Assessment

The following is a check list for assessment. The GP’s role at first presentation of a gender issue is significant, especially if there is already a trusted relationship. It validates and supports the patient at a very difficult time. The GP needs to find the best assessment pathway for the patient, ensure the patient has counselling if required, be alert to suicide risk, and monitor general health.

Follow a client-centred approach and find out how the patient perceives their situation, their needs, and their future. Ask fairly open-ended questions such as “how do you feel about your gender identity?” and “how much do the people in your life know about your feelings?” The initial assessment should be broad, and exploratory. It may be necessary to rebook for mental health referral and rebook for physical assessment.

Gender History – Identity, current expression, disclosures, body transformations so far.

Medical and surgical history, health status and risk.

Medications past and current.

Psychiatric history - current distress, anxiety, depression, personality vulnerability, past trauma, self-harm, previous and current therapy.

Substances past and current.

Family History - medical (particularly Cardiovascular, Diabetes), psychiatric, social.

Relationships and support.

Sexual history - sexual risk, fertility knowledge and concerns.

Vocational history - employment, financial and insurance issues.

Gender literacy - level of knowledge, perceptions of what would help, expectations.

Essential physical exam : BMI, BP

Bloods: FBE, E&LFTs, lipids, baseline Testosterone and SHBG level.
Consider FSH, LH, TSH, DHEAS, 17-OHprogesterone, prolactin, karyotype (if XXY suspected)
Blood-borne viruses and STI check, Pap, PSA, depending on clinical requirements.

It is useful for the assessing Practitioner to have a list of Orange Flags which need extra advice.

The list will depend on the practitioner’s skills. For example
Complex trauma, dissociation, severe self-harm, poorly-functioning Borderline Personality
Poor historian on the Autistic Spectrum
Complete lack of all social support
Intellectual Disability or multiple specific learning disabilities
Personal history of stroke, pulmonary embolism, breast cancer, poorly controlled Diabetes.