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Case 5.7 Sexual Identity

By Betsy Gaffney, MSN, APRN, FNP‐BC

SUBJECTIVE

Michelle, a 17‐year‐old Caucasian female, presents to a primary care practice where she has been a patient since 5 years of age. She is accompanied by her maternal aunt. Michelle is usually accompanied by her mother. She is up to date with her immunizations including HPV series. Her last visit was 10 months ago for strep pharyngitis. She was very quiet and less interactive at that visit but when asked if anything was bothering her said “just my throat.”

Michelle tells you she is here today because she identifies “more as a boy,” saying “I’ve felt this way for about 2 years but was afraid to tell anybody before. I’m not afraid now and have told my mother and my aunt. I’m tired of lying by not saying anything and want to do things differently. My mom said I should come and talk to you because we like and trust you.” Michelle’s aunt verifies this, saying, “My sister is still a little freaked out about this but wants what is best for Michelle. That’s why she asked me to come with her today.” Michelle’s mom would also like her to have a physical check‐up, since she hasn’t been seen for almost a year. Michelle’s aunt leaves the exam room to allow her privacy.

Past medical/surgical history: Michelle has a positive medical history for strep pharyngitis, which resolved with antibiotics. She has no chronic illnesses, surgery, or hospitalizations.

Menstrual history: She began menarche at age 11 with a regular 28‐day cycle and moderate bleeding. She expresses a desire to “not have my period.”

Family history: Maternal family history is positive for grandmother with COPD, grandfather with hypertension. Mother and 9‐year‐old sister have no health issues. Paternal history is unknown. Father has problems with substance abuse.

Social history: Michelle lives with her mother and younger sister in a rural, farming area. Her father is known but has little contact with the family. Michelle is a sophomore at the public high school. Her mother works full‐time at a local manufacturing plant. Michelle has a close relationship with her mother and maternal aunt. She denies alcohol and tobacco use, does admit to “smoking weed once but I hated it.” She denies depression but admits previous anxiety about her lifestyle choice. She reports her anxiety is “pretty much gone” since she has “come out” to her mother and aunt. She admits being attracted to other girls but denies any sexual experiences. She has recently told a few other students about identifying as a boy, noting “it’s hard to be different in this area.”

Medications: No regular medications.

Allergies: Seasonal (spring) allergies. NKDA.

OBJECTIVE

General: Alert, pleasant adolescent; well groomed with good hygiene. Cooperative with good eye contact.

Vital signs: Height: 63.5 inches; weight: 112 pounds; BMI 19.5 (43rd percentile); B/P: 108/70; HR: 72; RR: 15.

Cardiac: RRR; S1‐S2 normal; no murmur, rub, or gallop.

Respiratory: Normal respiratory effort; lungs clear to auscultation bilaterally.

Abdominal: Soft, nondistended, nontender, with positive bowel sounds x 4 quadrants.

Breasts: Tanner stage IV.

PHQ‐9: Negative.

CRITICAL THINKING

1 What concerns should be addressed at this visit?_____Sexual identity_____Anxiety/Depression_____Desire for amenorrhea

2 What case‐specific questions should be asked addressing Michelle’s desire for amenorrhea?

3 Are any referrals needed?

4 What complications exist related to the rural setting?

5 Are there implications for future medical care?

6 What psychosocial challenges present with “coming out”?