Some factors found within the dream worlds could be seen as representing transgender or other queer identity. A duplicate Madotsuki can be found inside a closet at two points in the game - one in the
Checkered Tile Path and a
ghost in the middle of
Mini Hell. These two instances could be a literal interpretation of the term "in the closet", a term meaning one has not come out to those in their life. The phrase is typically used in cases relating to sexuality or gender identity. Another thing to note is that a male and female
Restroom appear in different areas in the dream world, both of which Madotsuki can enter.
Many of the effects relating to appearance, such as the Hair effects, could be seen as representative of appearance or body dysphoria. Many creatures throughout the dream world could also be seen as relating to body dysphoria as well. For example, creatures resembling reproductive organs appear in Madotsuki's dreams, such as the uterus-like
Floyag and the phallic
KyuuKyuu-kun. Some fans also interpret
FACE as such imagery, though another interpretation is that Madotsuki simply dislikes her own facial appearance, considering FACE is presented in a disturbing or distorted manner. The
Henkei Shita could also play a role in this theory, as they resemble pregnant or fat people. Many of the more distorted creatures, such as the
White Desert monsters and the
Sewer Drawings, have abnormal limbs that give off the appearance of something inside them trying to escape, which may be metaphorical for "coming out" in terms of identity.
Even the ending of the game can be interpreted as symbolic. Many fans think that Madotsuki's death and the ending of the game overall represent a "reawakening" of sorts. In the context of transgender or sexual identity, this could be interpreted as coming out or revealing such things publicly, reawakening as a completely new person.