Delusion and a complete lack of self awareness.  He is a "man" …with tits.  He has a fupa that covers his genitals. If you could prop the fupa out of your way, he has probably  already developed an inny dick. So, he's effectively neutered himself. He must walk around wheezing and sweating through his clothes, not realizing that no healthy person does those things.  He gets passed by pensioners in the mall and assumes that they must be speedwalkers rather than that he's just slow.