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.  You provide ongoing assessment for any associated mental disorders that may further complicate the client’s coming out process

Question: You provide ongoing assessment for any associated mental disorders that may further complicate the client’s coming out process. According to the DSM-5-TR, gender dysphoria is comorbid with all of the following EXCEPT:
(A): Anxiety disorders
(B): Depressive disorders
(C): Attention-deficit/hyperactivity disorder (ADHD)
(D): Autism spectrum disorder

Correct Answer: Attention-deficit/hyperactivity disorder (ADHD)
Explanation: According to the DSM-5-TR, gender dysphoria is associated with all of the answer choices except ADHD. Per the DSM-5-TR, adolescents that are referred with gender dysphoria most commonly present with anxiety and depressive disorders, while children that are referred with gender dysphoria commonly present with autism spectrum disorder. For most males, adolescence starts between the ages of 10 and 14. Identifying comorbid diagnoses or symptoms can help counselors select appropriate interventions and address any additional barriers affecting the client. For example, considerations for gender-diverse individuals on the autism spectrum may require a tailored approach for effectively handling social transitions and interpersonal relationships. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis