Mental Health · Full case
Gender Dysphoria
Gender Dysphoria · Clinical Reasoning Framework v2
GP & SCA · GMC guidance · affirming, respectful care · referral to a Gender Identity Clinic · mental-health & risk support · general healthcare · bridging & shared care · don't gatekeep
Respect & affirmUse the person's correct name and pronouns, take their experience seriously, and provide respectful, non-judgmental care. Gender incongruence is not a mental illness; gender dysphoria is the distress that can arise from a mismatch between gender identity and sex assigned at birth. Affirming care reduces distress
The GP's role: refer & supportA GP does not need to be a gender specialist. Make a direct referral to a Gender Identity Clinic (GIC) when the person asks — you do not need a mental-health assessment first, and referral should not be gatekept or delayed. Meanwhile, support mental health and general health
Long waits → support meanwhileGIC waiting times are very long. The GP's continuity matters: support mental health, monitor risk, manage general healthcare, and signpost peer/third-sector support. Don't leave the person unsupported while they wait
Mental-health & suicide riskTrans and gender-diverse people have markedly higher rates of depression, anxiety, self-harm and suicide — largely driven by minority stress, discrimination and lack of support, NOT by being trans. Assess and treat mental health and risk proactively and compassionately
Bridging & shared careWhere a person is already self-medicating with hormones (bought online) or at risk, GMC guidance supports GPs considering "bridging" prescriptions to reduce harm, ideally with specialist advice. Engage in shared-care arrangements with the GIC rather than refusing to be involved
Don't forget routine healthcareTrans people need the same general healthcare as everyone — and organ-based screening: a trans man with a cervix still needs cervical screening; a trans woman may need prostate awareness; consider bone health and cardiovascular risk on hormones. Tailor screening to anatomy, not recorded gender
Young people: specialist pathwaysChildren and young people with gender incongruence are managed through specialist services with a holistic, cautious, multidisciplinary approach (following current national service models). Involve the family appropriately and safeguard. Avoid initiating interventions in primary care
Avoid harm: don't gatekeep or pathologiseRefusing referral, demanding proof, misgendering, or treating the person's identity as a problem to be solved causes harm and erodes trust. So does conversion practices (unethical and harmful). Provide affirming, person-centred care within your competence, and refer for specialist input
📋 Clinical Stem — Gender Dysphoria
A 24-year-old trans man, anxious about being dismissed, asking for a referral to a gender clinic — and quietly disclosing low mood, self-harm and that he's started buying testosterone online
Sam Okoro, 24 (he/him), assigned female at birth, attends asking to be referred to a gender clinic. He has felt a persistent mismatch between his gender identity and his body for years, with significant distress, and has socially transitioned. He's braced to be questioned or refused. As trust builds he discloses low mood, episodes of self-harm, and — hesitantly — that he has recently started buying testosterone online because the waiting list is "years long" and he couldn't wait. He has no regular contact with mental-health services. He is registered as female and is overdue cervical screening. He fears being judged, misgendered, or told he needs to "prove" anything.
This stem tests the ability to deliver respectful, affirming, person-centred care: using the correct name and pronouns; understanding the GP's role is to refer directly to a Gender Identity Clinic on request (without gatekeeping, demanding a mental-health assessment first, or pathologising the identity); to proactively assess and support mental health and suicide/self-harm risk (driven by minority stress, not by being trans); to respond safely to self-medication with online testosterone — recognising the harm-reduction issues, considering specialist advice and (per GMC guidance) the possibility of bridging prescribing and shared care, and arranging monitoring — rather than simply refusing involvement; to address general healthcare and anatomy-based screening (a trans man with a cervix still needs cervical screening); and to signpost support during the long wait. The SCA challenge is building trust with someone braced for rejection, and balancing affirming care with safety.
Scenario A — Referral + risk + self-medication (this stem) Affirming care; direct GIC referral without gatekeeping; assess/treat mood & self-harm; harm reduction + consider bridging/shared care & monitoring for online testosterone; anatomy-based screening; signpost support.
Scenario B — Straightforward referral request Person wants a GIC referral; refer directly, support general & mental health, signpost peer support, manage the wait.
Scenario C — Shared care on established treatment Person on specialist-initiated hormones; GP monitors per shared-care protocol (bloods, BP, bone/CV health), continues general care.
Scenario D — Mental-health crisis Active suicidality/self-harm → urgent mental-health assessment & safety plan, alongside affirming support.
Scenario E — Young person / family Child/adolescent with gender incongruence → specialist young-people's pathway, holistic/multidisciplinary, family involvement, safeguarding; avoid primary-care-initiated interventions.
Key variables to adapt for Adult vs young person; referral (don't gatekeep) vs shared care vs crisis; mental-health/suicide risk; self-medication & bridging/harm reduction; anatomy-based screening & general health; hormone monitoring (bone/CV); social support & minority stress; respectful language throughout.
Steps:
1
Step 1
History — Affirming Opening · Their Goals · Risk · Self-Medication · ICE
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The consultation opens by establishing respect — correct name and pronouns — and by understanding what the person wants (here, a referral) rather than interrogating their identity. Then, with trust built, sensitively assess mental health and risk (high in this group, driven by minority stress), uncover any self-medication, and address general healthcare. The GP's job is to refer, support and keep the person safe — not to gatekeep or to "assess whether they're really trans".
🎓 SCA framing — affirm, don't gatekeep
"Thanks for coming, Sam — and just so you know, I'm happy to make that referral to the gender clinic today; you don't have to prove anything to me. I'd also like to understand how you're doing in yourself and make sure you're supported while you wait, because the waits are unfairly long."
Sam is braced for rejection. Affirming his identity, committing to the referral up front, and using his correct name/pronouns is what builds the trust needed to then explore risk and the online testosterone safely.
1A — Goals, experience, risk and self-medication
1B — Red flags / things not to miss
🚨
Red Flags — safety and harm to avoid
| Red flag | Why it matters | Action |
|---|---|---|
| Active suicidality / self-harm | Markedly raised in trans/gender-diverse people (minority stress). | Risk assessment; urgent mental-health support; safety plan |
| Unmonitored self-sourced hormones | Health risks without monitoring; concealment if the GP refuses to engage. | Harm reduction; specialist advice; consider bridging/shared care; baseline & monitoring bloods/BP |
| Gatekeeping / refusing referral / pathologising | Causes harm, erodes trust, delays care. | Refer directly to GIC on request; affirming, person-centred care |
| Missed anatomy-based screening | Trans man with a cervix still at risk of cervical cancer; recorded-gender errors miss invitations. | Tailor screening to anatomy; ensure cervical/other screening offered |
| Child / young person | Needs specialist, holistic, cautious multidisciplinary care; safeguarding. | Specialist young-people's pathway; family involvement; avoid primary-care-initiated interventions |
| Conversion practices / misgendering | Unethical, harmful, damages trust and mental health. | Never; provide affirming care; use correct name/pronouns |
1C — ICE
💭 Ideas
"What's your understanding of how the referral and treatment work?"
Sam may expect to be questioned or refused, or be unclear about the pathway and waits. Clarifying it honestly — direct referral, long wait, support meanwhile — sets realistic expectations and shows you're on his side.
😟 Concerns
"Has anything worried you about coming today — being judged, perhaps?"
His central concern is being dismissed, misgendered or made to "prove" himself. Naming and dispelling this directly is what builds the trust needed to discuss his mood, self-harm and the online testosterone safely.
🎯 Expectations
"What would make today feel like it went well for you?"
He wants the referral and to be respected. Meeting that — and adding proactive support for his safety and health — lets him leave feeling helped and trusting the GP, which matters hugely given the long road ahead.
1D — Psychosocial context
🗣️ Respectful language
Correct name/pronouns; ask, don't assume.
"I want to make sure I get this right — can you tell me the name and pronouns you'd like me to use? I'll update your records too."🚪 No gatekeeping
Commit to the referral up front.
"You don't need to convince me of anything — I'll refer you to the gender clinic today. My job is to support you, not to put hurdles in the way."🛟 Harm reduction on hormones
Engage, don't refuse, around online testosterone.
"I understand why you couldn't wait years. Rather than you doing this alone and unmonitored, let's talk about keeping you safe — I can seek specialist advice about a bridging prescription and arrange some blood tests."🧠 Mental health matters
Address distress proactively and compassionately.
"The distress and self-harm you've described are real and important — and they're often about how the world treats people, not about who you are. Let's get you some support for that too."🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"I'll refer you to the gender clinic today — you don't have to prove anything." — affirming, no gatekeeping.
"Have you harmed yourself or had thoughts life isn't worth living?" — proactive risk assessment.
"Rather than do this alone, let's keep you safe — I can seek advice about a bridging prescription." — harm reduction.
Deductions
- Misgendering; gatekeeping/refusing or delaying referral; pathologising identity
- Not assessing mental health/self-harm risk
- Refusing to engage with self-medication (no harm reduction)
- Missing anatomy-based screening (cervical)
🔴 Red
Misgenders; gatekeeps/refuses referral; no risk assessment; refuses to engage with hormones; screening missed
🟠 Amber
Respectful; refers; some risk assessment; self-medication noted but no harm-reduction plan; screening/support partial; ICE partial
🟢 Green
Affirming language; direct referral (no gatekeeping); assesses/supports mood & risk; harm reduction + considers bridging/shared care; anatomy-based screening; signposts support; ICE all three
2
Step 2
Triage — Crisis (Risk) · GIC Referral & Bridging · Ongoing Support
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Triage by safety: active suicidality/self-harm needs urgent mental-health support now; the referral to specialist gender services and any harm-reduction/bridging decision proceed in parallel; and ongoing general/mental-health support continues throughout the long wait.
🔴 Urgent
Same day / soon
Risk- Active suicidality / self-harmUrgent mental-health assessment; safety plan
- Acute distress / crisisSupport; crisis services
- Unsafe self-medicationHarm reduction; specialist advice promptly
🟠 Specialist
Refer / share care
GIC- GIC referral (adult)Direct, on request — no gatekeeping
- Bridging / shared careWith specialist advice; monitoring
- Young personSpecialist young-people's pathway
🟢 Ongoing
GP continuity
During the wait- Mental-health supportTreat mood/anxiety; monitor risk
- General & anatomy-based screeningCervical for Sam; bone/CV on hormones
- Peer/third-sector supportSignpost
🎓 SCA Checkpoint — Step 2Tasks
Triage rationale
"I'll refer you to the gender clinic today, and because of the self-harm I want to get you some mental-health support now too — and we'll sort out keeping the testosterone safe while you wait."
Deductions
- Not escalating active risk
- Delaying/gatekeeping the GIC referral
3
Step 3
Assessment — Mental State & Risk · Hormone Effects & Monitoring · General Health
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"Examination" here is a mental state and risk assessment, attention to the effects/safety of any hormones being taken, and general physical health and anatomy-based needs — all delivered respectfully.
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Demonstrating the formulation
"My assessment: gender dysphoria with significant distress, low mood and self-harm needing support, currently self-medicating with testosterone that needs monitoring and safety, and overdue cervical screening — with a direct GIC referral the priority."
Deductions
- No risk assessment / safety plan
- Ignoring hormone monitoring / anatomy-based screening
4
Step 4
Investigations — Baseline & Hormone Monitoring · Screening · Mental Health
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Investigations support safety on hormones (baseline and monitoring bloods, BP), anatomy-based screening, and mental-health assessment — gender dysphoria itself is a clinical diagnosis made by specialist services, not a lab test.
🎓 SCA Checkpoint — Step 4Tasks
Key reasoning
"Since you're on testosterone, I'll do some baseline bloods and check your blood count and blood pressure, and we'll arrange your cervical screening — which still matters for you."
Deductions
- No monitoring for self-administered hormones
- Not arranging anatomy-based screening
5
Step 5
Formulation — Needs, Risks & the GP's Role
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The "diagnosis" is a needs-and-risk formulation that clarifies the GP's role: refer to specialist services, support mental health and general health, and respond safely to self-medication — not to make or contest the gender-identity diagnosis (a specialist task) and not to gatekeep.
🚩 Refer, support, keep safe — without gatekeeping
Sam's formulation: gender dysphoria with significant distress, comorbid low mood and self-harm (minority stress), currently self-medicating with online testosterone, and overdue anatomy-based (cervical) screening. The GP's plan is to make a direct GIC referral today (no gatekeeping), proactively support and treat his mental health with a safety plan, respond to the self-medication with harm reduction and consideration of bridging/shared care and monitoring (with specialist advice), arrange his cervical screening, and signpost peer support — all with affirming, respectful care.
🎓 SCA Checkpoint — Step 5Tasks
Explaining the plan
"My role isn't to assess whether you're trans — that's for the specialist clinic, and I'll refer you today. What I can do is support your mental health, keep you safe on the testosterone while you wait, and look after your general health."
Deductions
- Treating identity as something to diagnose/contest in primary care
- Not clarifying/owning the supportive GP role
6
Step 6
Referral — GIC · Mental Health · Shared Care · Peer Support
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Referral is the GP's core action: a direct referral to a Gender Identity Clinic on request; mental-health services for risk/comorbidity; shared-care/specialist advice for hormones and bridging; and signposting to peer and third-sector support — with specialist young-people's pathways for under-18s.
🎓 SCA Checkpoint — Step 6Tasks
The key action
"I'll write the referral to the gender clinic today. I'll also seek specialist advice about your testosterone and shared care, get you mental-health support, and point you to some peer support while you wait — and I'll be here throughout."
Deductions
- Not referring to the GIC / adding barriers
- Refusing shared care / specialist advice on hormones
7
Step 7
Management — Refer · Support Mental Health & Safety · Harm Reduction · General Care
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Management is affirming, continuity-based care: make the referral, support and treat mental health with a safety plan, respond to self-medication with harm reduction and (per GMC) consideration of bridging/shared care with monitoring, deliver anatomy-based screening and general health, signpost support — and keep the door open throughout the long wait.
🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills
A plan that scores
"So: I'll refer you to the gender clinic today, get you mental-health support and make a safety plan, seek specialist advice about a bridging prescription and do some monitoring bloods so the testosterone is safer, arrange your cervical screening, and give you some peer-support contacts. I'll keep seeing you throughout — you're not on your own with this."
Deductions
- Referral only, with no mental-health/safety support
- Refusing all involvement with hormones (no harm reduction)
- Missing anatomy-based screening; not keeping the door open
Gender Dysphoria — SCA Consultation Scorecard
Affirming language · direct GIC referral (no gatekeeping) · mental-health/risk · harm reduction/bridging · anatomy-based screening
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, referral, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
Misgenders; gatekeeps/refuses referral; no risk assessment; refuses to engage with hormones; screening missed; pathologises
🟠 Amber
Respectful; refers; some risk assessment; self-medication noted but no harm-reduction plan; screening/support partial; ICE partial
🟢 Green
Affirming; direct referral; assesses/supports mood & risk; harm reduction + bridging/shared care + monitoring; anatomy-based screening; signposts support; ICE all three
Complete the checklist to see your score and feedback
(Guarded, expecting resistance) "Hi. I'm Sam — he/him. I've come to ask for a referral to a gender clinic. I'm guessing you'll want me to jump through hoops or tell me I have to see a psychiatrist first?"
Who you are
Sam Okoro, 24 (he/him), assigned female at birth. You've felt a persistent mismatch between your gender and your body for years, with real distress, and have socially transitioned. You're here to ask for a referral to a gender clinic and you're braced to be questioned, misgendered or refused. As trust builds, you'll disclose low mood and episodes of self-harm, and — hesitantly — that you've recently started buying testosterone online because the waiting list is "years long" and you couldn't wait. You're registered as female on the system and overdue cervical screening (which you find distressing). You most fear being judged or told you have to "prove" you're really trans.
Hidden concerns (reveal if explored)
Fear of rejection/gatekeeping (main): if the GP affirms you and agrees to refer without hurdles, you relax and open up.
Mood & self-harm: you'll disclose these if asked compassionately — you've not had support.
Online testosterone: you fear being told off or refused help; honesty depends on a non-judgmental approach.
Cervical screening: distressing/dysphoric for you; needs sensitivity.
Clinical details if asked
- Persistent gender incongruence/dysphoria for years; socially transitioned; wants GIC referral
- Low mood; episodes of self-harm; no current mental-health support; no active plan to end your life today
- Recently bought testosterone online; taking it unmonitored; waiting list "years"
- Registered female; overdue cervical screening; otherwise generally well
- Some peer/online community support; variable support from family
Reactions at key moments
- If misgendered or asked to "prove" yourself / refused referral: you withdraw, become defensive, lose trust.
- On "I'll refer you today, no hoops": visible relief.
- On compassionate risk questions: you open up about the self-harm.
- On harm-reduction re testosterone (not a telling-off): relieved, willing to have monitoring.
- Challenge line: "You're not going to refuse to refer me or report me for the testosterone, are you?"
"So are you actually going to refer me — without making me prove I'm 'really' trans — and are you going to give me a hard time about the testosterone?"
Resolution: Sam is well served if the GP: (1) uses his correct name and pronouns and provides affirming, respectful care, agreeing to refer him directly to a Gender Identity Clinic on request — without gatekeeping, demanding a mental-health assessment first, or pathologising his identity; (2) proactively and compassionately assesses and supports his mental health and self-harm risk with a safety plan; (3) responds to the online testosterone with harm reduction — seeking specialist advice, considering a bridging prescription/shared care and arranging monitoring bloods — rather than refusing involvement; (4) arranges his (anatomy-based) cervical screening sensitively and maintains general health; (5) signposts peer support and offers continuity through the long wait. He disengages if misgendered, gatekept, judged about the testosterone, or left unsupported.
Clinic Quick Reference
Gender Dysphoria — Clinical Decision Framework
Affirm · refer (no gatekeeping) · support · keep safe
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🤝 1 — The GP's role
Affirming care: correct name/pronouns; non-judgmental. Refer directly to a Gender Identity Clinic on request — no gatekeeping, no mandatory mental-health pre-assessment. Support mental health (high suicide/self-harm risk from minority stress) and general health through long waits. Don't pathologise identity or use conversion practices.
🛟 2 — Safety & general health
Self-medication: harm reduction; consider bridging prescription & shared care with specialist advice + monitoring (haematocrit/BP/CV/bone on testosterone). Anatomy-based screening: trans man with a cervix needs cervical screening; tailor screening to anatomy not recorded gender. Young people: specialist holistic pathway, family/safeguarding, avoid primary-care-initiated interventions. Signpost peer support; provide continuity.
SCA Quick Reference
Gender Dysphoria — Consultation Playbook
Affirm · refer · support safely
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🎯 The three pivots that pass this case
1 · Affirm & refer
Correct name/pronouns; refer directly to a GIC on request — no gatekeeping or "proof". The GP supports, doesn't diagnose identity.
2 · Mental health & risk
Proactively assess/treat mood and self-harm (minority-stress driven); safety plan; signpost support through the wait.
3 · Safety & general health
Self-medication → harm reduction + bridging/shared care + monitoring; anatomy-based screening (cervical); routine care.
⛔ Don't misgender, gatekeep, demand "proof", or pathologise identity · Don't refuse to engage with self-sourced hormones — harm-reduce, consider bridging/shared care & monitoring · Don't miss the high mental-health/suicide risk · Don't overlook anatomy-based screening (cervical for a trans man) · Never use conversion practices; provide affirming, person-centred care