Gender-affirming adolescent care OSCE — assessment, staging and a family conversion request

Station objectives

1. Conduct an affirming, developmentally appropriate biopsychosocial assessment, using the young person's chosen name and pronouns. [1]
2. Establish pubertal stage, persistence of dysphoria, and eligibility for suppression. [2]
3. Plan bone-health and fertility surveillance alongside the staged pathway. [10] [3]
4. Decline respectfully a family request for conversion-style therapy and redirect to the affirmative model. [8]

Candidate brief

You are the paediatric registrar in an adolescent clinic. You have 8 minutes for Station A (assessment and eligibility with the young person) and 8 minutes for Station B (family discussion). Examiners score affirmation, safety, eligibility reasoning, communication and the fidelity of the conversion refusal. [1] [2]

Station A — Affirming assessment and the suppression decision

Setup: A 12-year-old assigned male at birth, who uses she/her pronouns and the name Mia, presents with intensifying dysphoria as puberty begins. She is consistent, persistent and insistent about a female identity. Tanner stage 2 is confirmed. [2] [7]

Expected actions:

• Use Mia's chosen name and pronouns throughout; open with an affirming stance. [1]
• Take a gender history (onset, persistence, consistency, intensification at puberty, desired changes) layered onto a HEADSS-style biopsychosocial assessment (mood, suicidality, school, peers, family, safety). [1]
• Screen for and treat comorbidity (depression, anxiety, autism) in parallel; confirm no acute safety crisis. [3]
• Confirm Tanner stage 2 and set out the staged, reversible-first pathway. [2]
• Establish eligibility for pubertal suppression: persistent well-documented dysphoria, early pubertal stage, multidisciplinary assessment, comorbidity addressed, assent plus parental consent. [2] [3]
• Plan baseline investigations (gonadotropins and sex steroids, height/weight/BMI, baseline DXA) and bone-health, fertility and mental-health surveillance. [10]

Trap: promising a fixed medical timeline, or — conversely — dismissing the identity as a phase. [1]

Station B — The family conversion request

Setup: Mia's father says he wants 'therapy to help her accept the body she was born with' and refuses to use her chosen name. [8]

Expected actions:

• Listen to the father's concern with respect before responding. [1]
• Clearly decline conversion-style therapy, explaining that any intervention intended to change gender identity is harmful (associated with increased psychological distress and suicide attempts) and ethically indefensible. [8]
• Offer family psychoeducation on the affirmative, exploratory model and on the role of family acceptance as the strongest protective factor — and family rejection as the strongest risk factor. [1] [8]
• Offer connection to affirming family support and a staged, multidisciplinary plan; agree concrete next steps (e.g. parent information session, counsellor referral). [3]

Trap: agreeing to a 'compromise' exploration that is in substance conversion, or framing rejection as a parenting preference rather than a harm. [8]

Marking anchors

Clear pass: consistent use of chosen name and pronouns; structured affirming assessment; correct Tanner-2 suppression eligibility with multidisciplinary and consent reasoning; bone-health and fertility planning; a clear, respectful, evidence-based refusal of conversion with redirection to the affirmative model. [1] [2] [8] Borderline: affirming rapport but vague eligibility reasoning, missed bone-health or fertility planning, or a hedged conversion refusal that leaves the family expecting identity change. Fail: use of incorrect pronouns; promise of identity change; agreement to conversion-style therapy; commencement of suppression without eligibility, comorbidity treatment or consent; failure to assess safety. [8] [2]

Debrief pearls

• Using the chosen name and pronouns is itself a clinical intervention, not a courtesy. [1]
• Suppression is fully reversible and starts at Tanner 2 — get the timing right. [2]
• Bone-health and fertility planning belong on the plan from the outset. [10]
• Conversion efforts are harmful and unethical — decline clearly and redirect to affirmation and family acceptance. [8]