Can you provide a step‑by‑step questionnaire for a gender‑dysphoria OSCE case for the National Assessment Collaboration (NAC) in Canada?

Step-by-Step Questionnaire for Gender Dysphoria OSCE Case (NAC Canada)

For a NAC OSCE gender dysphoria case, structure your interview using a trauma-informed, affirming approach that prioritizes establishing safety, documenting key identity information, assessing distress and mental health, and screening for barriers to care. 1

Opening and Establishing Rapport

Start by introducing yourself with your name AND pronouns (e.g., "I'm Dr. Smith, I use she/her pronouns"). This signals safety and cultural competence 1.

• Ask the patient: "What name would you like me to use?" and "What pronouns do you use?"
• Use these consistently throughout the encounter—never use a "dead name" 1
• Acknowledge the history of discrimination TGD persons face in healthcare settings 1

Core Identity Assessment

Gender Identity Questions

Ask these specific questions in this order 1:

1. "What sex were you assigned at birth?" (Use "assigned" or "recorded," never "biological" or "natal") 1
2. "How do you identify your gender now?" (Allow for spectrum responses: male, female, non-binary, both, neither, questioning)
3. "Has your gender identity changed over time, or has it been consistent?"
4. "Does your legal sex match your gender identity?" (Important for billing/documentation) 1

Gender Expression

• "How do you express your gender in daily life?" (clothing, hairstyle, name, voice, behaviors) 1
• "Are there situations where you feel unable to express your gender authentically?"

Assessing Gender Dysphoria

Focus on three core domains of distress 2, 3:

Body Dysphoria

• "Which parts of your body cause you distress related to your gender?"
• "How does this distress affect your daily functioning?"
• "Do you avoid looking at yourself or specific body parts?"

Alienation/Identity Distress

• "How often do you think about the mismatch between your gender identity and your body?"
• "Do you feel disconnected from your body or sense of self?"
• "How much psychological distress does this cause you?" (Rate 0-10)

Gender Role Pressure/Social Dysphoria

• "How do you feel when others use the wrong name or pronouns for you?"
• "Do you experience distress in gendered social situations (bathrooms, changing rooms, social gatherings)?"
• "How does being perceived as your assigned sex affect you emotionally?"

Mental Health Screening

TGD persons have documented higher rates of depression, anxiety, and suicidality due to minority stress and discrimination 1. Screen directly:

• Depression: "Over the past 2 weeks, how often have you felt down, depressed, or hopeless?"
• Anxiety: "How often do you feel anxious or worried about your gender identity or how others perceive you?"
• Suicidality: "Have you had thoughts of harming yourself or ending your life?" (If yes: assess plan, intent, protective factors)
• Self-harm: "Do you engage in any self-harming behaviors?"

Social Support and Safety Assessment

• "Who knows about your gender identity?" (Family, friends, work, school)
• "Do you feel safe at home? At school/work?"
• "Have you experienced discrimination, harassment, or violence related to your gender identity?"
• "What support systems do you have?" (Affirming friends, family, community groups)

Functional Impact

• "How does gender dysphoria affect your daily activities?" (School, work, relationships, self-care)
• "Do you avoid certain situations because of your gender identity or dysphoria?"
• "How has this impacted your quality of life?"

Medical and Transition History

Current Status

• "Have you taken any steps toward social transition?" (Name change, pronouns, clothing, coming out)
• "Are you currently receiving any gender-affirming care?" (Hormones, therapy, other)
• "Have you had any gender-affirming surgeries?"

Organ Inventory (Critical for Screening)

Ask directly about current anatomy 1:

• "To provide appropriate health screening, I need to know what organs you currently have. Do you have a uterus? Ovaries? Testes? Breasts? A prostate?"
• This determines cancer screening needs regardless of gender identity

Desired Interventions

• "What gender-affirming treatments are you interested in exploring?" (Social transition, therapy, hormones, surgery)
• "What are your goals for transition?"

Barriers to Care Assessment

TGD persons face significant healthcare disparities 1:

• "Have you had difficulty accessing healthcare in the past?"
• "Do you have health insurance? Does it cover gender-affirming care?"
• "Have you experienced discrimination from healthcare providers?"
• "What are your main concerns about seeking care?"

Fertility Considerations

Fertility preservation counseling is mandatory before gender-affirming hormone treatment 4:

• "Have you thought about whether you want biological children in the future?"
• "Are you aware that hormone therapy may affect your fertility?"
• "Would you like information about fertility preservation options?"

Sexual Health and Relationships

• "Are you currently sexually active?"
• "What is your sexual orientation?" (Separate from gender identity) 1
• "Do you need contraception or STI screening?"
• "How do you refer to your anatomy during intimate situations?" (Use patient's preferred terms) 1

Substance Use and Coping

TGD persons have higher rates of substance use 4:

• "Do you use alcohol, tobacco, or other substances?"
• "Do you use these to cope with gender dysphoria or discrimination?"

Past Medical and Psychiatric History

• Previous mental health diagnoses or treatment
• Current medications
• Chronic medical conditions (TGD persons have higher rates of chronic disease) 1
• Previous hospitalizations

Closing

• Summarize key findings
• Validate their experience: "Thank you for sharing this with me. Gender dysphoria is a recognized medical condition, and there are effective treatments available"
• Outline next steps: "Based on what you've told me, I recommend..." (referral to gender clinic, mental health support, endocrinology, etc.)
• Ensure safety plan if suicidal ideation present
• Provide resources (local TGD support groups, crisis lines)

Critical OSCE Pitfalls to Avoid

• Never use outdated terms: "transsexual," "transvestite," "transgenderism," "biologically male/female" 1
• Never say "a transgender"—it's an adjective, not a noun 1
• Never call them by their birth name 1
• Never assume gender identity from appearance
• Never conflate gender identity with sexual orientation 1
• Never skip the organ inventory—you need this for appropriate screening 1
• If you make a mistake with pronouns/language: Acknowledge it, apologize briefly, correct yourself, and move on 1

Documentation Considerations

Document in the chart 1:

• Sex assigned at birth
• Current gender identity
• Affirmed name and pronouns
• Legal sex (if different)
• Organ inventory
• Level of gender dysphoria and functional impact
• Mental health screening results
• Social support and safety concerns