Chapter 7. Charles’s Case: Welding and Nail Polish

7.1 Screen 1

Clinical Choices
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You must read each slide, and complete any questions on the slide, in sequence.
Male Hypoactive Sexual Desire Disorder

1. For at least 6 months, individual repeatedly experiences few or no sexual thoughts, fantasies, or desires.
2. Individual experiences significant distress.
(Information from: APA, 2013)
Erectile Disorder

1. For at least 6 months, individual usually finds it very difficult to obtain an erection, maintain an erection, and/or achieve past levels of erectile rigidity during sex.
2. Individual experiences significant distress.
(Information from: APA, 2013)
Premature Ejaculation

1. For at least 6 months, individual usually ejaculates within one minute of beginning sex with a partner and earlier than he wants to.
2. Individual experiences significant distress.
(Information from: APA, 2013)
Delayed Ejaculation

1. For at least 6 months, individual usually displays a significant delay, infrequency, or absence of ejaculation during sexual activity with a partner.
2. Individual experiences significant distress.
(Information from: APA, 2013)
Transvestic Disorder

1. For at least 6 months, individual experiences recurrent and intense sexually arousing fantasies, urges, or behaviors involving cross-dressing.
2. Individual experiences significant distress or impairment over the fantasies, urges, or behaviors.
(Information from: APA, 2013)
Pedophilic Disorder

1. For at least 6 months, individual at least 16 years old experiences recurrent and intense sexually arousing fantasies, urges, or behaviors involving sexual activity with a prepubescent child -- at least 5 years younger than individual. In most cases, the child is at most 13 years of age.
2. Individual acts on these urges or experiences significant distress or impairment over the urges or fantasies.
(Information from: APA, 2013)
Gender Dysphoria

1. For 6 months or more, individual’s gender-related feelings and/or behaviors is at odds with those of his or her assigned gender, as indicated by 2 or more of the following symptoms:
  • Gender-related feelings and/or behaviors clearly contradict individual’s primary or secondary sex characteristics
  • Powerful wish to eliminate one’s sex characteristics
  • Yearning for the sex characteristics of another gender
  • Powerful wish to be a member of another gender
  • Yearning to be treated as a member of another gender
  • Firm belief that one’s feelings and reactions are those that characterize another gender.
2. Individual experiences significant distress or impairment.
(Information from: APA, 2013)
Interview Notes

What brought you in?

Charles
- Doctor says need to see psychologist to discuss issues before treatment

Family
- Mom wants to be supportive but does not want to rush treatment
- Sister wants to be supportive
- Dad does not want to be there

Treatment:

Charles
- Hormone treatment → Monitored by Dr. Bird
- Simultaneous behavioral changes → hopes family can help
- Surgery

Family
- Mom supportive with reservations about timing
- Dad uncomfortable
- Sister 100% supportive
- Idea that this is potentially uncomfortable

When did issue first begin?

Charles/Cheryl
- Prefers to be called Cheryl
- Always felt like a girl in a boy’s body

Family

- From age 2 or 3
- Played dress up in sister’s clothes
- Potty training – insisted on sitting down to pee

School:

Cheryl
- Preschool teacher was great
- Liked to play with girls → typical girl activities
- Didn’t like doing typical boy activities
- Teacher and classmates were accepting

School later on:

Cheryl
- First grade → rough
- Didn’t like using boys bathroom
- Felt like had girl’s emotions
- Called a sissy
- Girls didn’t accept Cheryl
- Mom made wear boy’s clothes

Family
- Would change as soon as got home
  • Amanda’s hand-me-downs
- Conference with teacher
  • Concerns about social development
  • Recommended the family see a psychologist

Psychologist

Cheryl
- Very helpful
- Family and individual
- Play out scenarios as girl
- Coping skills

Family
- Dad did not find therapy helpful before
- Dad does not understand why they need to engage in therapy again
- Amanda found the therapy helpful in understanding Cheryl
- Mom thought they addressed the issue when Cheryl was too young

Family:

Cheryl
- Gets along well with Amanda
- Loved by parents
- Nice neighborhood
- Grandparents nearby
  • Grandfathers not supportive
  • Grandmothers supportive
- Private schools

Family
- Dad → investment banker
- Mom → English teacher
- Dad was jock, traditionally masculine, struggled to understand Cheryl/Charles as a result
- Grandparents thought Cheryl/Charles was gay
- Amanda didn’t understand at first but now supports Cheryl’s treatment fully
- Mom trying to accept and be supportive

Life right now:

Cheryl
- OK
- B average in high school
- Researched treatment
- Long hair and androgynous look
- Attracted to men but doesn’t see self as gay—wants men to want her as a woman
- Feels dad doesn’t accept
- Feels mom isn’t completely accepting

Activities:

Cheryl
- Dancing
- Art → ceramics, metal sculpture
- Wants to major in art

Family
- Dad likes that Cheryl welds → most masculine thing she does
- Mom likes that Cheryl dances
- Amanda likes cooking

Behavioral changes

Cheryl
- Buying more feminine clothes
- Mani/pedis
- Skin treatments
- Push the limits
- Afraid of what classmates will say

Family
- Mom will take shopping
- Amanda will go shopping and to salon

Cognitive model

The cognitive model proposes that we can best understand abnormal functioning by looking at cognitive (thinking) processes. The cognitive perspective holds that abnormal functioning results from the person’s maladaptive, irrational and inaccurate thoughts about and interpretation of a situation. Cognitive theorists and therapists believe that by substituting more realistic, rational thoughts for these irrational ones, clients can change their outlook on life and thus improve their symptoms.
Biological model

The biological model adopts a medical disease perspective on psychological disorders. The main focus of this model is that psychological abnormality is an illness brought about by malfunctioning parts of the organism. Typically, the biological model focuses on genetic predispositions for disorders and abnormalities in brain anatomy or chemistry. To treat psychological disorders, the biological perspective argues that abnormalities in the brain must be addressed through medication or other treatments that act on brain chemistry or circuits.
Behavioral model

The behavioral model argues that our actions are determined largely by our experiences in life. Behavioral theorists focus on principles of learning, in particular how abnormal behavior might be learned by observing others or reinforced by contingencies in our lives such as avoiding discomfort. Behavioral theorists and therapists are more interested in observable behaviors and environmental factors than the inner workings of the mind. To treat psychological disorders, the biological perspective argues that abnormalities in the brain must be addressed through medication or other treatments that act on brain chemistry or circuits.
Humanistic model

The humanistic model believes in the inherent worth of every individual and that all people have the capacity to strive towards bettering themselves. Those who endorse the humanistic perspective argue that psychological disorders occur when people encounter “conditions of worth” in their lives – unrealistic expectations that others create as conditions that must be met in order to gain love and respect. To counteract this problem, humanistic or client-centered theorists and therapists focus on creating a supportive, genuine environment in which the therapist offers unconditional positive regard – support no matter what the client does.

Author: Taryn A. Myers, Ph.D., Virginia Wesleyan College

Charles talks to a nurse in a hospital setting.

7.2 Screen 2

Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training. This particular case deals with a DSM-5 disorder that may be unfamiliar to some individuals and may make some individuals uncomfortable.

7.3 Screen 3

Get instructions for the interview
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The receptionist hands you the intake paperwork prior to your intake interview with your new client, Charles, who was referred to you for a psychological evaluation and treatment by his doctor before he begins a new treatment regimen for his disorder. Your receptionist mentions that Charles’s parents and sister are with him. Click the button below to review the paperwork before you begin the interview.

New Client
Charles: Case #10113

Psychological Clinic

Intake Paperwork

Client Name: Charles

Age: 15 years old

Gender: Male

Ethnicity: Biracial (White and African-American)

Occupation: Student

Current living situation: I live at home with my parents and sister, Amanda

Why are you seeking services at our clinic?

My doctor, Dr. Bird, wants me to see you before I start treatment for my condition and then I need to keep seeing you during the treatment. She says treatment is a long process, and I want to get this going before I start college. Dr. Bird also said it would help my family if we all talked to someone together about my condition. She’s concerned about me—how I’m going to adjust to everything.

7.4 Screen 4

Begin the interview

You will now ask Charles and his family a number of questions you would typically ask during the intake interview. As you conduct the interview with Charles, begin to think about his symptoms, what his diagnosis might be, and later, what type of treatment might be most helpful to him. Click the “play” button below the illustration to hear Charles’s and his family’s responses to your questions. To read the transcript for these answers, click on the “transcript” button. Take notes in the box provided as you listen to Charles’s responses.

7.5 Screen 5

Ask Charles the next question

“Hi Charles, it’s good to meet you. Mom and Dad – Lorna and Lee – and Amanda, thanks for coming today. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today, and I’m going to ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean continuing to come to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let’s start. Tell me about what brought you to the clinic today.”

Charles’s family and Amanda take part in Charles’s intake interview at a clinic.

Transcript

Charles: [quietly at first but then becoming louder and more direct] Dr. Bird says I have to talk to you before I start my treatment regimen. She says we’ll need to work together to assess my progress before she will agree to do my surgery. I want to get this going. I know treatment can be a really long process, and I want this to MOVE. But… [pause] Dr. Bird says my family—my mom and dad-- also need to talk about the issues they have with my diagnosis. [Rolling eyes] So everyone is here.

Mom: We want to be supportive, don’t get us wrong, but I don’t understand why we have to rush into this, Charles. You can wait to start the treatment. You’re only 15.

Amanda: [almost interrupting--some hostility towards her mother evident in her voice] I, for one, want to be as helpful and supportive as I can.

Dad: [uncomfortable and frustrated] I really don’t understand why I have to be here. Why are we all required to be here when this is Charles’s personal issue?

Question 7.1

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Check Your Notes

What brought you in?

Charles
- Doctor says need to see psychologist to discuss issues before treatment

Family
- Mom wants to be supportive but does not want to rush treatment
- Sister wants to be supportive
- Dad does not want to be there

7.6 Screen 6

Ask the next question

“Tell me about the treatment you hope to undergo, Charles.”

Charles’s parents talk to the nurse during the interview.

Transcript

Charles: I’ll start hormone treatment first; Dr. Bird says you’ll help her monitor my behavior as I go through the treatment changes…make sure I adjust ok to all the hormones, I guess?... I don’t really understand why I need to see you when she can just treat me. I will also make some behavioral changes before – or I guess during? – the treatment. I hope my family will help me with those, but [pauses, then softer] I know my mom and dad aren’t very comfortable with all this. Then in several years … such as long time to wait! ... when I’m ready, Dr. Bird will perform the surgery. [brighter and more hopeful] She’s known for this surgery. She’s world famous-- I feel really lucky to have her as my doctor.

Dad: [breaking in] This is really uncomfortable to talk about. Are you sure I need to be here?

Mom: We’re going to all try to be supportive, Lee. Even if I think it’s far too early for Charles to be taking these drastic steps.

Amanda: [to Charles] Even if mom and dad aren’t, I’m with you 100%. I’ve got your back!

Question 7.2

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Check Your Notes

Treatment:

Charles
- Hormone treatment → Monitored by Dr. Bird
- Simultaneous behavioral changes → hopes family can help
- Surgery

Family
- Mom supportive with reservations about timing
- Dad uncomfortable
- Sister 100% supportive
- Idea that this is potentially uncomfortable

Question 7.3

Which of the following options represent potential diagnoses for Charles? Check all that apply. To review the diagnostic criteria for each disorder, click on the disorder name.

wCfH0QtRgXJ8o+c+ Male Hypoactive Sexual Desire Disorder
bI0LPa9lfHQ+dYqk Erectile Disorder
wCfH0QtRgXJ8o+c+ Premature Ejaculation
bI0LPa9lfHQ+dYqk Delayed Ejaculation
wCfH0QtRgXJ8o+c+ Transvestic Disorder
wCfH0QtRgXJ8o+c+ Pedophilic Disorder
bI0LPa9lfHQ+dYqk Gender Dysphoria
Table
Correct! Charles’s symptom presentation and possible treatments (hormone therapy and/or surgery) are consistent with erectile disorder, delayed ejaculation, and gender dysphoria.
That’s not quite right. Charles’s symptom presentation and possible treatments (hormone therapy and/or surgery) are consistent with erectile disorder, delayed ejaculation, and gender dysphoria.

Hint

Think about which of the disorders might require hormone treatment and possibly surgery. There is more than one correct answer.

7.7 Screen 7

Ask the next question

“When did your issue first begin, Charles?”

Charles informs the nurse that he prefers to be called Cheryl.

Transcript

Charles: [softly and with some hesitation] I… I actually prefer to be called Cheryl. And I honestly don’t remember when I first felt like this. I never felt like I was a guy. From the time I understood the difference between girls and boys, I just felt like I was a girl trapped in the wrong body.

Dad: I remember telling him to stop whining like a girl and be a man at age 2.

Amanda: I think when he was around 3, he wanted to play dress up with my clothes, put barrettes in his hair. We had a blast.

Mom: [nervously] We thought it was no big deal! He looked so cute in Amanda’s clothes. Just kids being kids, playing dress up.

Dad: [breaking in angrily] I knew it was a big deal. I used to tell him to take those girl clothes off. I told ALL of you not to encourage that behavior.

Amanda: Nobody was getting hurt. It was really fun for both of us! And then one day they freaked out because I painted his nails.

Mom: [quietly] That set off some warning bells for me. It was taking it too far.

Dad: That was also around 3, wasn’t it? And then there was the potty training! He wanted—no, insisted on —sitting down to pee like a girl. [Sadly] It took me a long time to figure out that Charles is never going to act the way men act. No matter what I said, how I tried to show him how to fit in… it just didn’t make a difference.

Question 7.4

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Check Your Notes

When did issue first begin?

Charles/Cheryl
- Prefers to be called Cheryl
- Always felt like a girl in a boy’s body

Family
- From age 2 or 3
- Played dress up in sister’s clothes
- Potty training – insisted on sitting down to pee

7.8 Screen 8

Ask more about Cheryl’s school experiences

“Thank you for sharing your preferred name with me, Cheryl. I will try to respect your preferences, but if I mess up, don’t be afraid to correct me! What was it like for you when you started attending school?”

Cheryl shares her school experience.

Transcript

Dad: [aside] Cheryl. Such B.S. We named you Charles after my father - your grandfather.

Cheryl: Dad, I – [quiet, less comfortable] I started school when I was 4 or so, I think. My teacher, Mrs. Sabathia, was really nice. She saw that I was different from other boys, and she didn’t seem to care. I liked to be the mom when we played house, like pretending to clean and cook like my mom. I didn’t really like roughhousing or wrestling. I’d play hopscotch or jump rope with a group of girls, and no one seemed to mind – no one at school, that is.

Question 7.5

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Check Your Notes

School:

Cheryl
- Preschool teacher was great
- Liked to play with girls → typical girl activities
- Didn’t like doing typical boy activities
- Teacher and classmates were accepting

7.9 Screen 9

Ask Cheryl the next question

“How about when you got older? Was school still as easy to navigate when you felt like you were trapped in the wrong body?”

Cheryl explains her difficulties in school life, while her family further informs the nurse of Cheryl’s behavioral changes.

Transcript

Cheryl: [sadly] Things got really rough in first grade. We had separate boys and girls bathrooms for the first time, and I hated it! I don’t like to pee standing up, so I’d have to rush to be the first one in the bathroom so I could get a stall. I would complain about the other kids playing too rough with me or start crying – I mean, I really felt like I had emotions like a girl would, not a boy – and then I’d get called a “sissy.” The girls didn’t really accept me, even though I liked playing with them. It was like I didn’t fit in anywhere. And mom made me wear boy’s pants and overalls to school, so I felt really self-conscious and embarrassed.

Mom: [defensive] I made him wear boy’s clothes - as was appropriate … [sadly] but he hated it.

Amanda: As soon as Cheryl got home from school, she would change into my old clothes. She loved my pink and purple stuff! I’m only 2 years older, so lots of my stuff fit her. [To Cheryl] I remember that you always seemed more comfortable once you changed clothes, more like yourself…happier.

Dad: First grade was the first time someone outside the family expressed concern about Charles’s behavior. His first-grade teacher asked us to come in for a conference.

Mom: I remember she said how well he was doing in school! But—

Dad: [cutting her off] But she expressed concern about his social development. She told us that Charles’s behavior was – different – from that of the other boys. She said he wasn’t acting normal. She said that would get harder for him as he got older and she recommended that we go to see a psychologist.

Question 7.6

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Check Your Notes

School later on:

Cheryl
- First grade → rough
- Didn’t like using boys bathroom
- Felt like had girl’s emotions
- Called a sissy
- Girls didn’t accept Cheryl
- Mom made wear boy’s clothes

Family
- Would change as soon as got home

  • Amanda’s hand-me-downs

- Conference with teacher

  • Concerns about social development
  • Recommended the family see a psychologist

7.10 Screen 10

Ask about their family

“Did you go to see the psychologist as your teacher recommended?”

Cheryl shares experiences about her first visit to a psychiatrist as a teenager.

Transcript

Cheryl: [Brightening] Yeah, and she was great! We did some family therapy – I … I would say that wasn’t much help, but I got to do individual sessions, which were great. Dr. Edelman let me play out scenarios as a girl and we figured out how I could react when kids teased me. I saw her for about 3 years, I think. Super helpful!

Dad: [irritated] As Charles has explained, we already attended family sessions. We checked that box off. I don’t understand why Charles’s new doctor is making us go through this again.

Mom: I made sure we followed through together as a family, but Lee found the therapy sessions painful. The therapist knew about these sorts of things and had us bring in Amanda so that we could try to understand about Charles not wanting to be a boy.

Amanda: I was a little confused. Why were we going to a doctor that didn’t give us shots? [laughs a little, then more seriously] But it was helpful to have someone explain what was going on with Cheryl, because I was only 8 at the time, but I knew she was different. I felt like it was helpful, even if mom and dad didn’t.

Mom: [sharply] Amanda, being a child herself, has never understood what her father and I went through. We tried to understand. We went to—we paid for-- the sessions. It just never made sense to us to address this issue when Charles was still in elementary school. He was too young to know what he wanted or needed.

Dad: [grumbling under his breath] Ridiculous waste of time.

Question 7.7

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Check Your Notes

Psychologist

Cheryl
- Very helpful
- Family and individual
- Play out scenarios as girl
- Coping skills

Family
- Dad did not find therapy helpful before
- Dad does not understand why they need to engage in therapy again
- Amanda found the therapy helpful in understanding Cheryl
- Mom thought they addressed the issue when Cheryl was too young

7.11 Screen 11

Ask Cheryl about her current feelings

“Tell me more about your family. How do you all get along? What was it like for you growing up, Cheryl?”

Cheryl discusses her family.

Transcript

Cheryl: It was pretty good, I guess. Amanda and I had fun, and we got along with mom and dad—I mean, they loved us. We live in a really nice neighborhood. Our grandparents lived nearby, too, so we got really spoiled. My grandfathers didn’t get why I didn’t want to hunt and fish with them, but Grammy and Nana were totally cool about cooking with me, or taking me shopping. Mom and Dad sent me and Amanda to private schools, so I got a really good education.

Dad: I believe we gave Charles a good childhood, so I’m not sure why he continues to be so unhappy with who he is. [with pride] I’m an investment banker, so I can provide well for my family.

Mom: I teach high school English now. I started working again when Charles—I mean Cheryl-- entered junior high school. Lee and I met in college. He was quite a jock—played lacrosse, belonged to a fraternity. [Turning to her husband] That may be why it’s hard for you to understand what was going on with Charles.

Dad: [acknowledging his wife’s point] It was tough. It bothered me so much when he said he wanted to be a girl and wore his sister’s clothes and couldn’t enjoy sports the way I did as a boy. But it was even harder for our parents, especially our fathers. They thought Charles was a homosexual. They thought that was the only explanation for why he wanted to be a girl.

Amanda: I have to admit, at first it was a little confusing for me. I can basically understand where our grandparents were coming from. I always accepted Cheryl, but at first it was easier for me to think of her as gay. I have friends that are lesbians and gay guys, and I am completely cool with them – love whoever you want, right? But it took me a bit to understand what Cheryl meant when she said she wanted to be a girl instead of a boy. I think I get it now, though, and I really want you to be able to get this treatment, Cheryl.

Mom: I am trying to understand and accept this and love my child. I have helped him – her? – [to Charles] I don’t even know what to call you! –when kids bullied her at school. I love my children unconditionally and Lee and I have worked really hard to give them as happy a life as possible. But it’s so hard. I never learned about anything like this when I was growing up.

Question 7.8

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Check Your Notes

Family:

Cheryl
- Gets along well with Amanda
- Loved by parents
- Nice neighborhood
- Grandparents nearby

  • Grandfathers not supportive
  • Grandmothers supportive

- Private schools

Family
- Dad → investment banker
- Mom → English teacher
- Dad was jock, traditionally masculine, struggled to understand Cheryl/Charles as a result
- Grandparents thought Cheryl/Charles was gay
- Amanda didn’t understand at first but now supports Cheryl’s treatment fully
- Mom trying to accept and be supportive

Question 7.9

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Cheryl’s father and grandfathers do not seem to understand that she feels like she was born in the wrong body. It sounds like she got conflicting messages from family members – support from her sister, ambivalence from her mother, confusion and anger from her father – which likely made life difficult as she was growing up. Her mother and sister did support her when she had difficulties, and this family support likely helped her to become as well-adjusted as she could.

7.12 Screen 12

Ask Cheryl about her interests

“Cheryl, what is life like for you right now?”

Cheryl and her family express their emotions about Cheryl’s behavior.

Transcript

Cheryl: You know, it’s ok. I’m doing pretty well in high school--I have a B average. I’m excited to go to college in a couple of years and I’m looking for schools that have good support for transgender students. I know this treatment will be tough, and I probably won’t be able to get my surgery until after college, so I’m going to need an environment where I feel accepted. About a year ago, I started researching the sex reassignment surgery and hormone treatments. I read about how they don’t let you start till after puberty so your hormones don’t go all crazy. I like wearing my hair long, and because I’m skinny, I have this sort of androgynous look that I think my friends at school are into. There are definitely other kids who dress like me.

Dating has been really weird to figure out. I’ve realized that I have feelings for guys, not girls. [Looking at his parents.] I don’t think I’m gay, though – I want a guy to love me as his girlfriend. A lot of my friends have been girls, and Amanda is the best. Sometimes it’s hard, though, because my Dad doesn’t ever show me affection – you don’t, Dad – which sucks. It’s like me being me isn’t good enough. And Mom, sometimes I feel like I don’t know where you stand. It’s like you love me, but you could love me more if I were more like your idea of who I should be. And I need you to love me as ME.

Dad: You’re a good kid. I wish I could be even more supportive, son. I do love you. I just don’t understand this part of you and why you have to put us all through this.

Cheryl: [getting upset] It’s not something I’m putting you through! This is who I AM! I’m not doing it just to do it.

Mom: [a little emotional] I’m trying really hard. I just don’t know why you can’t wait until you are out of high school to make sure this is not just a phase.

Cheryl: It’s not a phase. It’s really not. It’s not going to go away, not matter how much you want it to. [louder] This is who I am.

Question 7.10

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Check Your Notes

Life right now:

Cheryl
- OK
- B average in high school
- Researched treatment
- Long hair and androgynous look
- Attracted to men but doesn’t see self as gay—wants men to want her as a woman
- Feels dad doesn’t accept
- Feels mom isn’t completely accepting

7.13 Screen 13

Ask Cheryl this question

“I want to take a minute to validate what Cheryl just said. Individuals like Cheryl genuinely feel they are born in the wrong body and biological and psychological research findings support this. I also, on the other hand, want to validate how difficult this must be to understand, as it is not an issue that is commonly discussed in our society. I feel like I have a good handle on the background of your issue now, Cheryl, but I want to get to know you a little better. Tell me about what activities you enjoy in your free time.”

Cheryl talks about her interests.

Transcript

Cheryl: I really like to dance. My mom encouraged me to take dance classes. I’m also good at art. I like ceramics, and I love metal sculpture and welding. I hope that when I go to college, I can major in art. I really can’t wait to get to college. I think things will be different for me there.

Dad: Welding is the most masculine thing he does. I guess he makes some great art – I wouldn’t really know how to judge it, but his teachers say good things.

Mom: And I love that he got into dancing – I think “Dancing with the Stars” made it more ok for boys and girls to dance again.

Amanda: I’m glad that you like to cook and I always get to be your taste-tester.

Question 7.11

Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=

Check Your Notes

Activities:

Cheryl
- Dancing
- Art → ceramics, metal sculpture
- Wants to major in art

Family
- Dad likes that Cheryl welds → most masculine thing she does
- Mom likes that Cheryl dances
- Amanda likes cooking

Question 7.12

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2
Correct.
Think about what else Cheryl will need to address as she goes forward with her treatment
Incorrect.

Hint

Think about what else Cheryl will need to address as she goes forward with her treatment.

7.14 Screen 14

Review Cheryl’s symptoms

“What behavioral changes are you planning to make as you start your treatment?”

Cheryl informs her family of the changes she would like to make.

Transcript

Cheryl: [excited] I’d like to get some clothes that are more “feminine.” I’m not sure if I’m ready to wear dresses yet, but maybe some leggings and brighter colors and patterns, and some cute shoes. I want to get a nice haircut and a mani-pedi. I think I might even paint my toenails but keep wearing closed-toed shoes. I’ve already started taking good care of my skin, but I don’t know if I’m ready to wear make-up yet. I’d like to start pushing the limits a little, [pauses, quieter] but I’m afraid of what the kids at school might say.

Mom: I told Cheryl we can go shopping right after this appointment if she wants. I’m going to try to be more supportive. I can do shopping.

Amanda: [excited] The three of us can go together! I loved painting your nails as a kid, Cheryl, and now we can do it together. This will be awesome – I’ve always wanted a sister to share this kind of stuff with.

Question 7.13

Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=

Check Your Notes

Behavioral changes

Cheryl
- Buying more feminine clothes
- Mani/pedis
- Skin treatments
- Push the limits
- Afraid of what classmates will say

Family
- Mom will take shopping
- Amanda will go shopping and to salon

7.15 Screen 15

Diagnose Cheryl

Question 7.14

Which of the following symptoms is Cheryl currently experiencing? Check all that apply. Use your interview notes to help you remember!

bI0LPa9lfHQ+dYqk inconsistency between assigned and experienced gender
wCfH0QtRgXJ8o+c+ sexual arousal from cross-dressing
bI0LPa9lfHQ+dYqk strong desire for sex characteristics of the other gender
bI0LPa9lfHQ+dYqk strong desire to be rid of one’s sex characteristics
wCfH0QtRgXJ8o+c+ sexual fantasies about cross-dressing
bI0LPa9lfHQ+dYqk strong desire to be a member of the other gender
wCfH0QtRgXJ8o+c+ fantasies about sexual activity with children of the same gender
wCfH0QtRgXJ8o+c+ fantasies about sexual activity with children of the opposite gender
bI0LPa9lfHQ+dYqk strong desire to be treated as a member of the other gender
bI0LPa9lfHQ+dYqk strong conviction that one has the typical feelings and reactions of the other gender
Table
Correct! Cheryl has a strong desire for the sex characteristics of the opposite gender and wants to be rid of her assigned sex characteristics. She has a desire to be the other gender and be treated as such. She believes that she has the typical feelings of a girl rather than a boy, and all of these factors lead to her feeling an inconsistency between her assigned gender (male) and the gender she believes she is (female).
That is not quite right. Cheryl has a strong desire for the sex characteristics of the opposite gender and wants to be rid of her assigned sex characteristics. She has a desire to be the other gender and be treated as such. She believes that she has the typical feelings of a girl rather than a boy, and all of these factors lead to her feeling an inconsistency between her assigned gender (male) and the gender she believes she is (female).

Hint

Review your notes from the interview or listen to Cheryl and her parents again to review her symptoms.

7.16 Screen 16

Next Question

Question 7.15

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2
Correct.
Think about the following symptoms Cheryl exhibits in making your choice:

- Wanting to be the opposite gender - Enjoying activities typical of the opposite gender
Incorrect.

Hint

Think about the following symptoms Cheryl exhibits in making your choice:

- Wanting to be the opposite gender
- Enjoying activities typical of the opposite gender

7.17 Screen 17

Next Question

Question 7.16

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Cheryl exhibited all of the following symptoms of gender dysphoria: feeling that she is the wrong gender, wanting to have the sex characteristics of the other gender (through hormones and surgery), desire to be treated as a member of the opposite gender, and feeling like she has the reactions of the opposite gender.

Gender dysphoria appears to be quite rare, with less than one-tenth of one percent (< 0.010%) of individuals of either biological sex seeking hormonal, surgical, or therapeutic services. However, it may also be possible that this disorder is underreported, as many people with the disorder may choose to live in silence rather than address it with a professional. Why do you think that is?

(http://www.cpa.ca/docs/File/Publications/FactSheets/PsychologyWorksFactSheet_GenderDysphoriaInAdolescentsAndAdults.pdf)

Question 7.17

rCYTwB+ZkQWI1ad1o39MlDjWqODh61KVIcbio2Z4+/N0Wz6lS2Tdnze1GEzD06Zym3eVimsq4vUOBzQzfRcijG8e7wDVpjmpSwau9L+jJhODJMFj

Check Your Notes

There is no real “correct” answer, this is your opinion. It is likely that gender dysphoria is a rare experience, but it may also be underreported, as it is falls outside of cultural norms of gendered behavior. However, it may also be very difficult for people with this disorder to reveal their feelings about being assigned the wrong gender because such feelings are not accepted in all sectors of society.

7.18 Screen 18

Next Question

From the File. You remember a former patient who shared symptoms similar to Cheryl’s. You review this case to help you as you think about Cheryl’s case.

Question 7.18

ryvX1zrg2AOcDuQymTXr1UCeBVd61ASUCnBg77YSa/qVidt+hIuWFMNpD/WA9V+U42bq2uU4iKgWxsDQOlK7W6KBph/DyOoD3pe68UIJXByO1VT1oxTCs1ijFAXFmbIWH+O303lgF9A9CpfPzO1zgsO3fLbgX8gTxY2jwQiQo+uD8ZbC97C62A==
Harper and Cheryl both feel that they were born in the incorrect body. Both of these patients had parents who at first struggled with understanding their children’s feelings, but were able to adapt at least somewhat. Harper’s parents are able to be more supportive at this point in time – Cheryl’s parents will become more supportive as she undergoes her treatment.

7.19 Screen 19

Choose a treatment

Question 7.19

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2
Correct.
In making your choice, think about the type of treatment Cheryl is planning to seek.
Incorrect.

Hint

In making your choice, think about the type of treatment Cheryl is planning to seek.

7.20 Screen 20

What happened to Cheryl?

Question 7.20

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2
Correct.
In making your choice, think about what function hormones might serve.
Incorrect.

Hint

In making your choice, think about what function hormones might serve.

Question 7.21

GEQA7NZ2jQ2SUwVsCrbsA4HnAyLPNzww41HPqk4w31dvL1xch0HxoLTrJ+VQ0171CL6rbJ/C3FYdmXWUZcwZzg6/CnPJ/UNIO1328eOpba74UecaFUm+nJAarkoDeKMlH2v719J5TZEkuWmEqc9AoQns7+lcHcJ5p8vYZyH+NREIpZnz4rWAmrVLYKX7MDLButQJwDGI2CMP0OQdBIxxBCzOL0KA9lH0zpg08nD/EkW9u6pt4ML+e3ktYwbtJ/W4
It is standard procedure for individuals with gender dysphoria to be referred for therapy to monitor their psychological adjustment as they begin biological treatments such as hormone therapy. Treatment in this case is not centered on fixing a problem but instead on making sure that Cheryl is psychologically healthy as she undergoes her adjustment to the opposite gender. In addition, it is important for individuals undergoing this transition to have support, so family therapy will be important as Cheryl’s family members are currently ambivalent about her transition.

7.21 Screen 21

Real World Application

EPILOGUE

Cheryl talks to a young man after undergoing surgery and living her life as she desires.

Cheryl was diagnosed with gender dysphoria. Her treatment was covered by the family’s health insurance. She continued to see Dr. Bird, her medical doctor, who carefully monitored her hormone treatments for the rest of high school and throughout college. As her psychologist, you helped her make behavioral changes such as beginning to wear makeup and purchasing bras to support the breasts that developed as a result of hormone therapy. Cheryl also role-played with you to learn to talk to friends about her feelings about her gender and her choice to undergo medical intervention to transition to becoming biologically female. Perhaps the most important part of therapy was working with Cheryl’s family—especially her parents-- to help them understand why she wanted to make this transition. While Amanda fully accepted Cheryl’s need to become female, and Cheryl’s mother became increasingly supportive, it took Cheryl’s father several years to accept that he was never going to have the son he thought he had. He begrudgingly supported Cheryl’s transition but remained emotionally distant.

You also encouraged Cheryl to reach out to the local gay, lesbian, bisexual, and transgender (LGBT) community. She attended a support group organized through her surgeon’s office for individuals undergoing gender reassignment and found others who felt the same way she did. Cheryl began college at the age of 18. She majored in visual art, continuing her sculpture work and exploring new media, such as digital art. She joined the Equality Alliance on her campus and found great support there. She also took psychology and gender studies courses, where she made new friends and expanded her knowledge of gender dysphoria and related issues.

At the age of 25, you, Cheryl, and her surgeon agreed Cheryl was mentally and physically ready to undergo surgery. She underwent a procedure where her penis was inverted to become a vagina. Although the recovery was difficult, as with any surgery, Cheryl was ecstatic with the results of the surgery. She immediately felt more comfortable and confident in her own skin.

Following the surgery, Cheryl’s father became more accepting of her gender. He is able to hug her again. Amanda’s relationship with her sister remains close, and their mother is happy to have another daughter.

Since her surgery, Cheryl has been working at a local LGBT resource center and creating art in her spare time. She is now pondering going to graduate school for art therapy so she can combine her love of art with her desire to help others like herself who struggle with their gender identity.

7.22 Screen 22

Real World Application

Watch the following video and answer the questions below.

Question 7.22

xnq6WmwVwZAT/misWCyttXIlDnRbd9CYxfwwyBm/3TUn3MZiCrhAOEgyC7eJlwo4DSkgdt2rD3IQruAwUnppL51luWSmLiu3jM2EI8L70iZw5ch4xttQeCfFwB+himB16st6ErvzJiLaXHj10XRRQpzlt96sXqB8usQS/h2zdmA=
There is no right or wrong answer to this question, only your personal opinion. However, children tend to make fun of behaviors they do not understand or anyone who they perceive to be “different.” Zoe is around 12 years old and she and her peers have undergone or are beginning to undergo puberty. The onset of puberty tends to increase preoccupation with gender roles and how gender is expressed, making anyone who deviates from societal expectations a likely target of bullying.

Question 7.23

CPp5zDNq/ybVbfF/nGxKI00Ed1hu1nmTzVKmmgVQ562uEx8e6G6FLnZNtQOlUvFdC5HNrytaJa5QnZJOe+THINn+5zqpInIcbL5PP0HIgL3IIm3y3BQiK1IPSgwnI2B8hHPtrhdophAnEpidADpoENPFQiBnaAgQSr/qU8kBtpxytVzJfISuV/SGugEnFFGjyrx3Pw==
Venice’s father hired a series of therapists to try to convince him to live as a girl -- the birth gender. In time, his father realized that he was trying to “fix” something that was not broken, and Venice did not need to be changed by a therapist. He likely came to accept Venice’s feelings about Venice’s gender.

The American Psychiatric Association (APA) put out a statement regarding the decision of the framers of DSM-5 to maintain the diagnosis of “gender dysphoria.” The name of this disorder was changed from “gender identity disorder” despite pressure to take this diagnosis out of the DSM from many who believed the disorder pathologizes people who identify as transgender and/or transsexual. The Sexual and Gender Identity Disorders Work Group argued that keeping the diagnosis in the DSM allows for insurance reimbursement for procedures that individuals with gender dysphoria may choose to undergo, such as gender reassignment surgery. In addition, changing the name from "disorder" to "dysphoria" might reduce the stigma surrounding this diagnosis and emphasize that people with gender dysphoria are not "disordered," but rather unhappy living in a body that they feel does not match the gender with which they identify.

(http://www.dsm5.org/documents/gender%20dysphoria%20fact%20sheet.pdf)

Question 7.24

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There is no right or wrong answer to this question, only your personal opinion.