Obsessive-compulsive Disorder, Major Depressive Disorder, and Gender Dysphoria Complicated by Genital Self-injury: A Case Report from Sudan

Abstract

Genital self-injury is rare and typically reflects severe underlying psychiatric morbidity, including psychosis, obsessive–compulsive disorder (OCD), gender dysphoria, and major depressive disorder (MDD). Reports from Arab and sub-Saharan African contexts remain scarce, and stigma and limited access to integrated psychiatric and gender-affirming care may contribute to irreversible, non-medical intervention. Distinguishing OCD-driven self-punishment from gender-affirming motivation is a recognized diagnostic challenge. A man in his twenties, a university student in Sudan, presented with chronic insomnia and depressive symptoms superimposed on a nine-year history of untreated, contamination-related OCD (onset age 13). Approximately four years earlier he had undergone non-medical bilateral orchiectomy performed by an unlicensed practitioner. Using DSM-5-TR clinical criteria without rating scales, he was diagnosed with OCD and a single severe major depressive episode without psychotic features. Sertraline was titrated from 50 to 100 mg daily; over two months his mood, sleep, and obsessive–compulsive symptoms improved and he resumed his studies. Over six months of monthly follow-up no psychotic symptoms were observed, and he gradually and only partially disclosed gender dysphoria while continuing unsupervised use of informally obtained feminizing hormones. Within about a year of presentation he performed penile amputation on himself at home under local anesthesia, resulting in severe hemorrhage and hospitalization for surgical suturing. He was then lost to follow-up, and his records could not be retrieved after the outbreak of armed conflict in Sudan. This case suggests that guilt-driven obsessions and gender dysphoria can coexist and evolve over time, and that they may be difficult to disentangle when access to integrated, multidisciplinary care is limited. As a single case with incomplete follow-up it cannot establish causation, but it supports early, culturally sensitive, multidisciplinary reassessment of this differential.