You are an FY2 in GP

Personal Details:

Name: Assigns female name at birth (Alexandra), but wishes to be called ‘Alex’.

Age: 16

Medical Record:

Past medical history: None.

Regular medication: None.

Allergies: None known.

Notes:

A 16-year-old has booked an appointment to discuss some personal concerns. The reason for the appointment is listed as “confidential”.

Task:

1. Create a safe and confidential space.

2. Take a sensitive history to understand their feelings and situation.

3. Address their concerns and explain the next steps in a supportive manner.

Opening Sentence: (After confirming confidentiality) “Doctor, I need to ask you something… Can I change my sex?”

Open History (to give freely): “I’m a girl, but I don’t feel like one. I feel like I’m in the wrong body. I’ve felt like this for years, but I’ve never told anyone before. I want to be a boy.”

Cues to give: “I’ve done a bit of research online… I found the LGBT Foundation website.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I know it’s possible to change. I’ve read about hormones and surgery. I want to be called Alex.”

Concerns: “What will people think? What will my parents say? Is it a really long process?”

Expectation: “I want you to help me start the process. I want to be referred to a specialist.”

How to Act: You are nervous and hesitant at first, but as you start talking, you become more confident and clear about what you want. You are articulate and have clearly thought about this for a long time.

More History (only if asked): You have felt this way since you were about 8 years old. You’ve always preferred boys’ clothes and games. As you went through puberty, the feeling of being in the wrong body got much stronger. You bind your chest with bandages, which is uncomfortable. You have no history of mental health problems, self-harm, or suicidal thoughts. You are doing well at school and have friends, but you don’t feel you can be your true self with them. You are not being bullied or forced into this.

Social History: You live with your parents and a younger sister. You have a good relationship with them, but are terrified of telling them. You are not in a relationship. You do not smoke, drink alcohol, or use recreational drugs.

Questions to ask:

“Do I have to tell my parents?”

“How long will it take before I can start treatment?”

“Will you call me Alex?”

Opening & Establishing Confidentiality:

Thank you for coming in. I want to start by reassuring you that we don’t disclose any information about health records. We would only share information if I was seriously worried about your safety or the safety of someone else. Is that okay?

Exploring the Presenting Complaint (Using Preferred Name): You’ve asked if you can change your sex. Thank you for trusting me with that question. Can you tell me more about how you’re feeling? You mentioned you want to be called Alex. I will call you Alex. How long have you felt that you want to be a boy? What does it feel like for you, being in the wrong body?

Social & Psychological History: How are things at home? Who do you live with? Have you been able to talk to anyone else about these feelings? Any friends or family? How are things at school? Are you being supported there?

How has this been affecting your mood? Have you been feeling low or anxious? Have you had any thoughts of harming yourself?

Exploring Steps Taken & Risks: You mentioned you’ve done some research. What have you found out? Are there any steps you have taken to affirm your gender identity, for example, with your clothing or hairstyle? You mentioned binding your chest. Can you tell me how you are doing that? Is it causing you any pain or problems with your skin or breathing?

ICE (Ideas, Concerns, Expectations): What are your own ideas about what the process of transitioning involves?

You mentioned being worried about what your parents and others will think.

Can you tell me more about that? You said you want me to help you start the process.

What were you hoping for from today’s appointment?

Explain the situation:

Thank you so much for having the courage to talk to me about this, Alex. It sounds like you’ve been carrying a heavy weight for a long time. What you’re describing is something we call gender dysphoria. It’s the feeling of distress or discomfort that occurs when the gender you identify with is different from the sex you were assigned at birth. It’s a recognised medical condition, and you are absolutely not alone in feeling this way.

Addressing and answering the patient’s ICE:

You’re asking about the process and your concerns about what others will think. The journey is different for everyone, and it’s important to go at your own pace. My role is to support you. The first step is to refer you to a specialist Gender Identity Clinic, or GIC. They are the experts who can explore these feelings with you in-depth and discuss all the options for the future, including social transition, hormones, and surgery.”

Next Steps:

I will make that referral for you today. It’s important for you to know that there is, unfortunately, a very long waiting list for these services, often several years. While you are waiting, there are many things we can do to support you. I can give you details of youth support groups and online resources, like the LGBT Foundation you mentioned, which can be a great source of information and community.

Self-help measures if relevant:

You mentioned binding your chest with bandages. It’s really important to do this safely, as improper binding can cause skin damage, breathing problems, and pain. There are organisations that can provide proper binders and advice on how to use them safely. We can look that up together.

You asked if you have to tell your parents. As you are 16, you are considered to have the capacity to make your own medical decisions, so our consultation is confidential. However, going through this journey is much easier with family support. The specialist service will be able to offer support and guidance for your family as well, when and if you decide to tell them. We can talk about how you might approach that conversation if you’d like.

Addressing ideas, concerns, and expectations: Validate their feelings. Use their chosen name. Manage their expectations about the long waiting list for the GIC while offering immediate support.

Refer to the Gender Identity Clinic. Provide details of support groups and resources. Offer harm reduction advice (safe chest binding). Discuss confidentiality and the role of family support.

What is scenario testing? This case tests the candidate’s ability to handle a sensitive and confidential consultation with a young person. It requires creating a safe, non-judgmental space, demonstrating knowledge of the referral pathway for gender dysphoria, and providing holistic support that addresses both the long-term process and immediate needs and risks. Key skills are communication, empathy, and knowledge of safeguarding and confidentiality principles.