Gender Dysphoria in an Adolescent Presenting With Self-Initiated Hormone Therapy and Genital Self-Mutilation: A Case Report From Bangladesh.

Gender dysphoria (GD) in adolescents requires timely, supervised gender-affirming care. We report a 16-year-old transgender girl in Bangladesh who, lacking access to formal services, self-initiated feminising hormone therapy with oestradiol and spironolactone and described substantial improvement over three and a half months. On psychiatric admission, the hormones were stopped because no clinician held prescribing authority for gender-affirming treatment in a minor and the provenance of her medication could not be verified; lithium, prescribed for anti-suicidal effect, was stopped the same day. She deteriorated and, on the thirteenth day, incised her scrotum in a premeditated attempt at bilateral orchiectomy requiring emergency repair, having stated that intention repeatedly. Means restriction, ligature-risk removal and family-delegated one-to-one observation had been in force since admission and remained so; the blade came from outside the hospital during a brief unsupervised interval. A modified scale for suicidal ideation the next day scored zero. These events occurred against a background of major depressive disorder diagnosed independently by three psychiatrists and suicidal ideation documented more than a year before she obtained any hormone. The case illustrates the absence of any option between unsupervised self-medication and complete cessation, and the limits of bedside means restriction on an open ward when a patient discloses a specific method.