Navigating Gender Identity in PLAB 2: Mastering the Gender Dysphoria Consultation with Compassion and Clarity

Summary:

This PLAB 2 case involves a teenager presenting with confusion and distress regarding gender identity, suggesting gender dysphoria. The candidate is expected to explore sensitive psychosocial, medical, and emotional aspects with empathy, gather relevant history, and provide a structured management plan, incorporating appropriate referrals and safeguarding principles.

Key Points:

Data Gathering & History Taking

Start with open-ended questions: “Can you tell me more about what brings you here today?”
Avoid diving straight into close-ended or Socratic questions without first allowing the patient to express their experience.
Explore:
- Duration and onset of gender-related distress
- Impact on body image and comfort with assigned gender
- Steps taken toward transitioning (name, dress, social identity)
- Any medications started without medical supervision (e.g., hormones)
- Sexual history (as it relates to understanding identity and safety)
- Social support systems: friends, family, school
- Mental health: mood symptoms, suicidal ideation, anxiety
- Past medical, psychiatric, and medication history (PIMAFTOSE-focused)

Identifying Red Flags

Psychological distress, signs of depression
Use of unprescribed hormone therapy
Lack of support or experience of abuse
Suicidal ideation or self-harm

Important Considerations:

Name and Pronouns: Always ask about preferred name and pronouns once gender dysphoria is suspected. It's a key GMC expectation and aligns with UK law on harassment and discrimination.
Confidentiality: While reassurance is good, avoid overused phrases. Only state confidentiality explicitly when relevant.
Documentation: Clearly record the consultation, especially concerns raised, support offered, and referrals made to ensure continuity of care.

Diagnostic Approach:

Initial Open Question: Encourage patient to share their story.
Explore Gender Dysphoria: Feelings about body, gender identity, social role.
Assess Psychosocial Impact: School, family, emotional health.
Check for Risky Behaviour: Self-medication, unprotected sex, STIs.
Evaluate Mental Health: Depression, anxiety, suicidal ideation.
ICE Approach: Ideas, Concerns, and Expectations – helps uncover hidden concerns and guides focused data gathering.

Management:

Referral Pathways:
- Gender Dysphoria Clinic: For evaluation and support through the transition.
- CAMHS (Child and Adolescent Mental Health Services): For mood disorders or psychological support.
- LGBTQ+ Foundations or Support Groups: For community and identity support.
Avoid prescribing hormones; this is done by specialists post-assessment.
Address Concerns About Coming Out: Discuss family involvement and coping strategies.
Support Planning: Discuss ways to cope with identity distress and social issues.
Safety Netting: Provide crisis contacts and make sure the patient knows how to access urgent help.
Follow-up Plan: Ensure continuity, inform the patient that notes will help other doctors assist in future visits.

Communication Skills:

Use clear, empathetic language.
Avoid over-reliance on memorized phrases.
Validate feelings: “It’s okay to feel confused. Many people experience similar thoughts.”
Provide reassurance without minimizing the issue.
Maintain neutrality, avoid assumptions or judgmental tones.

Ethical Considerations:

Respect for Identity: Follow GMC’s guidance on respecting patient autonomy and dignity.
Non-discrimination: Treat gender-diverse individuals without bias.
Informed Consent: Ensure discussions are understood, especially around referral options.
Safeguarding: If abuse or self-harm is suspected, follow appropriate safeguarding procedures.
Documentation: Crucial for continuity and medico-legal safety.

Additional Resources:

GMC’s Good Medical Practice (2024) – Domains on patient partnership, safeguarding, and continuity of care
NHS Gender Identity Development Service (GIDS) – for structured management of gender dysphoria
Stonewall UK / Mermaids UK – Community and professional support
GMC Ethical Guidance – Personal beliefs and medical practice, confidentiality, and end-of-life care