Author: Taryn A. Myers, PhD, Virginia Wesleyan University
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.
The receptionist hands you the paperwork prior to your intake interview with your new client, Cheryl, who was referred to you for a psychological evaluation and treatment by her doctor before she begins a new treatment regimen for her disorder. Your receptionist mentions that Cheryl’s parents and sister are with her. Select the button below to review the paperwork before you begin the interview.
New Client
Cheryl: Case #10113
Psychological Clinic
Intake Paperwork
Client Name: Cheryl
Age: 15 years old
Gender: Female
Ethnicity: Biracial (White and African-American)
Occupation: Student
Current living situation: I live at home with my parents and my sister Amanda
Why are you seeking services at our clinic? My doctor, Dr. Bird, wants me to see you before I start treatment, 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.
You will now ask Cheryl and her family a number of questions you would typically ask during the intake interview. As you conduct the interview with Cheryl, begin to think about her symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Select the “play” button to hear Cheryl’s and her family’s responses to your questions. To read the transcript for these answers, select the “transcript” button.
“Hi, Cheryl. It’s good to meet you. Mom and Dad—Lorna and Lee—and this is your sister Amanda, right?—thanks for coming in. 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 having you continue 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.”
Transcript
Cheryl: [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. I want to get this going. I know treatment can be a really long process, and I want – no, I NEED – this to MOVE [with desperation]. 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, but I don’t understand why we have to rush into this. 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. This is a personal issue, after all.
“Tell me about the treatment you hope to undergo, Cheryl.”
Transcript
Cheryl: 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 start changing my behavior before – or I guess during? – the treatment. I hope my family will help me with that, but [pauses, then softer] I know my mom and dad aren’t very comfortable with all this. Then in several years … such a long time to wait! ... when I’m ready and we’ve jumped through all the hoops, Dr. Bird will do the final step. [brighter and more hopeful] She’s known for this treatment. She’s world famous—and she has also been empathetic and supportive – 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 these drastic steps.
Amanda: [to Cheryl] Even if mom and dad aren’t, I’m with you 100%. I’ve got your back!
Which of the following options represent potential diagnoses for Cheryl? Select all that apply. To review the diagnostic criteria for each disorder, select the disorder name.
Female Sexual Interest/Desire Disorder
bI0LPa9lfHQ+dYqkFemale Orgasmic Disorder
wCfH0QtRgXJ8o+c+Exhibitionistic Disorder
wCfH0QtRgXJ8o+c+Transvestic Disorder
wCfH0QtRgXJ8o+c+Pedophilic Disorder
bI0LPa9lfHQ+dYqkGender Dysphoria
Hint
Think about which of the disorders might require both medical and physical treatment. There is more than one correct answer.
“When did your issue first begin, Cheryl?”
Transcript
Mom: How long has it been, Charles?
Cheryl: [softly and with frustration] Cheryl! I… I keep telling you that I 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 she was around 3, she wanted to play dress up with my clothes, put barrettes in her hair. We had a blast.
Dad: [breaking in angrily] 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 her nails.
Mom: [quietly] That set off some warning bells for me. It was taking it too far.
Dad: 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.
“Thank you for reinforcing your preferred name with us, Cheryl. Would you also share your preferred pronouns? 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?”
Transcript
Dad: [muttering under his breath] Cheryl. Such B.S. We named you Charles after my father – your grandfather.
Cheryl: Dad, I – [deep sigh, quiet, less comfortable] Thank you for asking about my preferred pronouns. I don’t think anyone except Dr. Bird has ever done that before. I prefer she/her. 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 the boys, and she didn’t seem to care. I liked pretending to cook like my Grammy and Nana. I’d play hopscotch or jump rope with a group of girls, and they didn’t seem to mind. The boys bullied me for doing “girly” things, though. They would chase me around the playground and call me names. One of them threw rocks at me. It got so bad that even though I loved everything we were learning I was afraid to go to school. I would pretend to have a stomachache to try to get out of it.
“I’m sorry you had that experience when you were so young. How about when you got older? Was school still as easy to navigate when you felt like you were trapped in the wrong body?”
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’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 … I felt really strange and like I didn’t fit in my own skin.
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 tear off her boy’s clothes and change into my old clothes. 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. You were so sad when you got home from school.
Dad: First grade was the first time someone outside the family expressed concern about Charles’s behavior. His first-grade teacher called us in for a conference. She told us that his behavior was – different – from the other boys’. She said he was different and that she was concerned about how much the other kids were teasing him, and how that was affecting his schoolwork. She told us that Charles was withdrawn in class and sat by himself inside during recess. She was worried that it would get harder for him as he got older and she recommended that we see a psychologist.
Mom: It was very hard for us to see him – er, her – come home so depressed and scared. I tried to blow off the stomachaches the year before as typical school avoidance, but it was difficult to see your own child seem so withdrawn and not know why or what to do to help. He-she- didn’t seem to have any friends, either.
Hint
Think about what Cheryl experienced at school and how it was affecting her.
“Did you go to see the psychologist as your teacher recommended?”
Transcript
Cheryl: [Brightening] Yeah, and she was great! We did some family sessions – 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 or worse – when they threw things at me or chased me. I got more assertive and learned to seek out help from the teacher… until I realized it just made the kids bully me more. It made me feel sad and hopeless, and Dr. Edelman was helping me to cope with those feelings. [ sadder] But then Dad said we couldn’t go any more after about 3 months.
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]. I felt like it was helpful to have someone explain what was going on with Cheryl, 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. He was too young to know what he wanted or needed. We thought it was clearly just a phase. I’m not convinced it’s still not!
Dad: [grumbling under his breath] Ridiculous waste of time.
“Tell me more about your family. How do you all get along? What was it like for you growing up, Cheryl?”
Transcript
Cheryl: It was okay, I guess. Amanda and I had fun. We live in a really nice neighborhood. Our grandparents lived nearby, too. My grandfathers seemed pretty offended that I didn’t want to hunt and fish with them – they used to call me names like “sissy boy,” but Grammy and Nana liked cooking with me, even if they didn’t understand me. Mom and Dad sent me and Amanda to private schools, so I got a really good education – when I could concentrate. But the kids were just as mean as the kids in public school, and that made it really difficult to do well.
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 started teaching high school English again when Charles—I mean Cheryl, I guess—entered junior high school. [pauses] 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 always accepted Cheryl, but at first it was easier for me to think of her as gay. It took me a while to understand what Cheryl meant when she said she felt like 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 Cheryl] I don’t even know what to call you! – when kids bullied him at school. I want to say 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.
Based on Cheryl’s and her parents’ description of her childhood, how might Cheryl’s childhood family environment have affected her? Select all that apply.
Cheryl’s grandfathers likely abused her when they did not accept her.
wCfH0QtRgXJ8o+c+Cheryl’s grandmothers were not accepting or understanding.
bI0LPa9lfHQ+dYqkThe hostility she received from her father and grandfathers was likely very difficult.
wCfH0QtRgXJ8o+c+Her sister’s support was not helpful since it conflicted with their parents.
bI0LPa9lfHQ+dYqkCheryl’s mother’s ambivalence about her was probably quite confusing.
bI0LPa9lfHQ+dYqkHer sister’s support likely helped Cheryl keep going.
Hint
Think about the ways in which the reactions of Cheryl’s family members may have affected a young child.
“Cheryl, what is life like for you right now?”
Transcript
Cheryl: [Sadly] It’s – it’s not great. You see how my parents don’t understand me. Then every day at school I get made fun of and I don’t really have people to sit with at lunch or friends to talk to. [quieter] Sometimes it’s actually scary. There are guys who threaten me physically, slam me into lockers. Sometimes I just can’t make myself go to school. [deep breath] It takes all the energy I have to maintain a B average – I know I could be an A student if I wasn’t so on my guard all the time. Things can just feel overwhelmingly bleak. The only thing I have to look forward to is going to college in a couple of years and getting out of here. I’m looking for schools with 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. [pauses]
Right now, it’s hard … I don’t feel like my parents … I don’t feel like you guys get me. [pauses] I don’t feel like you support me. 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 would 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: 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.
Hint
Think about what Cheryl has experienced at school and the interaction she is having with her parents throughout this interview.
“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. Research also supports the idea that identifying as transgender is very difficult, just as Cheryl described. 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 your background now, Cheryl, but I want to get to know you a little better. Tell me about what activities you enjoy in your free time.”
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 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 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.
Hint
Think about what else Cheryl will need to address as she goes forward with her treatment.
“What behavioral changes are you planning to make as you start your treatment?”
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 really afraid of what the kids at school might say and how it might increase the bullying. [quietly] Sometimes I worry about my safety.
Amanda: [seriously] Cheryl, I want you to tell me from now on when this stuff happens at school. We can go to the principal together. [excited] And when you’re ready, I could go shopping with you. This will be awesome – I’ve always wanted a sister to share this kind of stuff with.
Dad: [sighs] I can’t believe my son wants to wear “feminine” clothes.
Mom: [uncomfortably]This is all moving too fast for me…
Which of the following symptoms is Cheryl currently experiencing? Select all that apply.
Inconsistency between assigned and experienced gender
wCfH0QtRgXJ8o+c+Sexual arousal from cross-dressing
bI0LPa9lfHQ+dYqkStrong desire for sex characteristics of the other gender
bI0LPa9lfHQ+dYqkStrong desire to be rid of one’s sex characteristics
wCfH0QtRgXJ8o+c+Sexual fantasies about cross-dressing
bI0LPa9lfHQ+dYqkStrong 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+dYqkStrong desire to be treated as a member of the other gender
bI0LPa9lfHQ+dYqkStrong conviction that one has the feelings and reactions typical of the other gender
bI0LPa9lfHQ+dYqkSignificant distress or impairment
Hint
Think about Cheryl’s main symptoms and how she feels as a result of them.
Hint
In making your choice, think about the following symptoms Cheryl exhibits:
From the File. You remember a former patient who experienced symptoms similar to Cheryl’s. You review this case to help you diagnose Cheryl
Transcript
[MUSIC PLAYING]
HARPER ROBERTSON: As far back as I can remember, it was quite self-evident to me that it would have been much better to have been born a boy. I remember like my grandmother asking me when I was probably about seven or eight, she said, do you want to be a boy? And I said, of course, duh. I just felt completely trapped by the way that I looked.
NARRATOR: But there was always a sense of something not quite right.
THOMAS DOLBY: I never felt that Harper was very happy as a child. And it makes me think sometimes of families in which a kid is brought up as the other gender. You know, the parents wanted something different and sort of forced to live a different way. And looking back, I feel that Harper was, in a way, was trapped in the same way.
HARPER ROBERTSON: I felt like I didn't make sense to other people unless I could explain that I just wasn't a girl. And also, I wasn't making sense to myself in a lot of ways. It was really profound. It really had to happen. There was no way around it basically.
WOMAN: And I was pretty flabbergasted. It was like a lightning bolt. But it wasn't the end of the world. And your child is still there, they just want to live their life presenting differently.
THOMAS DOLBY: And also, you've now got something to focus on. If you've got an unhappy child and you discover this is the issue, then you've got something to focus your energy on rather than just worrying the whole time.
Hint
In making your choice, think about what function hormones might serve.
EPILOGUE
Cheryl was diagnosed with gender dysphoria because of the distress she was experiencing due to bullying at school and the lack of support at home because of the incongruence between her gender identity and her assigned gender. However, this diagnosis made her treatment eligible for coverage 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 focused primarily on Cheryl’s distress, which you treated much like symptoms of depression. Therapeutic techniques from cognitive-behavioral therapy—such as behavioral activation to get Cheryl doing activities she enjoys and thought records to address underlying negative beliefs—were helpful to her. 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 and to those who might reject her regarding her feelings about her gender and her choice to undergo medical intervention to transition. 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. Amanda fully accepted Cheryl’s need to become female, and Cheryl’s mother found the educational aspects of therapy helpful in understanding what Cheryl was experiencing. However, it took Cheryl’s father several years to accept that he was never going to have the son he thought he had. He remained emotionally distant.
You also encouraged Cheryl to reach out to the local gay, lesbian, bisexual, transgender, and queer (LGBTQ+) community. She attended a support group organized through her surgeon’s office for individuals undergoing treatments for gender reassignment, and there she found others who felt the same way she did. Cheryl began college at age 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 support that she had never experienced. She also took psychology and gender studies courses, where she made new friends and expanded her knowledge of gender dysphoria and LGBTQ issues.
When Cheryl turned 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.
Cheryl’s relationship with her sister Amanda remains close, and their mother is slowly coming around to accepting that she has another daughter. However, her father and other members of her family refuse to accept Cheryl’s changes, and thus she has lost the support she needed from them.
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.
Real World Application
Watch this video and answer the questions that follow.
Transcript
REPORTER: She could be any 12-year-old girl hanging out with her mom and sister. But Zoe was biologically born a boy. Zoe's family and her childhood friends in her town near Los Angeles have been supportive.
GIRL: Look at Zoe.
REPORTER: But a survey of nearly 300 transgender youth found that 89% reported being harassed in school.
JOHANNA OLSON: Come on. We're going back to the long room back here.
REPORTER: And Zoe, too, has endured cruel treatment from her schoolmates.
ZOE: Even like the kids that do seem like they're good kids, they even make fun of me. They'll be like, yeah, we're your friend. Just don't worry. Tell us more about yourself and how you're going through life. And then, they'll just turn on you. And they'll be talking about what you told them.
REPORTER: Zoe's doctor, Johanna Olson, is a specialist in the care of transgendered youth at Children's Hospital Los Angeles. She says that her patients have a condition known as gender dysphoria.
JOHANNA OLSON: The words that we use to describe persistent unhappiness, discomfort, and distress about the incongruence between the gender that you are assigned based on your anatomy at birth versus the way that you internally experience gender. I see between one and five new trans kids a week, so the growth is tremendous. We've had something like a 330% increase over the year 2013. It's just phenomenal.
REPORTER: What do you think is happening? I mean, are there more transgender children?
JOHANNA OLSON: It's not so much that there are more transgender kids, it's that trans people are coming out earlier. We also know that, among trans people, there are high rates of depression, anxiety, social isolation, suicide attempts. All of these things we see dramatically increased in trans youth. But young people that I've seen who socially transition in childhood and have support of their families, they have a very different experience.
REPORTER: But Venice has had other issues to worry about. His parents are separated. And while his mother and brother have always been supportive, his father was not.
MIKE: Nobody knows what we're going through.
REPORTER: Today Venice's father, Mike, has joined Venice's mother in a support group for parents of transgender kids.
MIKE: I was in a lot of fear and anxiety and especially when my kid came out.
REPORTER: He acknowledges that he hired a series of therapists in an effort to convince Venice to live as a girl, all to no avail.
MIKE: So I was totally in the wrong area, spending lots of money, trying to fix a kid that wasn't really broken.
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 entirely, at the urging of many who believed the disorder pathologizes people who identify as transgender. 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 are unhappy living in a body that they feel does not match the gender with which they identify. In addition, many trans advocates argue that those who are trans need whatever assistance they can get to gain access to the necessary medical and psychological services (APA, 2013).