa [antipsychotic drug], and told that I had schizophrenic delusions as a result of birth trauma’. […]

Psychiatric torture is widespread in Russian mental hospitals. Before hospitalisation, transgender individuals are made to sign an agreement on using drug treatment — even though their goal is to receive a diagnosis, not to be treated. In Krasnoyarsk, one person described what this treatment might be like: ‘I was in a madhouse for 30 days. I was injected with neuroleptics, without antidotes. I was subject to pressurising psychopathy, and 24 hours a day they watched to see whether I will cope with it or go mad’. This person reports that no one told her what she was being treated for, and which drugs were used. But, after a month, she received the diagnosis of ‘Transsexualism’. What is perhaps more astonishing is that such mistreatment is not only the result of incompetent doctors but is officially described in Decree N311 as a method of pharmacotherapy ‘in cases of psychogenic diseases, with employment of tranquilizers, antidepressants, anxiolytics, nootropics, sedatives’.

Contradicting the claims that pimozide could serve as an alternative to transitioning, trans people who were subjected to inappropriate treatment with antipsychotics continued to experience gender dysphoria and pursue transition. If their gender dysphoria were a manifestation of a delusional or psychotic disorder, we would expect it to be resolved following treatment for such conditions, as seen in a handful of case reports. This is not observed in trans people. The contemporary medical consensus, based on an abundance of evidence, is that transitioning is appropriate because it does effectively treat gender dysphoria.

6. Lack of adequate followup of patient

The 1996 case report lists a followup period of only three to four years, a length of time which may not be long enough to be conclusive in cases of questionable gender dysphoria. A 1997 study on transitioning had this to say about apparent long-term ‘cures’ via alternative treatments (Cohen-Kettenis & van Goozen, 1997):

Clinicians working with transsexuals know that some applicants refrain from SRS, even without psychotherapy, but, many years later, return to continue the procedure. So even the claimed cures might in fact have been postponements of SRS.

Contrast this with the extensive followup of transgender patients and their outcomes after transitioning. In a study of 71 trans people who had undergone hormone therapy and/or reassignment surgeries over an average followup period of 13.8 years, these patients showed a substantial reduction in psychological problems such as depressive symptoms, and a large increase in life satisfaction (Ruppin & Pfäfflin, 2015). Furthermore, a study of 767 trans people who had applied for sex reassignment in Sweden from 1960–2010 found a rate of regret of only 2.2% (Dhejne, Öberg, Arver, & Landén, 2014). The long-term outcome of one patient treated with pimozide should be much more firmly established before proposing this as a plausible alternative to transitioning, let alone one which shows “a huge amount of promise”.

How does this misinformation take hold?

To review: Claims of the efficacy of pimozide as an alternative treatment for gender dysphoria are based on the misinterpretation and exaggeration of a single case with an uncertain diagnosis and numerous complicating symptoms. The larger body of scientific evidence on the treatment of gender dysphoria points unambiguously toward transitioning as the most effective treatment for gender dysphoria. The notion that this publication was suppressed is contradicted by numerous references to the study within the medical literature, including citations by major psychiatric organizations, emphasizing the importance of recognizing delusional conditions that could present as apparent gender dysphoria. Altogether, the case report does not even remotely support the claims made in these videos and elsewhere.

So why has it been spread so widely by people who are under the impression that it proves far, far more than it actually does? Put simply, they want to believe. Suppose a person knows nothing at all about the most helpful approaches to gender dysphoria. If they were to begin looking into the medical findings on this condition, it’s overwhelmingly likely that they would first encounter a variety of sources from reputable medical organizations showing that transitioning has the best results for trans people. These sources are prolific, and it would be a very long time before they stumbled upon one obscure case report from 20 years ago.

The individuals promoting this myth clearly know nothing about the treatment of gender dysphoria, and don’t appear to be willing to read the wider medical literature or even the very study they’re citing. Yet somehow, that’s where they started. How did they end up in such an improbable place? They worked backward from a predetermined conclusion, seeking out whatever might even weakly support their desired belief.

But in all reality, this is one of those cases where you don’t really need to appeal to scientific authority, as it’s clear even enough to a layman to come to these conclusions.

They are not interested in the prevailing medical consensus on what’s best for our health. Instead, they simply don’t want trans people to transition, and apparently don’t even want to acknowledge that trans people exist. They don’t want to have to see us in the world around them at all. To those who’ve decided we need to be written out of existence, science doesn’t matter. Our health doesn’t matter. All that matters is anything that could conceivably “turn” us into cis people, no matter how remote the possibility, how inappropriate the treatment, or how inhumane and insulting this is.

Instead of making frivolous arguments rooted in nothing more than their own incompetence, these individuals could start with handling their own issues. Step outside your bubble of fantasies, and learn to see reality as it is: Trans people are real, and we’re not going anywhere. ■

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Special thanks to Brynn Tannehill and Cakeworld.info for assistance with research.