Station 68

Jessica Barratt

Age: 14 year old female

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis 

  • Ask why she feels reluctant or uncomfortable about going to school
  • Explore whether she has experienced any bullying or if anyone at school is making her feel unsafe or excluded
  • Ask about her relationships with peers and teachers, and whether she feels supported or isolated
  • Ask if she’s struggling academically or finding lessons harder to manage
  • Assess her emotional wellbeing: mood, sleep, appetite. If any of these are low, sensitively ask about suicidal thoughts or self-harm
  • Ask if she feels anxious, particularly in school settings or socially
  • Ask if she has had any recent physical health concerns or bodily changes that are worrying her
  • Ask whether she has spoken to anyone at school, such as a teacher, school nurse, or pastoral lead, about how she’s been feeling or what support might be available  
  • Ask whether she is taking any medications, including hormones or other gender-affirming treatments, or if she’s considering starting them
  • Ask how her transition journey has been so far, including how she feels about her identity and how others have responded 
  • Explore the home environment — who she lives with and whether there are any issues or conflicts at home
  • Ask about lifestyle: smoking, alcohol, or use of illicit substances
  • Explore what she hopes homeschooling will offer and how it might feel different or better than school
  • Ask whether she has explored other options such as moving schools or accessing additional pastoral or emotional support within her current school

Example of explanation to patient​

Jessica, it’s really clear you’re finding school difficult right now, and I want to acknowledge how hard it must be to feel like you don’t quite fit in. Even though you haven’t experienced bullying, feeling isolated or misunderstood can be just as upsetting. I’m really glad you’ve shared this with me.

I understand why you’re thinking about homeschooling. Wanting a space where you feel safer and more in control of your environment makes perfect sense, and in the short term, it could help give you some breathing room while things feel so intense.

That said, I would like to be honest with you about some of the longer-term considerations. Homeschooling can sometimes be expensive, and although it may reduce stress in the moment, it might not really tackle the deeper feelings of not being accepted or confident around others. It’s so important that you feel valued, included, and supported, not just now, but as you grow and take steps into the wider world. Building that confidence now, with the right support, can really help set you up for the future.

Before making any big decisions, there are other things we can explore together. We can look at connecting you with support groups where you can meet others going through similar experiences or speak with people in your school who are trained to support young people like yourself. We can also involve counselling or a social prescriber to help you explore your options and guide you through what feels right.

My aim is to make sure you feel safe, respected, and supported, and that we find a path forward that works for you. Would it be okay if we took this step by step and looked at these options together?

Regarding toilet facilities, ideally your school should have gender-neutral toilets so you can use a space where you feel safe and comfortable. Some schools may still restrict male or female toilets based on biological sex, but the law protects you from discrimination, and the school must make sure you have access to a toilet that you feel okay using. If you haven’t already, it’s worth speaking to someone at school you trust, and I can help support that conversation if needed.

Management

Management

  • Acknowledge her interest in homeschooling and explain that while it may offer short-term relief and help improve her mental wellbeing, there are potential long-term downsides, such as cost, reduced social interaction, and it may not fully address underlying feelings of not being accepted or confident in society. Emphasise that building self-confidence and feeling included now is important for long-term wellbeing and development.
  • Encourage patient to speak with a trusted adult at school, such as a teacher, head of year, or pastoral lead, about how she’s been feeling, and to explore what support the school might be able to offer
  • In the meantime, offer information about online support groups for transgender and gender-diverse young people, such as Mermaids, which offers peer support, youth groups, and counselling
  • Suggest organisations such as Stonewall, which provide resources and can connect her with counsellors or psychologists experienced in supporting LGBTQ+ youth
  • Offer a referral to the social prescriber, who can help explore local community support, youth groups, and discuss homeschooling as a short-term option if appropriate
  • Regarding school toilets: Advise that the school should ideally provide gender-neutral toilets. Explain that, according to the most recent Supreme court ruling and Equality and Human Rights Commission (EHRC) guidance, access to male or female toilets may be restricted based on biological sex, even for individuals who have transitioned However, reassure her that the law still protects her from discrimination, and she must never be left without access to a toilet. The school has a duty to ensure she has a safe, appropriate facility she can use comfortably.  
  • If she has not yet been seen by anyone regarding her transition or gender dysphoria, offer a referral to CAMHS or the community paediatric team for emotional wellbeing support and to initiate onward referral to a gender identity clinic, as referrals for young people under 16 must go through one of these services. 
  • Arrange a follow-up in 4–6 weeks to review how she’s doing emotionally and socially, and whether she’s accessed any of the support offered
  • Safety net: advise her (and her mother) to seek help urgently if her mood worsens, if she feels unsafe, or if she starts having thoughts of self-harm or suicide

Learning point from this station: ​

This case highlights the importance of providing empathetic, inclusive, and patient-centred care to transgender individuals, particularly following gender-affirming procedures. 

The UK Supreme Court has clarified that under the Equality Act 2010, the term ‘sex’ refers to biological sex.

This means that:

  • A ‘woman’ is defined as a biological female (assigned female at birth)
  • A ‘man’ is defined as a biological male (assigned male at birth)
  • A person who identifies as transgender does not legally change their sex under the Act, even if they hold a Gender Recognition Certificate (GRC)
  • Therefore, a trans woman is legally considered a biological man, and a trans man is considered a biological woman

This means that transgender women, who are biologically male but identify as women, can be lawfully excluded from women-only spaces under certain circumstances. However, the EHRC guidance also emphasises that trans individuals must not be left without access to suitable facilities, in settings where single-sex spaces exist, there should also be provisions available to ensure everyone has a safe and appropriate option to use.

Also remember that transgender individuals may be taking hormone replacement therapy (HRT). It is important to ask where this medication is being obtained. If the hormones are being sourced online or are not prescribed and monitored by a recognised gender identity clinic or specialist, the individual should be referred for appropriate care. Regular monitoring is essential to ensure both safety and effectiveness of treatment.

Further reading