The Transgender Journey and its Psychiatric Implications: A Case Observation and Comparative Analysis between Transgenderism and Clinical Lycanthropy

Introduction: The paper deals with gender dysphoria (gender identity) and helps the reader understand that people are not born in wrong bodies thus linking the understanding with unnatural behaviour. Methods: The second part compares transgenderism with a psychiatric condition: clinical lycanthropy. We see a case of someone believing he was a bird and how he was cured. Results: The author highlights similarities between the two conditions. In both scenarios there could be delusions and the individuals are unhappy with their bodies. The unshakeable belief in drastically changing one’s body is not normal and should receive psychological or psychiatric treatment. Conclusion: A number of bioethical statements are presented. The author reminds healthcare workers to adhere to the medical principle of ‘first do no harm’ when considering gender affirmative treatment and advises that political decisions should not be based on just palliative approaches. It is concluded that gender remains binary. The transgender or third gender is a socio-political


DISCLAIMER
The terms 'natural' and 'normal' are not used to denigrate transgender individuals but to analyse the act of transgenderism. The element of abnormality which will stem from this paper cannot generalise for the whole transgender population. It will be explained that not all transgender individuals are delusional (believing in something untrue). Furthermore, it is only during those moments of unshakeable (firm and unable to be changed) belief of permanently changing one's body drastically for his/her 'betterment' , especially when undergoing the actual multi-transformation processes that the act would be labelled as 'abnormal' . Otherwise, gender-dysphoric and transgender people can continue to socialize and lead normal lives. The article has no intention to impose any barriers on children and young people wishing to switch their gender. The mission is to raise awareness of certain dangers associated with the transformation process which is purely artificial. Towards the end, a list of ethical highlights also caters for the postoperative needs of transgenders to remain monitored for risks that persist even after surgery. Above all, the author is not transphobic and believes that transgender people deserve the same civil and human rights as the rest of the population and should not face any discrimination. He simply wants to convey what he genuinely believes is the 'right' message from a medical and ethical point of view based on the current knowledge of this trend. It stands to reason that those who advocate the 'social model' may have difficulties accepting the 'medical model' portrayed in this paper. Nevertheless, the author is open to constructive criticism.

PREAMBLE
The preamble and the flowchart which follows should make up for certain improper or misleading information. Please read carefully in order to understand the logical flow of this essay including the concepts of 'natural' and 'normal' that form the basis upon which several moral principles connected with transgenderism are founded. Misconceptions on certain terms also need to be addressed at this early stage. The Introduction is hoped to place the reader in the appropriate scenario and help to evaluate the current writings on transgenders. First of all, the issue of intersex is not to be confused with gender dysphoria. As evidence-based medicine on transgenderism is rare, the literature review also had to include some anecdotal evidence based on expert opinion. Although the concepts of 'natural' and 'normal' play essential moral philosophical roles, in this essay the natural aspect is tackled as much as possible through objective reasoning. Any basic dictionary Micallef.: The Transgender Journey and its Psychiatric Implications would define the term 'natural' as, existing in or derived from nature. The unnatural element of this controversial topic stems from the basic genetic facts of our sexuality and from the review of literature found in this section predominantly, in the twins' studies. If this is insufficient to convince the reader, a number of though-provoking questions are put forward for reflection in the Discussion particularly, when asking why a gender-dysphoric person is unable to transform into a different gender through a natural process. As gender dysphoria is linked to unnatural behaviour, one is tempted to automatically believe that it is also not normal. Even if gender dysphoria was established to bear strong genetic roots, this on its own would still not be evidence for normality. There is a tendency to believe that because something is genetically (naturally) rooted it can never be related to a mental or abnormal condition. On the contrary, several genetic traits and disorders show that the affected persons are recognizably different from the rest of the population, either in physical appearance (such as intersex) or in the way they behave. Furthermore, just because something is common or relatively common, it does not imply normality even though the two terms, 'normal' and 'common' are often interchanged in day-to-day talk. In the Introduction, an element of psychiatry is gradually introduced amongst gender nonconforming people. However, the aspect of abnormality comes out more independently from any unnatural characteristics later on in the body of the essay specifically in the comparison with clinical lycantrophy. As diagnostic means that produce objective evidence of a patient's condition is often lacking, psychiatry relies mostly on a complex set of mental constructs for its notions of normality. When thoughts deviate from physical reality they can be potentially harmful to the person and indicate an element of abnormality. From here onwards 'transgenderism' replaces 'gender dysphoria' in most of the text because apart from the state of unease or general dissatisfaction with one's body, the belief and the actual action to change (harm) the human body becomes more apparent. As not enough is yet known about transgenderism, the comparison with lycantrophy can help us answer the question of whether transgenderism is an abnormal condition or not. The argument is further strengthened later on particularly in the Conclusion when transgenderism will be linked with transableism and other psychiatric conditions. Although many authors interchange fundamental key terms, children and adolescents with 'gender identity' should not be confused with 'transgenders' . Simply having 'gender identity' and to some extent 'gender dysphoria' are not in themselves issues of great concern. They can be reversed. Furthermore, everybody is diverse. The real need for psychotherapy starts later on when they want to undertake the actual transformation process. If this sounds complex, the huge difference between gender identity and transgender can be highlighted in this scenario: if a boy rejected typically masculine toys, later on had strong preference for girls as friends, used to cross-dress, and for over six months during puberty he had a persistent desire to be a young lady and even insisted that he was a lady with a strong dislike to his sexual anatomy, it does not mean he has changed into a transgender lady and can freely mix with girls in the showers. What if the other girls do not feel comfortable with this physically not-yet-transformed body? That is why it is essential to understand that 'transgender' is only the final process of a long transformation journey. To complement the text, a visual representation of the transgender spectrum in the form of a flowchart is included before the Introduction. This should help readers follow the various stages of the transgender experience as will be put forward in this paper.
Flowchart showing stages of body transformation leading to the final phase of transgender as depicted in this paper

INTRODUCTION
The American Psychological Association 1 describes the term, 'transgender' as the full range of people whose gender identity and/or gender role do not conform to what is typically associated with their sex assigned at birth.* 1 Adults who identified as transgender are estimated to comprise about 0.6% of the US population. 2 In this article we will see that the term 'transgender' only applies to the final stage of a long journey. According to the American College of Pediatricians 3 there is no innate gender dysphoria (or gender identity, as it is referred to in some texts, although gender identity should more appropriately refer to an individual's awareness of being male or female). Through proper counselling, children with gender dysphoria could be helped to grow out of it. Studies suggest that the majority of gender-confused children (nearly 85%) revert to their birth sex when they reach puberty. 4 Some clinicians are also saying that in up to 98% of cases, children with gender dysphoria will outgrow this condition by adulthood. 5 The research question of this paper is twofold: Is it natural and normal to become transgender? In other words, the two components are: Is transgenderism a natural phenomenon? Is transgenderism a normal behaviour? The bulk of the text revolves around these questions and the objective is to guide the medically-oriented reader and the social scientist into finding out whether it is natural and normal behaviour to act transgenderly. So, before understanding the bioethics of gender transformation, the two pillars of this essay -'natural' and 'normal'need to be tackled thoroughly. In recent years, a radical shift has occurred from psychological counselling to what is called 'gender affirmative treatment' . 6 Some initial counselling is not excluded, but here children and teenagers are chemically castrated with puberty blockers (hormone suppressors). Then, most of them become infertile after receiving cross-sex (opposite sex) hormones (steroids)* 2 which put them at risk for stroke, blood clots, 1 *According to personal communication with Dr Vatel (details in Acknowledgements), no one's gender is "assigned" at birth more than the fact of being born human is assigned at birth. Except in very unusual cases where the genitalia appear ambiguous (which is a medical abnormality) the sex of the baby is obvious and the physician or midwife simply records what is plain to the eyes to see. The term "assigned at birth" is an ideological tool designed to make people think that there is no such thing as objective reality. 2 *Grouped under 'gender identity' (as it is more appealing than 'gender heart attack, type 2 diabetes, certain cancers and even the very emotional problems that experts claim to be preventing. 5,[7][8][9][10][11] Hormonal measures of sex change in children could even be regarded as child abuse. 7 Transgender ideology or the idea that people can be born in the wrong body does not hold scientific value; it lacks an evidence base. Human sexuality is binary: every cell in the body of a normal woman is genetically (chromosomally) XX and every cell in the body of a normal man is XY. Furthermore, there are at least 6,500 genetic differences between men and women; hormones and surgery cannot change this huge difference. 8 An identity is not biological; it is psychological. Identity has to do with thinking and feelings which are not biologically hardwired. 8 If gender identity were to be genetically determined before birth, monozygotic (genetically identical) twins would have the same gender identity at all times, which they do not. The largest transgender twin study to date examined 110 twin pairs of which 74 were monozygotic pairs. 12 Twin studies demonstrated that it is post-natal events (non-shared environmental factors) that predominate in the development and persistence of gender dysphoria because 72% of the identical twins were discordant for transgenderism or transsexualism, as some researches prefer to call it. This meant that at least 72% of what accounted for transsexualism in one twin and not in the other had occurred after birth and was not biological. It is an accepted fact that a child's emotional and psychological development is impacted by positive and negative experiences from infancy onwards. The high discordance rate among identical twins proved that no one is born pre-determined to have gender dysphoria let alone pre-determined to identify as transgender or transsexual. 3 Venkataramu and Banerjee 13 reported that gender dysphoria is socially constructed and depends on childhood experiences, upbringing, social expectations, beliefs, family environment and peer interactions. The 'born this way' argument holds no scientific basis. No innate trait to support this argument has been found. Others may argue that a concordance rate of 28% does point out to shared genetics but this does not exclude the fact that twins that probably were raised together in the same household would share the same social environment for a long time thus acting as a confounding factor because practically they may all have grown up under the same conditions. In any case, heritability should not be confused with normality. We will come to this later on. A balanced debate would be incomplete if the study on 380 transgender women (who were assigned males at birth) and 344 control males, which linked a genetic component to gender dysphoria and sex hormone signalling 14 is not evaluated. It is important to note that many of the so called 'transgender' participants were still at the gender dysphoria stage. However, even in cisgender women (cisgender is when gender identity corresponds to the gender at birth) you can have sex hormone imbalance linked to some genetics but it does not mean that these women are becoming men because significant hair grows on their skin. In any case, one can never transfer naturally into another gender. This is undisputable. Furthermore, this genetic element which is being associated with gender dysphoria does not eliminate the psychiatric part on which this paper focuses mostly. Although by the age of three, children can already identify themselves as either boys or girls, most children will not understand that a boy grows into a man and stays a man and a girl grows into a woman and stays a dysphoria' which carries more weight by implying a psychological problem) drug formularies of countries that support gender transformations include: goserelin, leuprorelin, cyproterone, ethinylestradiol, medroxyprogesterone, testosterone, finasteride and spironolactone. Some of these drugs (steroids and non-steroids) are used in malignant diseases.
Micallef.: The Transgender Journey and its Psychiatric Implications woman. For example, if a seven-year-old boy* 3 sees a man dressed as a woman with drastic makeup and feminine hair style, he may believe that that person became a woman, in other words, that gender is dynamic, which is false. 7 The misinterpretation of perceptions or experiences in situations that are either not true or highly exaggerated, including childhood maltreatments, could trigger gender identity and gender dysphoria. 3 More detail is found in the flowchart diagram and the underlying key explanations. Further research could also prove that as the child grows into a teenager, other environmental and psychological factors might aggravate the state of unease in the biological gender and contribute towards transgenderism or transgender delusion. These will be dealt with later on. Another compelling study which cannot be omitted is when research showed that transgender women tend to have brains that resemble cisgender women, rather than cisgender men. 15 However, it remains unclear when or why those differences developed and correlations do not necessarily reflect causal relationships. The brain is quite plastic in adulthood and the similarities identified between transgender and comparable cisgender people may not have been present from birth. It is known from several studies that by time, repeated behaviour changes the anatomy and physiology of the brain. 16 Biological exceptions do exist: 'intersex' is a collective term for genetic disorders consisting of anomalies in the reproductive and sexual system. In other words, these are physical disorders of sex development comprising a variety of medical conditions associated with atypical development of an individual's physical sex characteristics. 1 However, these congenital conditions do not invalidate the current argument even if the intersex anatomy does not always show up at birth because there is no underlying mental disorder. Hence, it may be appropriate within these conditions that the affected individuals would need chronic hormonal treatments and surgery on a case-by-case basis. 7 As with intersex, genomic variation (which non-arguably is natural) is also considered by some researchers as contributory towards normal other genders that is, biologic sex is not dimorphic. 17 In other words, they are saying that there is a biologic continuum or varieties (sometimes referred to as, diversity) of human beings between the male and female sexes. This is the 'social model' , where heritability is associated with normality. As to what has been said in the Preamble, Karasic 18 confirms that there has been little research on transgenders and mental health during the past decade, but there has been a particular European study in which significant data on the mental health of these people were collected. The Swedish cohort study had involved 324 sex-reassigned persons consisting of 191 male-to-females and 133 female-to-males. The population-based, long-term follow-up showed that transgender individuals had increased mental health morbidity and mortality even after surgery compared to the general population thus showing that psychiatrists have an important role in transgenderism. The average follow-up for all-cause mortality was 11.4 years. 19 More recent research is showing that amongst the LGBTIQ* 4 group, the 'trans' are the most vulnerable for psychiatric illnesses. A study using data collected over two years involving 315,893 subjects as part of the US Centres for Disease Control and Prevention particularly, the Behavioural Risk Factors Surveillance System has showed that transgenders and gender nonconforming people (grouped together as gender minority adults) have reported poorer health. Apart from sexually transmitted diseases, which have been constantly confirmed by scores of studies for the past three decades particularly amongst the gay communities, the novelty of this research is on the fact that gender minority adults are also encountering mental health problems compared with cisgender peers. For example, they are also more likely to report limitations and problems with memory, concentration and decision-making. 20 Clinical evidence also suggests that schizophrenia occurs in patients with gender dysphoria at rates higher than in the general population. 21 Particularly alarming is that through a national survey conducted in the USA, 41% of the transgender respondents (n = 6,456) reported at least one suicide attempt. [22][23] From other studies it is known that over 90 % of people who were suicidal or died of suicide had a diagnosed mental disorder. 24 In view of this, psychological and/or psychiatric therapy for gender identity, especially in children, is being encouraged so that they accept the gender assigned to them at birth. 25

METHODS: COMPARING TRANSGENDERISM WITH LYCANTHROPY
Every area of health risk can be informed by behavioural science research; 26 transgenderism is no exception. Here we compare the behaviour of transgenders with lycanthropy. Clinical lycanthropy is a rare psychiatric syndrome affecting individuals who believe that they are in the process of transforming or have already transformed into an animal. [27][28] The behaviour of the affected person (lycanthrope) has been associated with altered states of the mind that accompany psychosis, a mental state typically involving delusions and hallucinations. [29][30] In the past, lycanthropy was associated with mythical transformations into, for example, a wolf, but a Google Scholar search shows that it actually exists. 27,31 A study had reported a series of cases and proposed some diagnostic criteria by which lycanthropy could be recognised: the patient behaves in a manner that resembles animal behaviour, by for example, howling, growling or crawling. 30 The animals introduced in the literature of lycanthropy case descriptions include: wolf, bird, frog, gerbil, goose, horse, rhinoceros, snake, wild boar and six unspecified animals. 32 Here is a case report of a 'birdman/birdwoman' .* 5 He/she (from here onwards, represented as 'he') used to believe that he was a bird. Undoubtedly, he was bullied by other students at school when he was much younger and suffered a lot of humiliation. He was not autistic but felt more comfortable as a bird -in fact, he frequently used to flap his arms and hands pretending he was a bird. His delusions lasted from less than an hour to several hours with a recurrence of about once per week. He also complained of anxiety and restlessness. He never suffered any psychiatric or physical effects in the first years of his life until he was approaching puberty. He surely did not choose this way of life and definitely needed compassion, protection and support, which he probably received. However, even though he always felt more comfortable as a bird he was never encouraged or empowered to become a bird! He was so convinced that he was a bird that probably, if he was given the opportunity to acquire a pair of permanent wings instead of his arms, he would opt to amputate his arms in replacement of the artificial wings. His body actions were not under his control and during such episodes he insisted that he was transforming into a bird. However, he was never given any chemicals to stop his hair from growing and offered any skin-feather implantations! After several months of counselling and psychiatric treatment his mood improved considerably and he was considered to be euthymic and free from any delusions. He had been suffering from this condition for some years. This case was considered as a reactive psychosis due to loss of insight and presence of delusions about metamorphosing into a bird. Cases of clinical lycanthropy warrant proper investigations to rule out any underlying organic disease in certain brain areas.
As already remarked, current research is showing that the behaviour of transgender people is at times abnormal. Although at first the two conditions (lycanthropy and transgenderism) seem to differ enormously from each other, they share similar psychiatric disorders. Moreover, lycanthropy sufferers usually pass through similar starting stages: feeling that one's body is of the wrong species (or wrong natal sex in the case of transgenders), bullying at school, harassment and so on. This is also what transgender people normally experience and speak out in public when asked what they have been through. Therefore, basically in both conditions the individuals are not happy with their bodies. One looks in the mirror and sees himself as a woman (that is what his mind tells him) or vice versa if the natal sex was female, whereas in the other scenario, the individual keeps thinking that he is a bird or some other kind of animal. In both cases, the affected persons behave in obviously odd or bizarre manners with the major common denominator being the delusion that they can transform into different bodies. A person's belief that he is something or someone he is not is a sign of confused thinking; at worst, it is a delusion. 3,[33][34] We have also seen that 41% of transgender respondents had at least one suicide attempt [22][23] and it is also likely to have suicide attempts linked with lycanthropy. 35

RESULTS AND DISCUSSION
The message is clear. The persistent desire and the unshakeable belief of drastically changing one's body for the perceived 'betterment' is not normal and should receive counselling and psychiatric treatment. For the scope of this paper, there is no point adding further information about clinical lycanthropy. As for the methodology of the case report, behavioural studies can at times be subject to interpretation but there is no other full-proof method of scientifically comparing the two conditions: transgenderism with lycanthropy. The chances of a person subjecting him/herself to a battery of brain scans for research purposes are remote especially when they read the information letter stating the study objectives. Offering brain samples to analyse the chemicals inside the brain (unless perhaps postmortally) is non-debatable. Furthermore, in the case of transgenders, as stated earlier, adult gender differences in the brain can be due to neuroplasticity and socialisation experiences. In order to see these brain changes, researchers should have conducted similar brain studies earlier when they were still children and repeated them later when they grew older and identified themselves as 'trans' but it is not in their interest to identify neuroplasticity. So, these seemingly impressive brain experiments in favour of the transgender ideology are still shrouded with uncertainties. As for lycanthropy which is a rare syndrome, the author even considers himself as lucky to have at least managed to observe a single case from a distance, let alone performing rigorous brain tests on them! However, despite these limitations, the study did highlight common behavioural markers and negative experiences between the two conditions: such as feeling that one's body belongs to the wrong anatomical structure, bullying at school, emotional unhappiness and delusions. Even the onset -when they approach puberty -is similar in both conditions.
The attention now turns solely on transgenderism. It is understood that more thorough research is required in order to study transgender behaviour. Admittedly, these people are often left out from population health surveys and research. For example, a national study on sexual health aspects encountered by adults could be incomplete if it only randomly selected clear-cut genders without employing stratified sampling for gender-variant individuals. 36 It is also not correct to label all gender-dysphoric and transgender people as delusional. Many, especially as they grow older, realise that sex cannot change, but they may still keep believing that their emotional unhappiness can be resolved if they can physically and socially impersonate the opposite sex. The desire to knowingly imitate the opposite sex is not a delusion. However, it could still be debated as evidence of an underlying mental illness. In any case, based on the medical principle 'first do no harm' , even if instead of delusions the person is only suffering from prolonged sadness (which could lead to depression), it should not be treated with toxic chemicals and mutilating surgeries. Therefore, medical and political decisions should not be based only on mere palliative approaches, as is normally done with terminal illness, without treating the cause. Transgender people made everyone conscious and sympathize with their psychological sufferings (which included: never felt comfortable with their bodies, bullying, and so on) but instead of being offered the right (curative) treatment, they are encouraged and helped to change their gender status; an act performed legally in several countries. From the current scientific literature dealt with in the Introduction and the subsequent section, the third gender does not naturally exist and this is something which can be associated with mental illness (example, delusions). The essay raises suspicion that politicians took advantage of the vulnerability of transgender individuals and legislated policies to accommodate their wishes or needs for the promotion of a transgender ideology. Transgender rights have in fact become a mainstream political issue. In some countries gender reassignment treatment is also covered by the state because hormone and other treatments have become fundamental for most transgender people. For this line of thinking (which is different than that of the author), these treatments enable them to live and express themselves in a manner that corresponds to their identity and help them to keep sustaining their desired lives. In spite of these revolutionary changes, some questions are being put forward for reflection: Should children and young people thinking with a transgender attitude, be encouraged and helped to change their bodies drastically? Should their parents sign their consent forms in order to help them change their gender? Should any state fork out money for expensive surgeries and related treatments (basically, hormonal therapies) in connection with the transformations they need to undertake? Receiving protection, support and medical or psychiatric help is imperative. It is those treatments that are clearly not only dangerous (child abuse was mentioned in the Introduction) but also cosmetic in nature that are being questioned. Transgender people in public appearances including parades and other grandiose events have become popular sightings. These people should never be marginalized or treated inferiorly and they have every right to feel happy and to celebrate -but on the other hand, we all acknowledge that the minds of children are like a blotting paper; they absorb whatever they see and eventually try to imitate. We have seen from twin studies that environmental factors probably predominate in the development of gender dysphoria. Likewise, should children be adopted by transgender people? Although in the Introduction we saw that evidence suggests that gender dysphoria may have some genetic roots (28% monozygotic twin concordance) its exact biological correlates are unclear. What is certain is Micallef.: The Transgender Journey and its Psychiatric Implications individual. 3 There is no such thing as a third sex or third gender; it is a socio-political construct. It is also unlikely that researchers who still believe that gender dysphoria is of an inborn nature and that these individuals are not suffering any mental illness will be able to attribute it to a one neat, contained set of causes. 39 Even if researchers were to prove that some people are born as gender-dysphoric, the way the behaviour of these people has been linked with that of lycanthropy-affected people raises eyebrows and should inform society that policymakers should not rush in their decisions. The review of the literature showed that persons with gender identity experience psychological problems and psychiatric disorders. As already discussed, through continuous counselling in up to 98% of cases, gender dysphoria can be resolved by adulthood and if psychotherapy fails, psychiatric treatment can be employed. Therefore, taking puberty blockers, cross sex steroids and undergoing amputation surgeries when there is no need to do so, can be associated with self-harm. Harming yourself is certainly not a normal thing to do and in fact self-injury behaviour which warrants psychiatric treatment, is associated with mental health conditions particularly depression and borderline personality disorder. 40 Compared to cisgender heterosexuals, depressive personality disorders are common in people with gender identity especially if they are candidates for sex reassignment surgery. [41][42] Transgenderism is also considered as a psychological problem because the high suicide rate of these individuals does not significantly change after surgery. 23 Although it is understood that community attitudes and societal acceptance are contributory towards their mental health, posttransition physical attractiveness also plays a role. 43 It is understood that humans feel greatly for the sufferings of others but should we allow our emotions to overpower our decisions and forget the basics of human biology? Biology is hard science based on objective reasoning and the stigmatization of mental disorders per se is not considered a sufficient reason to eliminate a condition from the mental disorder category. However, in spite of the WHO's advocacy for mental health parity, a mental disorder diagnosis can exacerbate problems for transgender people in accessing health services, particularly those that are not considered to be mental health services. Therefore, whereas the 'ICD-10 classification of mental and behavioural disorders'* 6 supported by WHO for decades had included 'gender identity disorders' primarily, 'transsexualism' , these are now being grouped as 'gender incongruence' and have been included in the new ICD-11 chapter titled, 'Conditions related to sexual health' . [44][45] However, it is imperative to note that medically, transgenderism still remains an abnormal (unusual) health condition; from a mental disorder it now appears to be a sexual condition! Transgender people (including those in the process of becoming transgender individuals) form part of the LGBTIQ group whose common denominator is the right to be attracted to any gender or engage in any preferred type of sexual practice. Hence, even though being transgender does not imply any specific sexual orientation, altogether as an LGBTIQ group they are a strong pressure group, albeit with diverse sexual desires. So, although studying transgenders within LGBTIQs makes no scientific sense, -for example, depression and other morbidities in 330 transgender women were not associated with sexual orientation 46 -politically, transgender people and LGBTIQs are consciously mixed together according to their needs and agendas. Despite both being unhappy with their bodies, comparing transgenderism with clinical lycanthropy may seem too radical. However, no other mental disorder which allows for a persistent and drastic desire to be distinguishable and at the same time, practicaly unrecognisable from how people knew them before, compares better with transgenderism 6 *ICD stands for International Statistical Classification of Diseases. that our bodies are genetically programed to change and develop through hormonal changes; we grow up, mature sexually and then age naturally by time. So, if gender dysphoria was found to be purely inborn, why does it not gradually and automatically transform its body completely into the other desired gender (transgender) through a natural, self-contained process and sustain it for life? If you cut off an arm or a leg you are mentally ill -this will be emphasised in the Conclusion and referred to as a specific disorder. If you desire to become a wolf or a bird you are mentally ill as well. However, if you wish to amputate your breasts and genitals, 'modern' society considers you as transgender, but does this justify normal behaviour? To a certain extent it is understood why they call themselves 'transgenders' or simply 'trans' instead of claiming themselves as only 'females' if they were originally boys or only 'males' if they were born as girls. In other words, because you grow up breasts through hormones and implants, use heavy cosmetics and even invasive treatments for face and skin changes and ultimately altering the genitals, you still do not become a real female: you simply become a transgender woman (male-to-female person). A normal female's cells are all genetically XX and her anatomy is made to conceive and give birth. Cosmetic surgery and cross-sex hormones cannot turn them from one sex into the other. They only create an illusion of change. In fact, transgender is more like a pseudo-gender or third gender, if one is not happy with the prefix 'pseudo' meaning, false. For example, when a transgender woman officially recognised by the state enters spaces in which biological women are particularly vulnerable (toilets, showers and prisons) a clash of gender rights can arise. 37 As already stated in the beginning of this paper, scientific evidence does not support the third gender or the idiosyncratic belief that you could be another person or something else. Although case reports only describe particular findings and normally lack generalizability, the presented case, despite being rare in itself, together with the available literature and logical argumentations, should serve as a platform to inform the research community that transgenderism is not normal behaviour. The small, yet significant study of the lycanthrope confirms this literature. It consolidates the current body of knowledge via a concise piece of comparative behavioural observation. Moreover, it raises important questions for consideration.

CONCLUSION
Although evolution is a gradual and continuous process, despite our sophistication and wishful thinking about perfectibility, human nature or behaviour did not change much. On the other hand, transgenderism is a new reality and a highly sensitive issue. The author also acknowledges that in most cases the affected individual does not capriciously 'choose' a different identity simply because of a reaction to a sudden desire. Gender dysphoria and its sufferings are real, but it is a psychological phenomenon and not a medical one. In psychology, 'normality' is a relative term. Everyone has the right to live the life they want to, even if the majority might find it strange or abnormal. Above all, although not scientifically proved, socially, the third gender exists -they are around us and statistics confirm this. Even when it comes to gender status for entry into certain universities or formal requests for jobs, quite often they get it as: male, female and other. However, this does not mean that prevalence studies or any current research is proving that transgender behaviour is justified as a natural and normal act of behaviour. Although the idea of two sexes is considered by many researchers as simplistic, 38 human biology stands by what it is: biologically, gender remains binary; our sex has been dimorphicly recognised since birth as either 'boy' or 'girl' . Thoughts that deviate from physical reality are abnormal and can be potentially harmful to the that he is not against LGBTIQs having equal rights in society. However, this paper explains why the medical transitioning of a human body into the opposite sex, including the persistent belief of undergoing such transformation is neither natural, nor normal. It is morally wrong for any parent, guardian, teacher, healthcare professional and policymaker to encourage gender transformation; gender correction in specific cases of intersex is completely different.
Here are some ethical highlights resulting from this paper including considerations put forward by the American College of Pediatricians: 3 • We must accept the reality that biologically, gender is binary (intersex is something else Gender reassignment surgery should be the last resort for a genderdysphoric person only if he/she is eligible to voting (you can be 18 years old and still unable to decide between good and wrong choices), is fully informed about the option for safer approach and has fully understood the risks he/she will undertake, including any post-op repercussions. • Once they undergo the transition process and turn into transgender individuals, they should continue to be medically followed due to the possibility of serious adverse effects arising from long term treatment and the high suicide rate which persists after surgery. Finally, in addition to the substantial moral questions raised in this paper, adherence to established principles of evidence-based medicine necessitates a high degree of caution in accepting gender affirmative treatment as the preferred treatment approach. 50

ETHICAL STATEMENT
Patient consent for publication was not required. As clinical lycanthropy is a rare psychiatric syndrome, especially when the nature of the lycanthropy is specified (as in this case, when the subject behaved as a bird), to preserve any chances of possible identification, no details of the person affected (including the most basic ones such as age, gender and so on), or where he/she was treated, are given in this essay. In the main text, the author preferred to use the general pronoun 'he' simply to enhance the flow of text instead of repeatedly writing 'he/she' . than lycanthropy.* 7 Moreover, there is no documentation of lycanthropes ever wanting to undergo plastic surgery to alter drastically their bodies so, the comparison is not as extreme as one thinks. Furthermore, it is definitely less extreme than when comparing with transableism ('body integrity identity disorder') when sufferers feel trapped in fully functional bodies and they end up amputating their own arms or legs or make themselves blind or deaf so as to make their bodies comport with their perceived identity. One hopes that common sense, which judges such a desire as grotesque, prevails over those who would regard it as just another lifestyle choice. The wish to be rid of an offending limb is remarkably similar to the wish of a transgender person to be rid of an unwanted penis. 33 Transgenderism is also being compared with anorexia nervosa in that it also involves profound dissatisfaction with one's body. In the Introduction, specifically in the twins study it was mentioned that heritability does not necessarily imply normality. In fact, several studies on anorexia, long-accepted as a mental eating disorder carrying a genetic component, demonstrated an average identical twin concordance rate of 44%. 47 This is far much higher than the 28% concordance rate in the Diamond's transgender study on twins. 12 So, the nature (genetics) versus nurture debate should not distract us from the real question of whether transgenderism ought to be considered as a normal variant or an example of psychological abnormality, as is anorexia. There are many genetically inherited conditions which are examples of medical pathology. Going back to anorexia, seriously underweight anorexic patients who see themselves as obese are not treated with weight-reducing liposuction. Instead, anorexia is treated as a psychiatric illness. 33 In any case, counselling and psychotherapy which aims to help children and adolescents come to a comfortable self-acceptance of their natal gender 6,48 seems to be the safest approach towards gender dysphoria and any co-existing conditions. The latter, for example depression, may require psychiatric treatment. Any possibly underlying causes of emotional distress such as hormone imbalances can be corrected through medicine, in this case, endocrinology. Finally, apart from the fact that there is still more to be learned from transgender people, the implications of this paper go beyond the stimulation of further debate on the controversial topic of transgenderism. The essay may serve to arouse curiosity into the disorder of lycanthropy which at times is not even mentioned in textbooks of clinical psychiatry.

EXTENDED CONCLUSION: ETHICAL REFLECTIONS
Although the originality of this study is based on a single case report, the paper includes a literature review containing current writings that are both in favour and against the transgender ideology. Moreover, although the paper is medically and psychiatry oriented, the author tried to avoid confusing medical jargon as much as possible. For example, specific brain areas, names of hormones or drugs and details of surgical procedures were avoided. This should help the reader to focus more on the moral values of this timely issue. Any medical professional involved in gender dysphoria treatment is facing great bioethical challenges and dilemmas. 49 Transgenderism is definitely a pressing concern not only for the medical profession but also for parents and educators alike. The author wants to make it clear 7 * In clinical lycanthropy, as with transgenderism, we see the desire for complete or drastic transformation from one body to another. In the case of transgenger, from the body of one gender to another, and in the case of lycantrophy (birdman) from the body of one species (human) to a body of a bird (actually, there are thousands of bird species).
Furthermore, the patient was never interviewed or followed in close and annoying proximity. The sufferer of this illness was only observed and neither was there any access to his/her medical records. Moreover, the author believes that presenting more details on this particular lycanthrope would be superfluous. The focus of this article was not on the existence, diagnosis and treatment of lycanthropy, but on seeing transgenderism through a scientific and ethical lens. As regards bioethics of the terminology used throughout this paper particularly with the use of the term 'transgenderism' , the author reassures the reader that the suffix 'ism' is not used in any disrespectful way. The term denotes the atypical behaviour of some people wanting to change their bodies drastically at all costs or, a sexual condition (according to the new WHO classification). In any case, we are dealing with a pathological condition. The author was clear in the Disclaimer that he is not transphobic. It is the act of transgenderism (the behaviour of transgenders) that is compared with clinical lycanthropy and not the affected individuals per se. Although the example of the 'birdman' is admittedly a rare case, it still carries valid implications. The message is conveyed to be understood by as wide range as possible of readers. Even a medical practitioner may find it confusing to understand the reasoning behind the low concordance rate of identical twins with respect to transgenderism, or the explanation about the human brain being 'plastic' . So, the essay challenges the conscience of the reader by asking whether someone who persistently believes he is a bird should be assisted in becoming to look like one! Confronted with this weird situation any reader should immediately raise eyebrows and turn his body into a state of alertness that something is truly wrong with the current medical approach of assisting gender-dysphoric youths to transform their bodies into those that mimic their opposite sex using harmful chemicals and surgeries. There is absolutely no natural process in this transformation. Only some species of fish can automatically transform themselves into the other sex. The criticism is therefore centred on the artificial transformation process. Having in mind the cardinal principle of 'first do no harm' , the author is against the associated medical practices when transgenderism is basically a psychological condition.

CONFLICT OF INTEREST
The author declares that there is no conflict of interest.

HIGHLIGHTS
• Gender dysphoria, Gender identity, Transgender and Intersex are not to be mixed together. • The 'born this way' argument holds no scientific basis, and gender can never transform naturally. • Transgenderism can have similarities with clinical lycanthropy: delusions, suicide. • Puberty blockers and cross-sex steroids are harmful to gender identity adolescents: allowing body harm is not normal behaviour.