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: Since the intake, you have provided professional development training for school staff on transgender and gender nonconforming (TGNC) individuals. The administration supports your recommendations for keeping the client and others safe at school. The client continues to miss school, but they have had fewer absences this month. You learn that the client’s desire to be rid of their male secondary sex characteristics has become more persistent. They say that they have seen media coverage of individuals who have undergone sex reassignment surgeries and wondered what that would be like. The client also states they are confused about their sexual orientation. The client appreciates being an active participant in their treatment, and together you create relevant treatment plan goals. You discuss the upcoming family session with the client’s parents. The client articulates appropriate topics for this session and reports increased anxiety concerning their father’s participation

Question: Based on the client’s diagnosis, which treatment plan goal would you select for the client?
(A): To reduce distress caused by the desire to identify as another gender
(B): To reduce distress caused by sexual orientation uncertainty
(C): To reduce incongruence between gender expression and gender identity
(D): To reduce incongruence between nonbinary and cisgender identity

Correct Answer: To reduce distress caused by the desire to identify as another gender
Explanation: Based on the client’s diagnosis, an appropriate treatment plan goal would be to reduce distress caused by the desire to identify as another gender. The DSM-5 replaced the term gender identity disorder with gender dysphoria to avoid pathologizing one’s identity, which was maintained in the most recent version, the DSM-5-TR. Gender expression is defined as the outward expression of one’s gender and may or may not align with one’s gender identity. Gender identity is defined as one’s inner sense of being male, female, a combination of both, or neither. One’s gender at birth may or may not coincide with one’s gender identity or gender expression. Sexual orientation uncertainty is unrelated to gender dysphoria, making this answer option incorrect. Gender dysphoria is defined as the incongruence between one’s expressed or experienced gender and one’s assigned gender. Individuals who are nonbinary do not identify as male or female but instead identify as something in between or no gender at all. Cisgender describes individuals whose gender identity is consistent with their birth identity. Reducing incongruence between nonbinary and cisgender identity is not possible because the two are mutually exclusive. Therefore, the correct answer is (A)
Competency: treatment planning