This case concerns a 17 -year- old boy who was admitted for treatment at the psychiatric Day Centre, where I as clinical educator was working with my students. On the first day, he arrived accompanied by his mother. He appeared well presented and greeted each member of the team politely, shaking hands with us. He began praising the beauty of the centre and commenting enthusiastically on its different features. He particularly admired the new piano placed in the corner, the table tennis area, the colourful plants, the tea station, and even the chocolates bowel on the table.
At that time, several outpatients were sitting together on the couch, happily playing cards. The young man appeared comfortable in the environment and showed a noticeable interest in everything around him. The first day was intentionally kept unstructured, allowing him time to become familiar with the surroundings and settle into the environment at his own pace. He described the centre as “a pleasant area” and appeared comfortable exploring its different spaces while casually interacting with staff and other patients.
The following day, before the formal assessment commenced, the treating psychiatrist – who had known the young man from previous clinical encounters – provided important guidance to the students participating in his assessment. He emphasised that every interaction should be conducted with professionalism, empathy, and without judgement. The students were encouraged to listen carefully, collect the clinical information objectively, and complete his assessment without allowing personal opinions or assumptions to influence their observation. This advice served as an important reminder that effective psychiatric assessment begins with respectful observation.
Establishing trust and allowing individuals to express their experiences freely often provides the most valuable clinical information. Before the interview commenced, Dr K informed the students that this was the third occasion the young man had attended the Psychiatric Day Centre. Although his clinical records identified him as Reza, his mother consistently addressed him as Fatty, a female name.
This immediately attracted our attention and naturally raised questions. However, we remembered Dr K’s earlier advice: Remain non-judgmental, avoid making assumption, and simply gather accurate information to complete his clinical assessment. While one of my students and I conducted the initial interview, we observed that his mother frequently interrupted the conversation by repeatedly calling him by the feminine name, even when there appeared to be no practical reason to do so. Rather than interpreting the behaviour, we documented it as an objective clinical observation. After the routine demographic and background information had been completed, his mother explained the primary reason for seeking help.
She reported that Reza had been experiencing significant difficulties at school, where his peers had increasingly bullied and ridiculed him because of what they perceived to be his feminine appearance and mannerism. According, to his mother these experiences had become progressively distressing and were beginning to affect his emotional wellbeing, prompting the referral to the psychiatric day centre for further assessment, and treatment.
During the developmental history interview, his mother shared the events that preceded Reza’s birth. She explained that throughout her pregnancy she had strongly anticipated having a daughter. She was so convinced that the baby would be a girl that she never requested prenatal confirmation of the baby’s sex. Instead, she purchased baby girl’s clothing and prepared exclusively for arrival of a daughter.
Following an uncomplicated pregnancy and the birth of a healthy baby boy, the child’s father named him Reza. His parents maintained a respectful marital relationship throughout his childhood. Reza’s father was a successful businessman whose work commitments required him to spend much of his time away from home. Consequently, Reza’s mother, Ephie, became his primary caregiver during his early developmental years. According to the history provided Ephie continued to relate to Reza as though he were the daughter she had expected. At home, she dressed him in girl’s clothing, called him by the feminine name Fatty (Fatemeh), and allowed his hair to grow long.
As he grew older, she consistently presented him to others as a girl. Eventually, he was enrolled in the girl’s primary school. Developmentally, Reza reacted the expected milestones during infancy, toddlerhood, and the preschool years. His physical health was good, and there was no reported evidence of emotional, behavioural, or psychological difficulties during this period. He was described as a happy child who performed exceptionally well academically and was regularly praised and rewarded for his achievements at school.
This pattern continued throughout his primary school years until circumstances began to change. The transition to secondary school marked a significant turning point in Reza’s development. His father insisted that he be enrolled in a boy’s secondary school, where he attended using his legal name Reza. During the first two years, he continued to perform exceptionally well academically, maintaining high grade, especially in mathematics and physics. Socially. However, the transition proved far more challenging. As relationships with his male peers became closer, Reza found himself increasingly uncomfortable responding to questions about himself, his interest, and his personal identity.
During the clinical interview, he described numerous occasions on which he felt ridiculed and humiliated by classmates, including some whom he had considered close friends. Many of the comments centred on his feminine appearance, his mannerism, and perceived sexuality, leaving him feeling isolated and misunderstood. One experience remained particularly vivid in his memory.
During literature class, the teacher asked each student to write an essay describing their future aspirations. Reza recalled beginning the assignment confidently but stopping after writing only a few words. He described the experience by saying:” it became confusing and challenging. I felt as if I were two persons living in one body. “When invited to explain further, he described seeing two distinctly different futures.
In one he imagined himself becoming an electrical engineer, reflecting both academic strengths and his interest in mathematics and physics. In the other he saw himself as a professional ballerina, performing on stage as a dancer. During assessment, his mother spontaneously remarked,” Fatty dances beautifully, “reinforcing the feminine identity she had consistently encouraged throughout his childhood.
By the age of fifteen, Reza reported that the internal conflict had become increasingly difficult to tolerate. He described persistent confusion regarding his identity, frequently episodes of humiliation related to comments about his sexuality, and growing uncertainty about who he truly was, his self-doubt, his inner conflict and inability to recognise the different expectations that had shaped his development. We conducted home visit as part of assessment.
Throughout the visit Reza’s mother Ephie, consistently addressed him by the feminine name Fatty, and she proudly commented that Fatty is excellent in the kitchen, and can cook all kinds of food, suggesting that those patterns had become an established part of everyday family life. By the time Reza was referred to the day centre, his psychological distress had become severe. He had recurrent suicidal thoughts with several suicidal attempts, the reason his parent sought psychiatric intervention. Following comprehensive assessment.
Dr K developed an individualised treatment program, commenced with psychodrama which allowed Reza to explore his experiences followed by incorporated daily relaxation-based intervention, guided visualisation, meditation and structured breathing exercises. Staff called him Reza, allocated him men job like gardening, shopping with driver for the day centre. Within three months, Reza demonstrated gradual and encouraging improvement.
His confidence improved, his participation in daily activities expanded and his emotional state became more stable. Dr K explained that meaningful and lasting improvement would be difficult to achieve if treatment focused solely on Reza. In his clinical formulation, family intervention particularly psychological support for Reza’s mother was considered as essential component of care. He believed some long-lasting patterns of interaction within the family, whether conscious or unconscious, had contributed to Reza’s difficulties in developing a stable sense of identity. Accordingly, treatment was directed not only toward supporting Reza but also towards helping the family developing a healthier pattern of communication.
Although Reza’s mother openly acknowledged that the therapeutic process was emotionally challenging for her, she remained committed to participating in every stage of treatment. After three months treatments the relationship between mother and son became healthier and new patterns of communication and mutual understanding gradually replaced previous interactions.
As part of daily therapeutic programme, both Reza and his mother participated in guided mindfulness meditation, visualisation, and breathing exercise under Dr K’s supervision. These practices were incorporated to promote emotional regulation, self-awareness, psychological flexibility, and healthier coping strategies. Their willingness to participate fully in treatment significantly contributed to the positive outcome.
During family sessions, Reza’s mother reflected on her own expectations and gradually accepted that Reza was an intelligent and capable young man with the potential to build meaningful future. She began to recognise his academic strength, his capacity to make independent decision, and his ability to develop his own belief, interests, and long-term aspirations.
This growing insight represented an important step in the family’s therapeutic journey. Dr K emphasised that meaningful psychological change could not be rushed, instead, it required patience, consistency, encouragement, compassionate, guidance. After almost three months daily treatment, Reza no longer reported suicidal thoughts, and there were no further episodes of disturbed or self-destructive behaviour during treatment. Both Reza and his mother remained cooperative, appreciative, and actively engaged throughout the therapeutic programme.
Author’s note: This case has been presented for educational purposes. Identifying details have been modified to protect confidentiality. The discussion reflects one individual’s clinical presentation and should not be interpreted as representing all people experiencing identity related difficulties. Assessment and treatment should always be individualised and undertaken by appropriately qualified mental health professionals.