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residency training programs should attempt to incorporate measures that would help boost the social support and acculturation of international medical graduates (especially junior-level trainees). Acculturation could be improved by language training and courses in American history, culture, and customs, and social support could be expanded by mentoring relationships.

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Adolescent gender dysphoria is increasingly common. There has been documentation of the association of gender dysphoria with numerous other psychiatric conditions as well as attempted and completed suicide. The literature is unsettled on specific risk factors for self-harm within this population. Though there are published recommendations, there appears to be a need for additional clinical evidence for the determination of the safest and most effective treatment strategies for adolescent gender dysphoria. This clinical observation describes the unique case of an adolescent with gender dysphoria, severe body dysmorphia, and suicidal ideation who presented for emergency psychiatric evaluation. Gender-affirming hormone therapy had been administered to this patient at the age of 13, well earlier than published guidelines, though it was discontinued after a short course due to persistent gender uncertainty and distress. This case provides an opportunity to consider the complexity of adolescent gender dysphoria, including the unique individual features that affect the risk for self-harm and how treatment history may be related. With an increasing prevalence of gender dysphoria in this population, it is essential that every provider who cares for adolescents be well informed and prepared to recognize and respond to these risks.

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