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Nazario, Iigo Ricardo Alphonse R.

PSY 113 (Abnormal Psychology), Section C


9 October 2014
Psychiatric Case Study of a Person with Gender Dysphoria
Psychiatric History
Identification. The patient, R. S., sought consult on 16 September 2014 at the A
teneo de
Manila University. She was born on 18 January 1992 (22 years old), to parents R.
M. S. and
A. J. S., in Quezon City, Philippines. She was assigned the sex male at birth, b
ut currently
identifies as a female, making her transgender. She currently lives with her par
ents and
two siblings in Quezon City.
Chief Complaint. Patient: I never really felt like a boy. I always felt like a gi
rl.
History of Present Illness. The patient reported that she always felt like a fem
ale and never
a male. She has experienced different kinds of transphobic discrimination (discr
imination
due to ones identification as transgender) throughout her life. However, she also
reported
that she never had to come out of the family, because she said, They just knew, me
aning
her loved ones simply know that she identifies as a female. She reported taking
antiandrogen medication on her own, but later on discontinued use because it was
not
necessary, because she felt beautiful as a woman already.
Past Psychiatric History. The patient reported no past psychiatric episodes nor
symptoms.
Medical History. No major illnesses nor medical conditions were reported.
Family History. The patient reported no psychiatric illnesses within her family.
She has two
siblings; she is the middle child. She is not close with her older brother, but
she mainly
interacts with her younger sister. Her parents are currently not on speaking ter
ms, but she
does not know why. Despite this, she says that such a system in her family works
for the
household.
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Personal History
Early Childhood. She stated that she had a considerably normal happy family, dur
ing her
early childhood years. Her most prominent memory included dancing Barbie Girl in
front of her relatives.
Late Childhood. She recalled consistent bullying by her schoolmates due to her
expressed gender when she was younger. She noted a significant incident in schoo
l, when
group of adults asked her if she was bakla. (Bakla is the Filipino idea of gay w
hich included
effeminacy and wanting to be a female despite being assigned male at birth.) She
asked
them to explain what bakla is, and eventually agreed that she is. She marked thi
s incident
as the start of her transition from male to female.
Adolescence. She recalls one one incident in school where she was assigned to we
ar a
butterfly costume, and when a teacher saw it, she was asked Are you a girl or a b
oy?
Despite being a simple question, she broke down in tears and marked a significan
t event
of distress due to the incongruence of her experienced gender and sex assigned a
t birth.
Educational History. The patient attended Ateneo de Manila Grade School and Aten
eo de
Manila High School, both all-boys exclusive private schools. She was almost not
allowed to
continue her studies due to poor grades during her first year in high school, bu
t she took
her education more seriously afterwards. After high school, she was enrolled int
o the
multimedia arts program of De La SalleCollege of Saint Benilde, but after a year,
transferred to Ateneo de Manila University, where she is currently studying unde
r the
interdisciplinary studies program, with the tracks psychology and communication.
Occupational History. The patient has not had any job.
Romantic and Sexual Involvements. The patient had her first sexual encounter at
Grade 4,
although she is not completely sure of this. She has had at least 20 partners, w
ith 8 months
being the longest relationship that she was involved in. All her partners were m
ale. She is
currently not involved in a relationship.
Social Activities. The patient enjoys volleyball and playing computer games, suc
h as
Defense of the Ancients (DotA). In her free time, she practices her dancing with
friends.
Current Living Conditions. She currently lives with her family in Quezon City. S
he reported
no difficulties with her current living conditions.
Legal History. She reported no legal history during the course of her life.
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Fantasies and Dreams. She aspires to be a star, meaning she wants to be well known
and rich. But, she also dreams of marrying someone and having a family.
Mental Status Examination
Appearance. The patient wore a blouse, short shorts, and sandals during the cons
ult, and
was made up lightly. The patient was responsive to the examiner. Signs of physic
al illness
were absent.
Speech. The patient spoke in a mixture of Tagalog and English. Speech was sponta
neous,
appropriately loud enough during the consult, understandable, and at a comprehen
sible
speed.
Emotional Expression. Mood: The patient was in a neutral mood during the consult
.
Affect: The patient was calm and cooperative during the consult.
Thought Form. Circumstantiality: negative. Clang association: negative. Derailme
nt:
negative. Flight of ideas: negative. Neologism: negative. Perseveration: negativ
e.
Tangentiality: negative. Thought blocking: negative.
Thought Content. Delusions: negative. Ideas of reference: negative. Preoccupatio
ns:
negative. Obsessions: negative. Suicidal potential: negative.
Perception. Hallucinations: The patient reported no hallucinations. Illusions: n
egative.
Depersonalization: negative. Derealization: negative.
Alertness. The patient was alert and attentive during the consult.
Orientation. The patient was properly oriented with the person, time, and place
during
the consult.
Concentration. Good.
Memory. The patient does not remember some significant details of her personal h
istory.
Recall of immediate memory is good.
Calculations. Good.
Fund of Knowledge. The patient manifested signs of good fund of knowledge
appropriate to her circumstances and educational level.
Insight. The patients insight may be listed either as Level 1 or Level 4, dependi
ng on how
the patient views it. Level 1: The patient believes that she does not have an il
lness. Level 4:
The patient believes that her condition is caused by something unknown to the pa
tient.
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Judgment. Good. The patient spontaneously cooperated with the examiner during th
e
evaluation.
Salient Features
History. Positives: Incongruence between ones expressed gender and sex assigned a
t
birth; insistence that the patient is female; historically significant distress
in many aspects
of the patients life due to the incongruence.
Mental Status Examination. The patient does not recognize her condition as somet
hing
that must be treated (Level 1 insight). However, the patient believes that her e
xperienced
and expressed gender is caused by something unknown to her (Level 4 insight). No
other
significant features are presented in the mental status examination.
Core Symptoms
The patient exhibited inward and outward expression of her gender identity (fema
le),
which is incongruent with her sex assigned at birth (male). Though people she kn
ows
nowadays are comfortable with this incongruence, this incongruence has caused
significant distress throughout the patients life. She cannot convince herself to
express
her gender as a male, but always as a female.
Differential Diagnoses
The following differential diagnoses were taken from the DSM-5 (American Psychia
tric
Association [APA], 2013, p. 458).
Nonconformity to Gender Roles. Simple nonconformity to gender roles is distingui
shed
from gender dysphoria by the absence of the strong desire of being a gender that
is
different from the sex assigned at birth. The patient desires to become a female
; hence,
she cannot be diagnosed with simple nonconformity to gender roles.
Transvestic Disorder. Transvestic disorder is the act of cross-dressing that gen
erates sexual
excitement to the patient. The patient cross-dresses, but not for the goal of se
xual arousal,
but rather as a part of undertaking roles of her gender identity. Thus, she cann
ot be
diagnosed with transvestic disorder.
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Body Dysmorphic Disorder. Body dysmorphic disorder is the recognition of a body
part
as deformed (not because it belongs to another gender). The patient cannot be
diagnosed with body dysmorphic disorder.
Schizophrenia and Other Psychotic Disorders. Psychotic features, such as halluci
nations
and delusions, were reported as absent by the patient. She cannot be diagnosed w
ith a
psychotic disorder.
Diagnosis
Upon examination of the patient information above, the patient is diagnosed with
gender
dysphoria, with no comorbid disorder.
Psychodynamic Formulation
The core conflict of the patient is the conflict between her experienced and exp
ressed
gender and her sex assigned at birth. Upon examination of the patient informatio
n above,
the examiner has come to a decision wherein the diagnosis cannot be traced back
to
specific events or life conditions that caused her to be transgender. Furthermore,
tracing
the sexual orientation or gender identity of a person back to a historical life
event is
discriminatory because it implies that being heterosexual or cisgender (having a
gender
identity congruent with ones assigned sex at birth) has no traceable history and
is thus
considered normal; in the same light, the examiner believes that having a sexual
orientation other than heterosexual and having a gender identity that is not cis
gender
should not constitute a plausibility of examining where such sexual orientation
or gender
identity started to become abnormal.
Discussion of the Diagnoses
Gender dysphoria refers to the distress that may accompany the incongruence betwe
en
ones experience or expressed gender and ones assigned gender (APA, 2013, p. 451;
see also Royal College of Psychiatrists [RCP], 2013, p. 12). The historical back
ground of
gender dysphoria is rather controversial (Kring, Johnson, Davison, & Neale, 2012
). First,
homosexuality was not removed from the DSM until 1973. Homosexuality, as a disor
der,
was replaced by ego-dystonic homosexuality in 1980, but was later removed in 198
7.
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However, the diagnosis of gender identity disorder remains in the DSM until toda
y. In
2013, gender identity disorder was renamed gender dysphoria, to give emphasis on
the
distress that the patient is experiencing, and the diagnosis was moved from the
sexual
dysfunctions category to its own category in DSM-5, gender dysphoria.
Until today, gender dysphorias controversial inclusion in the DSM-5 comes with
two kinds of problems (see Kring et al., 2012, p. 364). First, gender dysphoria
is a
sociocultural problem because some of the symptoms listed under gender dysphoria
is
seen as normal in many cultures and societies; creating a diagnosis may contradi
ct such
social and cultural norms. Furthermore, it creates the stigma that transgender p
eople have
a disorder, meaning that they are considered as ill persons, when many transgender
people disagree with feeling sick. The existence of gender dysphoria as a diagnosi
s
further erases the idea of gender fluidity and reinforces the gender binary. Sec
ond,
gender dysphoria, as a disorder, is a moral problem because it enforces the idea
that
incongruence between ones sex assigned at birth and gender identity is something
that
must be cured, which implies that this incongruence is something that is abnorma
l and
must be fixed. Both these reasons create discrimination in such a way that ident
ifying not
as ones assigned sex is considered wrong, or at least not normal.
However, gender dysphoria is important to be kept as a diagnosis so that patient
s
may be recognized as persons who are in need of help to express their gender ide
ntity as
much as possible, by receiving hormonal therapy and sex reassignment surgery (RC
P,
2013). Without this diagnosis, patients with gender dysphoria may be denied of c
linical
access to treatment and full expression of their gender identity.
Gender dysphoria occurs in 0.005% to 0.014% of all natal males and 0.002 to
0.003% of all females. Not all those with gender dysphoria seek professional gui
dance;
hence, these percentages are likely to be modest. Persistence ranges from 2.2% t
o 30% of
natal males with gender dysphoria, and 12% to 50% in natal females with gender
dysphoria. (APA, 2013)
Treatment Plan
The patient stated that she does not wish to take treatment for her gender dysph
oria, at
least not in her current situation. Until the patient feels the need to receive
treatment, no
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treatment plan is to be made for her; it would be useless to make such a plan wh
en she
clearly states that she will not follow that plan in the first place.
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References
American Psychiatric Association. (2013). Diagnostic and statistical manual of m
ental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Kring, A. M., Johnson, S. L., Davison, G. C., & Neale, J. M. (2012). Abnormal ps
ychology
(12th ed.). Hoboken, NJ: John Wiley & Sons.
Royal College of Psychiatrists. (2013). Good practice guidelines for the assessm
ent and
treatment of adults with gender dysphoria. London: Author.