see attached
Transgender Youth
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Review the following case study and address the questions that follow.
IDENTIFICATION: The patient is a 14-year-old adopted African-American female-to-male transgender individual. The patient uses the name Joseph and masculine pronouns (he, him, his). He is evaluated in a child and adolescent inpatient crisis unit.
CHIEF COMPLAINT: “My parents don’t understand me.”
HISTORY OF CHIEF COMPLAINT: Patient came out as transgender on social media 2 years ago. At that time, he asked his parents and friends to call him Joseph and to refer to him using masculine pronouns (he, him, his). He wants to wear only boy’s clothing, use the boy’s bathroom at school, and participate in groups and activities for boys. Patient reports that his parents are not accepting of his transgender identity and that their lack of acceptance has contributed to increased anxiety, depression, and suicidal ideation. The patient told his outpatient therapist that he was planning to kill himself by running into oncoming traffic. The therapist contacted his parents, who brought him to the hospital for evaluation.
The patient reports engaging in self-injurious behavior by making superficial cuts to his forearms and occasionally to his breasts “because I hate them. I don’t want them.” Patient reports his last episode of self-injury was “two nights ago” when he used a razor to cut his left forearm.
He reports, “I can’t seem to focus” and that he is in danger of failing two of his classes. He has been sleeping most afternoons after returning home from school. Patient reports feeling “very sad” for the past month. He states he has been eating more than usual and has gained 10 lb in the past month. He is currently prescribed fluoxetine 40 mg by his outpatient psychiatrist.
PAST PSYCHIATRIC HISTORY: The patient has been in outpatient therapy on and off since age 4 because of anxiety and issues with gender identity.
He had several trials of medications for attention-deficit/hyperactivity disorder (ADHD) as a young child. He is currently taking fluoxetine 40 mg with some effect on anxiety and depression. They had in-home family therapy for 6 months following a referral from the patient’s school. This therapy ended 4 months ago. This is his first psychiatric hospitalization.
MEDICAL HISTORY: Exercise-induced asthma. Several superficial healing cuts observed on patient’s left forearm.
HISTORY OF DRUG OR ALCOHOL ABUSE: Patient reports smoking about five cigarettes per day. He denies use of alcohol, marijuana, or other illicit substances. He denies use of any unprescribed hormones.
FAMILY HISTORY: Limited information available about patient’s biologic family, but substance-abuse problems (specific substances unknown) were suspected in patient’s biologic mother. Patient’s adoptive mother has a history of depression.
PERSONAL HISTORY
Perinatal: Unknown because the patient is adopted.
Childhood: The patient was adopted at age 5 after having been in foster care since age 3 because of neglect and physical abuse by his biologic mother. No other children live in the home. The patient began to express cross-gender identity at age 12. He insisted on wearing boy’s clothing and used the boys’ bathroom at school even though the school did not permit this.
Adolescence: The patient expresses distress at developing secondary sex characteristics associated with females. He is currently binding his breasts to create the shape of a flatter chest. He reports intense dysphoria around the time of menstruation. He is attracted to girls and identifies as heterosexual.
TRAUMA/ABUSE HISTORY: Physical abuse and neglect by biologic mother from birth to age 3.
MENTAL STATUS EXAMINATION
Appearance: Short hair, dressed in masculine clothing, wearing eyeglasses.
Behavior and psychomotor activity: Restless, bouncing right leg throughout assessment.
Consciousness: Alert.
Orientation: Oriented to person, place, and time.
Memory: Not formally assessed but appears to be intact during this assessment.
Concentration and attention: Reports impaired concentration. Appears mildly distractible during assessment.
Visuospatial ability: Not assessed.
Abstract thought: Not assessed.
Intellectual functioning: Average.
Speech and language: Rapid, mildly pressured.
Perceptions: No evidence of perceptual disturbance.
Thought processes: Coherent, goal directed.
Thought content: No abnormalities.
Suicidality or homicidality: Suicidal ideation with plan to run into traffic. Uncertain intent.
Mood: “Down.”
Affect: Congruent with mood, constricted.
Impulse control: Good during the assessment. His history of self-injurious behavior may be an indication of impulsivity.
Judgment/Insight/Reliability: Fair/Moderate/Moderate.
Questions
1. What
screening tools and/or
laboratory tests would you use to further evaluate this patient?
2. What are your
differential diagnoses for this patient?
a. Include DMS-5 TR codes and ICD-10 codes
b. Include rationale for ruling in or ruling out the diagnoses.
c. What diagnosis would you rule in as your
working diagnosis?
3. What
pharmacological, psychoeducational, psychotherapeutic, and
complementary and alternative treatments would you recommend for this patient while hospitalized and at discharge?
4. What
cultural and ethical considerations would you consider with this patient?
