A 16-year-old boy comes to the office for an annual checkup before starting at a new school. Vital signs, physical examination, and growth curves are within normal limits. When asked if he is looking forward to starting school, the patient hesitates and says, "Doc, I really want to talk to you about something. I've never really felt right being a boy. I don't even like having a boy's body. I wish I had been born a girl because I feel and think like girls do; I always have." Last school year, the patient started skipping gym class due to feeling uncomfortable about changing in the boys' locker room. The patient says, "I heard there might be ways to change my appearance, but I haven't discussed this with anyone yet." In addition to providing support, which of the following is the best next step in management of this patient?

Question

A 16-year-old boy comes to the office for an annual checkup before starting at a new school.  Vital signs, physical examination, and growth curves are within normal limits.  When asked if he is looking forward to starting school, the patient hesitates and says, "Doc, I really want to talk to you about something.  I've never really felt right being a boy.  I don't even like having a boy's body.  I wish I had been born a girl because I feel and think like girls do; I always have."  Last school year, the patient started skipping gym class due to feeling uncomfortable about changing in the boys' locker room.  The patient says, "I heard there might be ways to change my appearance, but I haven't discussed this with anyone yet."  In addition to providing support, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d784_bc22_bc81_2be57f986239_MD0003_00 Gender identity is an individual's internal sense of being male, female, or a nonbinary alternative (eg, gender-fluid). This identity may either match or contrast with the gender to which the individual was assigned at birth (ie, gender presumed to be male or female based on newborn's sex). The DSM-5 refers to gender dysphoria as a discrepancy between the gender assigned at birth and the experienced gender of an individual that results in distress and/or impairment. Gender identity can be fluid and evolving, and gender dysphoria in early childhood does not always persist. However, when an intense, persistent desire to be another gender is experienced through adolescence, as in this patient, gender dysphoria is more likely to be enduring and requires further evaluation (Choice C). The most appropriate response is to evaluate the patient's safety, provide nonjudgmental support, and offer further consultation with specialists. Adolescents with gender dysphoria are at an increased risk for depression, suicide, anxiety, and bullying, all of which should be assessed. The management of adolescents with gender dysphoria should include the input of counselors and physicians with expertise in this area, because they can provide advice about the risks and benefits of treatments specifically tailored to the individual's medical and mental health needs. (Choices A and E) Although gender affirmation surgery is likely to be a future consideration for this patient, it is a process that requires extensive planning and consideration. Hormonal therapy to suppress puberty is another option, but it has many potential adverse effects (eg, height change, decreased bone mineral density, menopausal symptoms, depression). The decision to consider either of these options is best made after a complete assessment and input by specialists. (Choice B) Although adolescents should be encouraged to talk with their parents, approaching the parents before understanding the family dynamics or advising the patient to approach the parents before the individual is ready to do so will likely undermine rapport and trust. With further consultation, if the decision is made to pursue hormonal or surgical interventions, the patient should be informed that the parents will need to be involved. Educational objective: Gender dysphoria is diagnosed when a persistent, intense desire to be another gender is accompanied by distress or impairment. The initial approach involves providing nonjudgmental support, assessing the patient's safety, and offering evaluation with a multidisciplinary team of specialists in order to tailor treatment to the individual's medical and mental health needs. References: Gender variance and dysphoria in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/26210629) Gender dysphoria in adolescence. (http://www.ncbi.nlm.nih.gov/pubmed/26828376)

A 16-Year-Old Boy Comes to the Office for an Annual