This chapter presents a case study of a 9-year-old girl whom the author met for weekly counseling sessions over a 4-month period in her private practice. Synthesizing developmental, relational, and systemic perspectives, the author describes her initial presenting concerns related to gender nonconformity, as well as how she conceptualized the patient and her needs within her familial, school, community, and cultural contexts. Additionally, the author describes the creative arts and expressive treatment approach she utilized within a relational-cultural framework, and the outcomes related to the patient’s developing gender identity. The patient’s struggles began with the school’s expectations that students begin changing into gender-specific uniforms for physical education (PE) classes. As a lesbian, gay, bisexual, and transgender (LGBT) affirming counselor with a specialty in working with children and adolescents, the author’s informed consent communicates her validation and affirmation of the full range of gender identities.