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.  Counselors must carefully examine the benefits and risks associated with medical interventions for adolescents with gender dysphoria

Question: Counselors must carefully examine the benefits and risks associated with medical interventions for adolescents with gender dysphoria. Which ethical principle considers the client’s capacity to participate in the decision-making process?
(A): Fidelity
(B): Justice
(C): Autonomy
(D): Beneficence

Correct Answer: Autonomy
Explanation: Autonomy is the right of an individual to participate in decisions affecting the direction of their life. Autonomy is an integral part of informed consent. Informed consent is the process by which one understands the benefits and risks of a specific treatment and freely consents to that treatment. Counselors who work with TGNC teens are tasked with providing accurate information on the pros and cons of medical treatment for gender dysphoria. In general, counselors must educate families on the detrimental effects of withholding medical interventions, including increased psychiatric comorbidity (eg, suicidality, substance abuse). Alternatively, there are risks inherent in hormonal or surgical interventions, including the timing of administration and the irreversible nature of some of these interventions. Because the client is 13 years old, their ability to make an informed decision may not be developmentally appropriate, particularly for hormonal and surgical interventions. The principle of beneficence is honored by working for the good of the client’s overall mental health and wellbeing. Fidelity is the ethical principle that is used when keeping commitments and promises. Fidelity is most commonly practiced when conducting research and engaging with other professionals. Therefore, the correct answer is (D)
Competency: professional practice and ethics