Sexual orientation, identity and inclusive care — formative SAQs

SAQ 1 — The affirming history and the three components of orientation (10 marks)

A 15-year-old attends with her mother for a "general check-up." Once you speak with her alone, she discloses she has a girlfriend, has been bullied at school for months, and has had fleeting thoughts of ending her life. [2] [6]

Questions

1. Outline how you would take a sexual orientation history using the three components of orientation, and justify why they must be asked separately. (5 marks) [2] [4]

2. Describe your immediate assessment and management, including confidentiality, suicide-risk assessment and safety planning. (5 marks) [6] [3]

Model answer

Three components, asked separately (5). Sexual orientation has three components — attraction, behaviour and identity — that frequently do not align, so a single question produces wrong care. Ask attraction ("are you attracted to guys, girls, both, or neither?"), identity ("what word, if any, do you use for yourself?"), and behaviour ("have you been sexually active, and with partners of what gender?") as separate questions. Identity drives rapport and respect; behaviour and anatomy drive pregnancy and STI screening; attraction captures young people not yet sexually active. A bisexual-identifying young woman with male partners still needs contraception and an affirming environment; a heterosexual-identifying young man with male partners still needs behaviour-based screening. [2] [4]

Assessment and management (5). Establish confidentiality and its limits before the history, and hold it: do not involuntarily disclose her orientation to her mother. Take a structured suicide-risk assessment — ideation, intent, plan, means access, protective factors, past attempts — rather than a passing question; any positive screen is a medical emergency requiring a safety plan, means restriction, and crisis or mental-health referral. Screen mood with the PHQ-A, ask about safety (bullying, home), and ask about protective factors (an accepting adult, belonging). Connect her to affirming supports, arrange follow-up, and begin family-acceptance work only with her consent and when safe. [6] [3]

SAQ 2 — Family rejection, change efforts and the limits of confidentiality (10 marks)

A 14-year-old boy discloses he is gay. He tells you his parents sent him to a "counsellor" who tried to make him heterosexual, that he feels worthless, and that he does not want you to tell his parents he is gay. His mother, who is in the waiting room, asks you directly "is my son gay?". [5] [8]

Questions

1. Explain the minority-stress model and why this young person is at elevated risk, and address the harms of sexual orientation and gender identity change efforts. (5 marks) [1] [5]

2. Describe how you would respond to the mother's question, justify your approach to confidentiality, and outline your disposition. (5 marks) [8] [9]

Model answer

Minority stress and change-effort harms (5). Minority stress is the chronic, identity-based social stress that stigma places on sexual minority people; it splits into distal stressors (prejudice, victimisation, rejection) and proximal stressors (internalised stigma, expectation of rejection, concealment), which together drive excess depression, anxiety, self-harm and suicidality. This boy carries compounded load: family rejection plus exposure to change efforts, the latter documented to cause significant mental-health harm. State plainly that sexual orientation and gender identity change efforts are harmful, are condemned by major bodies, and are never to be offered or referred for; affirm him as he is and link him to trauma-informed, affirming support. [1] [5]

Confidentiality and disposition (5). Do not disclose his orientation to his mother without his consent. Confidentiality is therapeutic, and involuntary outing can precipitate family violence, homelessness or self-harm; explain its limits (serious risk, mandatory reporting) to him up front. To the mother, respond within those limits — share general adolescent-health and support information without confirming his orientation, and document your reasoning. Disposition: complete a suicide-risk assessment and safety plan, arrange affirming mental-health follow-up, explore whether home is safe and whether child-protection or housing responses are needed, and plan longitudinal review. [8] [9]