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. Case Study 2 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. Case Study 3 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. Case Study 4 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. Case Study 5 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. Case Study 6 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 Case Study 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. 7 Case Study 8 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.