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N754 Ethical and Policy Implications for Healthcare Outcomes
Cast Study #3 Module 4
Triz is a 15 year-old who presents to the inner city STI, primary care, and transgender free clinic
where you work as an RN or NP. On the intake form, the address and emergency contact
information is blank, which you know is often because the patient is homeless. The reason for
visit section states “check-up for infection”, gender is left blank.
During the health history and vital signs Triz describes what sounds like a current sexually
transmitted infection, and reports being treated for gonorrhea, syphilis, and genital herpes in
the past 6 months. Triz reports 14 sexual partners in the past 3 months, using condoms
sometimes. The substance abuse screen is positive for daily tobacco, monthly use of
methamphetamine, oxycodone, LSD, marijuana, and occasional alcohol use. The PHQ-9 screen
for depression is above the cut off range (abnormal). When you ask the patient about goals for
education or career, Triz states that “dancing in a club” is the preferred occupation and that
“school is not for me, I dropped out last year”.
When you perform the family health history, Triz says that there has been no contact with the
family of origin for almost 11 months, and the health history is unknown. Previously, Triz lived
in Arizona with a mother and her boyfriend. There was much violence and conflict in the home
resulting in Triz’s physical and sexual abuse from the mother’s boyfriend from age 9 until 14.
As you question Triz about current and past health issues, a history of mild asthma with
occasional albuterol use and an appendectomy at age 8 is mentioned. Triz finally tells you that
the gender assigned at birth was male but that is not accurate because Triz has always felt
female and wants gender confirming treatment with hormones, starting today. You counsel Triz
on the risks, benefits, side effects, expected outcomes, and alternative to gender affirming
hormone treatment, provide information on safer sexual practices, and offer free condoms. The
physical exam, vital signs, and STI testing is performed. You ask Triz to return next week for lab
results and counseling on hormone therapy.
Triz returns the following week. Results reveal a positive RPR (syphilis), other STI, HIV, and
general metabolic tests are negative. Triz agrees to treatment with penicillin. When you counsel
Triz on sexual abstinence for one month after syphilis treatment, Triz states, “If I don’t do tricks,
I can’t get by on the street, I won’t make it”. Triz asks “Can I start my hormones today? I
understand the stuff you told me about the side effects, I just want to get started so I can be
me. Can you give me the shot today?”
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