Adamo and Evita P. have scheduled an appointment with you. At their first session, Evita expresses concern that her husband "has not been himself lately." He is drinking heavily, spends most all of his time alone, seems unhappy and distant, and has lost all interest in sex. She worries that he is falling out of love for her and that she is failing as a wife, or worse, that he is seeing someone else. One of Adamo's co-workers, who is Evita's cousin, privately told her that Adamo's work performance has declined recently and that if this continues, he could lose his job. Evita explains that she was raised in a traditional Hispanic home. She is devoutly religious and devoted to her family; in fact, she is a caregiver for Adamo's ailing mother. Evita exudes a quiet grace and a gentle innocence. She appears virtuous, self-sacrificing, humble, and respectful. Adamo explains that he, too, grew up in a traditional Hispanic family. He starred on his high school soccer team with a reputation for aggressive play. In the army, he earned accolades for volunteering for dangerous, high-risk missions. He is a "man's man," he tells you. His wife nods approvingly.

The couple has been married for 17 years, having dated throughout high school and marrying soon after graduation. They have three children, ages 18, 16, and 5. Adamo is a carpenter by trade. Evita is a homemaker who has never worked outside the home.

Adamo describes Evita as a wonderful, loving wife. He has no complaints about her, stating, "She is the best wife and mother a man could hope for." Evita describes her husband as a good man, stating, "He has always provided well for our family."

Adamo reassures his tearful, anxious wife that he has never been unfaithful, nor has he ever "been with another woman." He acknowledges that he has been drinking and isolating. He attributes his lack of desire for physical intimacy to his demanding work as a construction foreman. His problems are temporary, he promises Evita, and that he will "snap out it."

Adamo reluctantly agrees to return for a session by himself. During this follow-up session, Adamo describes feeling stressed about finances, work-related pressures, extended-family obligations, and other ordinary life-domain stressors. He admits that he hadn't wanted another child so long after the first two but assented to Evita's wishes.

At the third session, Adamo breaks down. Sobbing, at times inconsolably, he tells you that he has spent his lifetime in excruciating emotional agony, desperately trying to dissuade himself from what he has always feared, but secretly known, since he was 4 years old. He has endured a psychological double-life; one by all outward appearances unremarkable and conventional - the other, an invisible private hell. Having arrived at a good, comfortable life, the inner voice he has fought his entire life to silence is screaming louder, undeniably, in rage and despair. He is afraid that he can no longer live a lie...

Adamo confides that he wants to be, and live as, thegirl - and nowwoman - she has always knownherselfto be, as "Renata Esperanza" (a private name no one else knows). But doing so will "destroy" his (unsuspecting) sweet wife, shame his children, and scandalize both his and Evita's families. He cannot bear to cause them to suffer [N.B.: pronouns are deliberately mixed herein].

Based on the information provided, summarize your initial clinical impressions of Adamo. Highlight any risks that concern you and indicate how you will monitor them. Specify additional information you might wish to inquire about and/or assessments you might deem relevant to administer. Describe any challenges the you anticipate working with Adamo (and maybe Evita) as their counsellor. Address salient cultural, ethnic, religious, familial, social, and occupational implications of Adamo's struggles. Examine Adamo's ethical and moral dilemma. Finally, formulate a provisional treatment plan and include the therapeutic modality/ies that you think will most effectively serve this client's needs - explain your rationale.