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:    e  The client’s mother and father are both realtors. The mother states that she used to see a therapist for anxiety, which she now manages with medication. The father works long hours, and the mother returns home early to attend to the client’s needs. The mother states that she realized that the client wished to be another gender when they were younger, but she believed it was just a phase. She explains that the father is not supportive and refuses to discuss the issue. The mother is concerned about the client’s truancy and desires to be supportive but has mixed feelings about it. She says that she is fearful every day and believes that if she accepts the client’s truth, it will set the child up for “a lifetime of prejudice and discrimination.”  Your religious beliefs prohibit you from affirming the gender identity of a 13-year-old

Question: Your religious beliefs prohibit you from affirming the gender identity of a 13-year-old. Which of the following is your best first response?
(A): Conduct a trauma-informed assessment to determine the etiology of the client’s gender identity to help refine the treatment focus.
(B): Use self-reflection and self-assessment to examine the personal biases and stereotypes you may have about transgender individuals.
(C): Self-disclose your misgivings with the mother to help establish a therapeutic alliance.
(D): Refer the client to a counselor who specializes in counseling transgender youths to prevent imposing your personally held values and beliefs.

Correct Answer: Use self-reflection and self-assessment to examine the personal biases and stereotypes you may have about transgender individuals.
Explanation: Your best first response is to use self-reflection and self-assessment to examine the personal biases and stereotypes you may have about transgender individuals. Per the ACA Code of Ethics, disclosing your misgivings is unethical because it is not aligned with transaffirmative care and can be detrimental to the client. Conducting a trauma-informed assessment is appropriate, particularly for clients who are at risk for or may have experienced victimization or assault. However, providing this assessment to determine the etiology of the client’s gender identity suggests that there is an underlying cause that should be addressed to “fix” or change the “damaged” client. Assessments can be helpful appraisals for gender dysphoria rather than gender identity. Lastly, the ACA Code of Ethics states that counselors must “refrain from referring prospective and current clients based solely on the counselor’s personally held values, attitudes, beliefs, and behaviors” It is important to note that, although making values-based referrals is unethical, counselors are ethically responsible for practicing within the boundaries of their professional competence. Therefore, the correct answer is (C)
Competency: professional practice and ethics