Case Study
Patient Demographic: Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4)
Mental Status Exam: Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th
Presenting Problem: You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school.
Other Contexts: You work with the client and their parents to help the parents understand how the client conceptualizes their gender identity. You use the client’s self-identified, gender-affirming pronouns and praise the client for taking a brave first step. The client’s mother is fearful and anxious, particularly when thinking about the client’s safety. The client’s father expresses an overall lack of understanding and thinks it could be a phase. You recognize the father’s efforts to understand and help the client explain the distressing emotions associated with coming to terms with their gender identity, including an increase in severity since the onset of adolescence. The father states that he is unsure if he can accept the client’s transgender identity but says that he is committed to the counseling process

Question: What is the main purpose of supporting the client’s use of self-identified, gender-affirming pronouns?
(A): To lay the groundwork for reparative therapy as an evidence-based practice (EBP)
(B): To illustrate potential difficulties associated with social transitions
(C): To normalize and validate gender diversity as a natural human variation
(D): To help the parents become acclimated to the lifelong use of the client’s selected pronouns

Correct Answer: To normalize and validate gender diversity as a natural human variation
Explanation: The purpose of supporting the client’s use of self-identified, gender-affirming pronouns is to normalize and validate gender diversity as a natural human variation. Some research has shown that gender-affirmative care is associated with improved outcomes for gender dysphoria. Counselors using gender-affirmative care provide a safe and supportive environment for gender-diverse individuals through advocacy, psychoeducation, and person-centered counseling. Social transitions for TGNC include identifying preferred pronouns; however, the counselor’s primary purpose for using preferred pronouns in family therapy is to affirm, normalize, and validate gender diversity. Gender diversity is fluid; therefore, the client may or may not use the same pronouns in the future. Therefore, the correct answer is (D)
Competency: professional practice and ethics