from the wiki
"She is male but identifies as a woman and lives and dresses in her desired gender role. It could also be vice-versa. The characters could be distorted versions of friends, family, and peers that have alienated her (or him) after she/he came out to them as a trans woman or a trans man. In support of Madotsuki actually being a female to male transgender, the psycho Toringen could stem from Madotsuki feeling that his own, female body is working against him. The blood, and imagery of female reproductive systems are signs of hate and resentment towards periods and female puberty. While the phallic imagery could hint, in this case, towards his desire for a penis and male reproductive organs, they could also hint that when he came out as a man, it was met with violence. Many trans men are victims of rape from cisgender male attackers, as the attackers feel that raping them will put them back in their "place". The Toringen party could hint at Madotsuki's separation from the cisgendered girls.
In support of the theory that Madotsuki is a male to female transgender, the Toriningen party could actually mean that she is isolated from them due to her not being a real girl in their eyes. The psycho Toringen could be classmates that shamed her into dropping out of school and locking herself away. She still could have been raped by cisgender men on coming out, as it is also a common method of "teaching" a lesson in hate crimes, but the more horrific instances of phalic imagery could be Madotsuki fighting against her own biology, and resenting it.
There is also a small possibility of Madotsuki actually being intersexed. She could either have breasts, and female genitalia on the outside, with testes where her ovaries are meant to be, or she could have the male organs outside, and the female inside, which could explain why both female and male reproductive organs have such a horrific depiction in many areas of the game. Many intersexed people suffer from anemia caused by lack of appropriate hormones. This could explain, possibly, that Madotsuki sleeps so much because she is lacking energy. "