Obsessive–Compulsive Disorder, Major Depressive Disorder, and Gender Dysphoria Complicated by Non-Medical Self-Castration and Subsequent Genital Self-Injury: A Case Report from Sudan

The human mind is a complex landscape where different emotional and psychological struggles can overlap, sometimes creating a perfect storm of distress. When a person suffers from obsessive-compulsive disorder, they experience intrusive, unwanted thoughts that feel impossible to ignore, often leading to repetitive actions meant to reduce anxiety. When this is joined by major depression, a deep and persistent sadness can make the world feel hopeless. In some cases, these conditions intersect with gender dysphoria, a profound discomfort with one's physical sex characteristics that does not align with a person's internal sense of self. In environments where mental health care is scarce or where social stigma prevents people from seeking help, the pressure to resolve this internal conflict can become unbearable. Without access to safe, professional medical support, individuals may turn to dangerous, irreversible measures in a desperate attempt to silence their suffering.

This reality is brought into sharp focus by a detailed case report from Sudan, which documents the tragic journey of a young man navigating these overlapping conditions. The story begins with a twenty-two-year-old university student in Khartoum who arrived at a psychiatric hospital unable to sleep for more than two months. While his immediate complaint was insomnia, a deeper look revealed a five-year history of untreated mental health struggles. He had been battling contamination-related obsessive-compulsive disorder since his early teens, a condition characterized by relentless fears of germs and compulsive washing rituals that offered only temporary relief. As he grew older, these intrusive thoughts twisted into a heavy burden of guilt centered on his sexual desires, leading him to believe that removing his sexual organs was the only way to find peace.

The situation escalated when, nine months before his hospital visit, he underwent a bilateral orchiectomy, the surgical removal of both testicles, performed by an unlicensed practitioner outside the medical system. This was not a medically supervised procedure but a desperate, non-medical intervention driven by his untreated psychiatric symptoms. Although he hoped this act would end his guilt, it did not stop the cycle of depression or the obsessive thoughts. Instead, his condition worsened. He began to experience the classic signs of major depressive disorder, including a loss of interest in life, extreme fatigue, and thoughts of suicide. During this time, he also began to disclose a long-held, concealed struggle with gender dysphoria, a distress that had been hidden due to the intense social stigma surrounding gender identity in his community.

Doctors at the hospital began a careful treatment plan, starting him on an antidepressant medication called sertraline and creating a safety strategy to manage his risk of self-harm. Over the next six months, the medication helped stabilize his mood and improved his sleep, and his compulsive rituals began to fade. However, the underlying issues remained complex. He continued to use feminizing hormones that he had obtained informally and without medical supervision, a practice that carried significant health risks. Despite the initial improvement, the story took a devastating turn approximately four years after his first surgery. In a moment of severe crisis, he inflicted a penile amputation on himself at home, an act that caused severe bleeding and required emergency hospitalization.

This case, one of the first of its kind reported from Sudan, illustrates how the lack of integrated, culturally sensitive care can lead to catastrophic outcomes. The patient's history showed no signs of psychosis, such as hearing voices or believing things that are not real, which distinguishes his case from other instances of severe self-harm often linked to that condition. Instead, his actions were driven by the crushing weight of untreated obsessive-compulsive disorder, severe depression, and gender dysphoria, all compounded by a system that failed to provide him with a safe path to care. The authors of the report emphasize that when patients are forced to navigate these profound struggles alone, or when they must rely on unlicensed practitioners due to a lack of accessible services, the risk of irreversible harm increases dramatically.

The report concludes that preventing such tragedies requires early detection and a multidisciplinary approach that brings together psychiatrists, psychologists, and medical specialists. Clinicians are urged to look beyond surface-level symptoms like insomnia or sadness to screen for hidden gender dysphoria and guilt-driven obsessions, especially in young adults. In societies where discussing gender identity is taboo, the silence can be deadly. By creating confidential and culturally aware pathways to treatment, medical professionals can offer a lifeline before a patient feels compelled to take matters into their own hands. This single case serves as a stark reminder that mental health care is not just about managing symptoms, but about providing a safe, humane environment where the most vulnerable individuals can find relief without having to destroy themselves to find it.