KFP – Sexual health and gender diversity

Amira Hossain, aged 27, presents for a consultation regarding vaginal discharge that has developed over the last 5 days. She reports the discharge is yellowish and malodorous, associated with mild pruritus and dyspareunia. She denies any dysuria or systemic symptoms. She is otherwise well and is not on any medications.

Past history: Mild eczema. No known drug allergies. Last Pap smear was normal (performed 10 months ago). No previous STIs.

Sexual history: Amira is in a non-monogamous relationship and uses condoms inconsistently. She has had three male partners and one female partner in the past year.

Examination findings: External genitalia appear normal. Speculum examination reveals mucopurulent discharge from the cervix and mild cervical excitation tenderness. No adnexal tenderness on bimanual exam. No ulcers or external lesions.

Investigations: [Insert Image Here]

What are the most appropriate next steps in management? Select three (3) from the following list:

Jordan Chen, aged 18, presents for a general health check and mentions during the consultation that they identify as non-binary and have recently begun engaging in sexual activity with multiple partners, of all genders. Jordan requests a ‘full check-up’ and expresses concern about HIV, as they are unsure of their partners’ statuses. They are not using condoms consistently and have never had an STI screen.

Medications: None

Allergies: Nil known

Past history: No medical conditions reported

Psychiatric history: Reports past anxiety, currently well

Social history: Lives with friends, works casually in retail. Reports alcohol use on weekends and occasional recreational cannabis use. Feels supported in their identity but nervous about disclosing to some healthcare professionals.

Examination findings: Unremarkable physical exam. No genital lesions or discharge. No lymphadenopathy.

What are the most appropriate next steps in assessment and management? Select four (4) from the following list:

Thomas Nguyen, a 41-year-old gay man, presents for routine follow-up. He has been on daily HIV pre-exposure prophylaxis (PrEP) for the last 18 months. He reports no issues with adherence and remains sexually active with multiple male partners. He uses condoms inconsistently and is otherwise well.

Medications: Tenofovir disoproxil fumarate/emtricitabine (daily PrEP)

Allergies: Nil known

Past history: GORD (on-demand esomeprazole)

Social history: Non-smoker, moderate alcohol intake (4–6 standard drinks/week), employed full-time in IT. No injecting drug use.

Examination findings: Weight stable, vital signs normal, no oral or genital lesions, no lymphadenopathy, no tenderness on abdominal or rectal exam.

Investigations (6 months ago): HIV negative, eGFR 85 mL/min, Hep B immune, Hep C negative, STI screen all negative.

What investigations and management steps are appropriate today? Select four (4) from the following list:

Claire Patterson, aged 34, presents for ongoing care. She began gender-affirming hormone therapy 12 months ago (transfeminine). She is taking oestradiol valerate intramuscularly every 2 weeks and spironolactone daily. She reports good mental health and improved wellbeing since commencing therapy. She has no specific symptoms today but is attending for a check-up.

Medications: Oestradiol valerate 10 mg IM fortnightly, spironolactone 100 mg daily

Allergies: Nil known

Past history: Mild asthma, well controlled

Social history: Non-smoker, minimal alcohol use. Works as a hairdresser. Supportive family and social network. Sexually active with one male partner, monogamous, condoms used inconsistently.

Examination findings: Normal BP, BMI 24.2, no clinical signs of thromboembolism or other abnormalities. Feminising changes noted.

What monitoring and management steps are appropriate during this review? Select four (4) from the following list:

Emily Zhao, aged 22, presents with pelvic pain and abnormal vaginal bleeding over the past 10 days. She reports irregular bleeding since ceasing the combined oral contraceptive pill 3 months ago. She has recently started dating someone new and reports unprotected sex. She has no known allergies and no significant past medical history.

Medications: Nil

Obstetric/sexual history: Gravida 0. Regular menstrual cycles prior to COCP use. Sexually active with men. Uses condoms inconsistently. Has never had STI screening or cervical screening.

Examination findings: Abdomen soft with mild suprapubic tenderness. Speculum exam reveals blood-stained discharge and contact bleeding from the cervix. No cervical motion tenderness. Bimanual exam reveals mild cervical tenderness but no adnexal masses.

Investigations: Urine pregnancy test – negative; CRP – mildly elevated; FBC – normal; [Insert Image Here]

What are the most appropriate next steps in management? Select three (3) from the following list:

Oscar Daly, aged 56, presents for routine care. He is a transgender man who transitioned over 25 years ago with chest reconstruction surgery and long-term testosterone therapy. He reports no current medical issues and is not on any medications. He has not seen a doctor for several years and wishes to ‘get everything checked.’

Medications: Nil

Past history: Gender-affirming testosterone therapy (ceased 5 years ago), top surgery (bilateral mastectomy)

Social history: Works full-time, in a long-term relationship with a cisgender woman. No smoking or alcohol. No significant mental health history. No children.

Sexual history: Monogamous, vaginal intercourse. Not using contraception. No recent STI screen.

Examination findings: BP 125/78, BMI 27, normal general and cardiovascular exam. Genital exam deferred by patient — requests it be done another time with a trusted provider.

What are the most appropriate next steps in preventative care and screening? Select four (4) from the following list:

Leila Rahimi, aged 16, presents accompanied by her mother, requesting a check-up. During the consultation, Leila asks to speak to you alone and discloses that she identifies as pansexual and has recently become sexually active with a female partner. She wants to know if she needs any ‘tests’ or vaccines, and whether she should be on ‘the pill’. Leila is well, has no medical issues, and takes no medications. Her last period was two weeks ago and is regular. She is not experiencing any symptoms.

Medications: None

Allergies: Nil known

Past history: No significant illness or surgeries

Social history: Year 11 student. Supportive home environment. Non-smoker. Occasional alcohol on weekends. Not sexually active with male partners.

Examination findings: BP 112/70, BMI 22. No signs of STI or pelvic pathology. Leila does not wish to have a genital examination today.

What are the most appropriate steps in care and education? Select four (4) from the following list:

Isaac Coleman, aged 32, presents with a three-day history of dysuria and rectal discomfort. He reports mucous rectal discharge and mild urgency. He is otherwise well, afebrile, and has no systemic symptoms. Isaac identifies as a gay man and is sexually active with multiple male partners. He is not on PrEP and does not consistently use condoms during anal sex. He last tested for STIs over a year ago.

Medications: None

Allergies: Nil known

Past history: None of note

Social history: Works in hospitality, moderate alcohol intake, occasional recreational drug use (poppers), non-smoker.

Examination findings: Abdomen soft, mild tenderness on digital rectal exam, no masses. No perianal lesions. No inguinal lymphadenopathy.

What are the most appropriate investigations and initial management steps? Select four (4) from the following list:

Asha Singh, aged 29, presents to discuss fertility planning. She is a transgender woman who began feminising hormone therapy (oestradiol and spironolactone) at age 24. She has not undergone any surgical interventions. Asha has a supportive partner and is now considering starting a family using her own genetic material. She is currently still on hormone therapy.

Medications: Oestradiol valerate IM fortnightly, spironolactone 100 mg daily

Allergies: Nil known

Past history: Well-controlled asthma

Social history: Works in education, non-smoker, occasional alcohol. In a stable relationship with a cisgender woman who is willing to carry a pregnancy.

Asha wants to understand her options and the process. She expresses that having a genetic child is important to her.

What are the most appropriate next steps in assessment and counselling? Select three (3) from the following list:

Michael Latu, aged 45, presents for follow-up after recently being diagnosed with HIV. He is emotionally distressed and has many questions about his future, including whether he can continue to have a sexual relationship with his partner, who is HIV-negative. He started antiretroviral therapy (ART) two weeks ago and is tolerating it well. Michael is in a long-term relationship with a cisgender male partner. They use condoms inconsistently.

Medications: Dolutegravir/abacavir/lamivudine (ART regimen)

Allergies: Nil known

Past history: Newly diagnosed HIV, no opportunistic infections

Social history: Non-smoker, moderate alcohol use, monogamous relationship. Employed full time in administration.

What are the most appropriate aspects of counselling and care at this stage? Select four (4) from the following list:

Alina Petrova, aged 26, presents to discuss irregular bleeding and pain during intercourse. She has a history of polycystic ovarian syndrome (PCOS) and is currently not using any form of contraception. Alina is in a same-sex relationship and has not been sexually active with men for the past five years. She reports inconsistent use of barrier protection. Her last cervical screening was four years ago, and she is unsure if she still needs them now that she is not having sex with men.

Medications: None

Allergies: Nil known

Past history: PCOS, mild acne

Social history: Works in hospitality, moderate alcohol, no smoking, lives with her partner of 3 years

Examination findings: Abdomen soft, non-tender. No discharge or lesions on external genitalia. Bimanual exam reveals mild cervical excitation. No adnexal masses.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Jonas Tan, aged 23, presents for a general check-up and shares that he identifies as a transgender man. He began testosterone therapy 2 years ago and has not had any gender-affirming surgery. He reports no current health concerns and is sexually active with both men and women. He is in a casual relationship and does not consistently use barrier protection. He has never had an STI screen and is unsure if he still needs cervical screening.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: Anxiety (managed without medication)

Social history: Lives with housemates, employed full-time, drinks socially, no smoking or drug use

Examination findings: Healthy appearance, BP 118/74, BMI 25. No clinical concerns on general exam. No genital exam performed at this visit by patient request.

What are the most appropriate next steps in preventative care and health screening? Select four (4) from the following list:

Lina Moreno, aged 31, presents for a post-sexual assault medical review. The assault occurred 5 days ago, and she did not attend emergency care at the time due to fear and shame. She now feels ready to engage with care. Lina identifies as bisexual and is in a monogamous relationship with a female partner. She is not using contraception and has not had STI screening in the past 18 months.

Medications: Nil

Allergies: Nil known

Past history: Depression (in remission), no chronic medical issues

Social history: Works as a teacher, drinks alcohol occasionally, no tobacco or drug use

Examination findings: Alert and oriented. No acute physical injuries noted. Declines genital examination today. No fever or systemic signs of infection.

What are the most appropriate components of care at this stage? Select four (4) from the following list:

Samuel Kwong, aged 50, presents for a sexual health check. He is a cisgender gay man who is HIV-positive and on effective antiretroviral therapy (ART) with an undetectable viral load for the past 8 years. He has had three new partners in the past 6 months and uses condoms occasionally. He is concerned about other STIs and would like advice on what else he should be screened for.

Medications: Dolutegravir/tenofovir/emtricitabine

Allergies: Nil known

Past history: HIV diagnosed 9 years ago, no opportunistic infections, vaccinated for hepatitis A and B

Social history: Lives with partner, works full-time, occasional alcohol, no smoking or drug use

Last STI screen: 12 months ago, all negative

What are the most appropriate next steps in his STI screening and sexual health care? Select four (4) from the following list:

Zahra Osman, aged 36, presents requesting a review of contraception. She is a cisgender woman in a polyamorous relationship structure involving two male partners and one non-binary partner (assigned male at birth). She is sexually active with all three partners. Barrier protection is used inconsistently. She wants a reliable contraceptive method and also wants to ‘stay on top of sexual health.’

Medications: None

Allergies: Nil known

Past history: Migraine without aura

Social history: No smoking, occasional alcohol, regular employment, no children, not currently planning pregnancy

Examination findings: BP 122/78, BMI 23. No signs of STI or pelvic pathology. Cervical screening up to date.

What are the most appropriate next steps in contraceptive and sexual health care? Select four (4) from the following list:

Nikau Thompson, aged 19, presents for a follow-up after coming out as non-binary and requesting assistance with gender-affirming care. Nikau uses they/them pronouns and is interested in exploring options for medical transition but is uncertain about next steps. They experience distress around their chest and voice but have no current mental health diagnosis. They are sexually active with both male and female partners and use condoms inconsistently. They would like a full health check.

Medications: None

Allergies: Nil known

Past history: Acne (previously treated with topical agents)

Social history: Lives with supportive family, university student, occasional alcohol, no smoking or drug use

What are the most appropriate next steps in supporting Nikau’s care? Select four (4) from the following list:

Elise Tanaka, aged 38, presents for follow-up after being treated for pelvic inflammatory disease (PID) two weeks ago. She reports improvement in pain but is now experiencing significant emotional distress after learning her female partner tested positive for syphilis. Elise identifies as a lesbian and reports inconsistent use of barrier protection during sex. She wants to understand what testing she needs and whether she is still infectious.

Medications: Completed 14-day doxycycline and single-dose IM ceftriaxone

Allergies: Nil known

Past history: PID, depression (currently stable)

Social history: Lives with partner, employed full-time, no smoking, low alcohol intake

Last STI screen: Over 2 years ago

What are the most appropriate steps in her current sexual health management? Select four (4) from the following list:

Thomas Riley, aged 27, presents for a routine check-up. He is a transgender man who had a hysterectomy and bilateral oophorectomy 2 years ago, and he continues on intramuscular testosterone therapy. He reports feeling well and has had no recent health concerns. He is sexually active with male partners and does not use condoms consistently. He has not had an STI screen in over 18 months.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: Gender-affirming surgery (hysterectomy and oophorectomy), mild acne

Social history: Non-smoker, occasional alcohol, works in retail

Examination findings: Vitals normal. No signs of androgen excess or cardiovascular complications. No external genital abnormalities. Patient declines rectal exam today.

What are the most appropriate next steps in Thomas’ preventative care and screening? Select four (4) from the following list:

Riley Stephenson, aged 21, presents requesting advice about initiating HIV pre-exposure prophylaxis (PrEP). Riley identifies as non-binary and is sexually active with cisgender men and trans women. They report inconsistent condom use and one recent partner living with HIV. Riley is otherwise healthy, takes no medications, and has never used PrEP before.

Medications: None

Allergies: Nil known

Past history: None

Social history: University student, occasional alcohol, non-smoker, supportive home environment

Examination findings: Unremarkable physical exam. BMI 22, BP 114/70

What are the most appropriate next steps in initiating PrEP for Riley? Select four (4) from the following list:

Mara Jovanovic, aged 44, presents with persistent genital skin irritation and pain during sex. She identifies as a trans woman and has been on feminising hormone therapy for 12 years. She underwent vaginoplasty 5 years ago. Mara is sexually active with male partners and reports reduced lubrication and thinning of the neovaginal lining, making intercourse painful. She feels embarrassed and worried about long-term complications.

Medications: Oral oestradiol, spironolactone

Allergies: Nil known

Past history: Gender-affirming vaginoplasty (5 years ago)

Social history: Non-smoker, drinks socially, lives alone, employed full-time

Examination findings: External genitalia appear healthy. Mild erythema at introitus, no discharge or ulceration. Neovaginal canal shallow and mildly tender to touch. No lymphadenopathy.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Jamie Leung, aged 17, presents with worsening mood, anxiety, and body image concerns. They identify as gender diverse (agender) and are distressed by the onset of menstruation and breast development. Jamie has not disclosed their gender identity to their family and has had difficulty accessing support at school. They are not sexually active and are not using any contraception.

Medications: None

Allergies: Nil known

Past history: No significant medical conditions. No previous psychological care.

Social history: Lives with parents, attends Year 11, has a small group of supportive friends, no alcohol, smoking, or drug use.

What are the most appropriate steps in Jamie’s care at this stage? Select four (4) from the following list:

Adam Youssef, aged 62, presents with fatigue and weight loss over 3 months. He is a cisgender gay man with a long-standing history of well-controlled HIV (undetectable viral load for 10 years). He denies fever or cough but reports some diarrhoea and reduced appetite. He lives alone and has not had recent sexual partners. His last STI screening and HIV monitoring were 6 months ago.

Medications: Bictegravir/emtricitabine/tenofovir alafenamide

Allergies: Nil known

Past history: HIV (diagnosed 20 years ago), hyperlipidaemia, hypertension

Social history: Retired, non-smoker, occasional alcohol, socially isolated since partner died last year

Examination findings: BMI 21 (previously 24), afebrile, no lymphadenopathy, mild abdominal tenderness, no skin lesions

What are the most appropriate next steps in his assessment and management? Select four (4) from the following list:

Jessie Nguyen, aged 30, presents requesting information about fertility options. Jessie is a transgender man who ceased testosterone 3 months ago in the hope of conceiving with their cisgender female partner. They report the return of light menstrual spotting but have not resumed regular cycles. Jessie expresses anxiety about whether conception is possible and what support is available.

Medications: Previously on testosterone enanthate for 5 years, ceased 3 months ago

Allergies: Nil known

Past history: Anxiety (well managed), no surgical history

Social history: Works as a photographer, supportive partner, no smoking or alcohol

Examination findings: Normal vital signs, BMI 24, no signs of androgen excess

What are the most appropriate next steps in Jessie’s fertility care? Select four (4) from the following list:

Sofia Duarte, aged 25, presents with genital ulcers and a new rash on the palms and soles. She identifies as bisexual and has had three new partners (both male and female) over the past 4 months. She reports inconsistent condom use and denies other symptoms. Sofia is otherwise well, takes no regular medications, and has no known allergies.

Medications: None

Allergies: Nil known

Past history: None

Social history: Works in hospitality, drinks socially, non-smoker, no drug use

Examination findings: Multiple painless ulcers on the vulva, non-tender inguinal lymphadenopathy, faint maculopapular rash on the palms and soles. No fever or mucosal lesions noted.

What are the most appropriate next steps in Sofia’s management? Select four (4) from the following list:

Leo Marshall, aged 35, presents with concerns about erectile dysfunction (ED) over the past 6 months. Leo is a cisgender man in a monogamous relationship with a transgender woman. He reports reduced libido and occasional difficulty maintaining an erection. He denies pain or penile abnormalities. Leo is otherwise healthy and has not had any previous sexual health assessments.

Medications: None

Allergies: Nil known

Past history: Mild anxiety (managed without medication)

Social history: Non-smoker, drinks 3–4 standard drinks per week, no recreational drugs. Works full time, relationship supportive and sexually active.

Examination findings: BP 128/76, BMI 26. External genitalia normal. No testicular masses or penile plaques. No signs of systemic illness.

What are the most appropriate next steps in assessment and management? Select four (4) from the following list:

Amina Al-Khatib, aged 33, presents for routine screening. She identifies as queer and is in a non-monogamous relationship with two partners (one cisgender male and one transgender woman). She is sexually active with both and reports occasional condom use. She has no current symptoms, no past STIs, and is otherwise well.

Medications: None

Allergies: Nil known

Past history: Iron deficiency anaemia (diet-controlled)

Social history: Works in media, non-smoker, drinks occasionally, menstruates regularly, no pregnancies

Last cervical screening test: 4 years ago, normal

What are the most appropriate next steps in her sexual health care? Select four (4) from the following list:

Jordan Petrou, aged 29, presents to discuss concerns about genital warts. Jordan is a transgender man who began testosterone 4 years ago and has not had any gender-affirming surgery. He is sexually active with multiple partners (cisgender men and women), uses condoms inconsistently, and has noticed new growths around the vulva over the past 3 weeks. He is otherwise well and has never had an STI screen before.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: Mild acne

Social history: Non-smoker, occasional alcohol, works in retail, supportive friend group

Examination findings: Multiple soft, skin-coloured papules around the perineum and external genitalia, consistent with condylomata acuminata. No discharge or ulceration. No inguinal lymphadenopathy.

What are the most appropriate next steps in management? Select four (4) from the following list:

Natalie Ho, aged 49, presents for a general health check. She is a cisgender woman married to a transgender man. They are in a monogamous relationship and have vaginal intercourse. Natalie has not had STI screening in over 10 years and has not had a cervical screening test since her early 30s. She has no current symptoms and is otherwise healthy.

Medications: None

Allergies: Nil known

Past history: None

Social history: Non-smoker, drinks occasionally, works in administration

Examination findings: BP 122/80, BMI 24, no abnormal findings on general examination

What are the most appropriate next steps in preventive health care for Natalie? Select four (4) from the following list:

Max Fraser, aged 41, presents requesting a sexual health screen. He is a non-binary person (they/them) with a history of receptive anal and vaginal sex with male partners. Max reports using condoms inconsistently and is not on PrEP. They are otherwise well, with no current symptoms. Their last STI test was more than two years ago.

Medications: None

Allergies: Nil known

Past history: None

Social history: Lives alone, works in creative arts, drinks socially, no drug use

Examination findings: General exam normal. Declines genital and rectal examination but consents to testing.

What are the most appropriate components of Max’s care today? Select four (4) from the following list:

Lucia Romano, aged 34, presents with postcoital bleeding and new onset of vulval discomfort. She is a cisgender woman in a monogamous relationship with a transgender man. Her last cervical screening test was 7 years ago. She reports that her partner has undergone phalloplasty and they engage in vaginal and anal intercourse. Lucia is otherwise well and not using any contraception.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in retail, non-smoker, no alcohol or drug use. No prior STIs reported.

Examination findings: Vulval erythema and mild swelling. Speculum exam reveals cervical contact bleeding. No obvious lesions or discharge. Bimanual exam: non-tender, normal uterus and adnexa.

What are the most appropriate next steps in her assessment and management? Select four (4) from the following list:

Kai Evans, aged 22, presents requesting support with gender transition. They identify as non-binary and would like to begin gender-affirming hormone therapy (GAHT) but are unsure what that might look like. Kai is not experiencing significant distress but wants to explore low-dose testosterone to align more closely with their gender identity. They are otherwise healthy and not on any medications.

Medications: None

Allergies: Nil known

Past history: None

Social history: University student, lives with supportive friends, drinks socially, no smoking or drug use

What are the most appropriate next steps in supporting Kai’s care? Select four (4) from the following list:

Erin Black, aged 52, presents with vaginal dryness, pain with intercourse, and urinary urgency. She is a cisgender woman in a monogamous relationship with a transgender woman. Erin has not had a cervical screening test in over 8 years and reports low libido and difficulty with arousal. She has never used hormone therapy and entered menopause 2 years ago.

Medications: None

Allergies: Nil known

Past history: Menopause (age 50), no prior STIs

Social history: Works as a librarian, non-smoker, occasional alcohol use, no drug use

Examination findings: Atrophic vulvovaginal tissue, no ulcers or discharge. Speculum exam reveals pale vaginal walls, contact bleeding. No masses or lesions.

What are the most appropriate next steps in Erin’s care? Select four (4) from the following list:

Eli Navarro, aged 24, presents seeking guidance on transitioning. Eli identifies as genderfluid and is interested in accessing chest masculinisation surgery and potentially low-dose testosterone. They have no significant medical history and no current medications. Eli is sexually active with people of all genders and reports occasional use of condoms and sex toys.

Medications: None

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, works part time, drinks occasionally, non-smoker

Examination findings: Normal general examination. No signs of endocrine pathology or other contraindications to GAHT or surgery.

What are the most appropriate next steps in Eli’s gender-affirming and sexual health care? Select four (4) from the following list:

Alex Park, aged 38, presents with rectal bleeding and discomfort during bowel movements. He is a cisgender gay man who reports recent receptive anal sex. He denies weight loss, fever, or systemic symptoms. He has had previous episodes of haemorrhoids but says this feels different. His last STI screen was over a year ago.

Medications: Nil

Allergies: Nil known

Past history: Intermittent haemorrhoids, no other medical history

Social history: Works as an accountant, lives with partner, moderate alcohol use, no smoking or drug use

Examination findings: Mild anal erythema, tenderness on digital rectal exam. No palpable masses or fissures. No external haemorrhoids.

What are the most appropriate next steps in Alex’s management? Select four (4) from the following list:

Harper Wilson, aged 31, presents with concerns about painful urination and increased urinary frequency. Harper is a transgender woman who began feminising hormone therapy (oestradiol and spironolactone) 3 years ago. She has not had gender-affirming genital surgery. She is sexually active with male partners and uses condoms inconsistently.

Medications: Oral oestradiol 4 mg daily, spironolactone 100 mg daily

Allergies: Nil known

Past history: Well-controlled asthma

Social history: Lives with one partner, works as a barista, non-smoker, occasional alcohol use

Examination findings: Abdomen soft, mild suprapubic tenderness. External genitalia: intact penis and testes, no discharge or lesions. No inguinal lymphadenopathy.

What are the most appropriate next steps in Harper’s assessment and management? Select four (4) from the following list:

Skye Thompson, aged 28, presents with vulval irritation and pruritus. She identifies as a transgender man and has not had gender-affirming surgery. She has been on testosterone therapy for the past 18 months. Skye reports occasional bleeding and discomfort with penetrative sex and is not using any contraception. She has a regular partner (cisgender woman) and uses sex toys. Barrier protection is used inconsistently.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: Mild depression, no known STIs

Social history: Works full-time in retail, drinks socially, non-smoker

Examination findings: Vulval skin appears pale and thin with patchy erythema and areas of fissuring. No discharge or visible lesions. External examination causes mild discomfort.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Reece Donovan, aged 48, presents for a general health check and mentions feeling increasingly fatigued and low in mood over the past 6 months. Reece is a transgender woman who has been on feminising hormone therapy (oral oestradiol and spironolactone) for 6 years. She has not seen a doctor in over 3 years and is unsure when she last had any blood tests. She has not had any surgery and is sexually active with one male partner.

Medications: Oestradiol valerate 2 mg daily, spironolactone 100 mg daily

Allergies: Nil known

Past history: Depression (previous episode 10 years ago)

Social history: Works in administration, lives with partner, drinks alcohol socially, non-smoker

Examination findings: BMI 27, BP 132/78. No signs of androgen excess or cardiovascular disease. Mood appears low but engaged.

What are the most appropriate next steps in Reece’s care? Select four (4) from the following list:

Taylor Morgan, aged 19, presents to discuss menstrual suppression. They identify as non-binary and report significant distress during menstruation, which exacerbates their gender dysphoria. Taylor is not sexually active and does not wish to pursue testosterone therapy at this stage. They are otherwise healthy and do not smoke.

Medications: None

Allergies: Nil known

Past history: Mild acne, no mental health diagnoses

Social history: Lives with family, studying at university, supportive peer group, no alcohol or drug use

Examination findings: Normal general exam, BP 110/70, BMI 22. No signs of hirsutism or endocrine abnormalities.

What are the most appropriate next steps in Taylor’s care? Select four (4) from the following list:

Morgan Bell, aged 43, presents for a cervical screening test. They are a transgender man who has retained their cervix and uterus. Morgan has not had cervical screening in over 8 years due to prior negative experiences in healthcare. He is sexually active with a cisgender male partner and reports no symptoms. He has been on testosterone therapy for 5 years.

Medications: Testosterone undecanoate IM every 12 weeks

Allergies: Nil known

Past history: Anxiety (currently stable), no history of abnormal cervical cytology

Social history: Works in IT, lives with partner, drinks alcohol occasionally, non-smoker

What are the most appropriate steps in supporting Morgan’s cervical screening and sexual health care? Select four (4) from the following list:

Charlie Singh, aged 26, presents requesting advice on starting pre-exposure prophylaxis (PrEP) for HIV prevention. Charlie is a transgender woman who is sexually active with cisgender men. She uses condoms inconsistently and has had two new partners in the past 3 months. Charlie has never used PrEP and has not had an STI screen in over a year. She is on oral oestradiol and spironolactone.

Medications: Oestradiol valerate 4 mg daily, spironolactone 100 mg daily

Allergies: Nil known

Past history: No known STIs, no chronic illnesses

Social history: Works in fashion retail, supportive home environment, non-smoker, drinks socially

What are the most appropriate next steps in Charlie’s care? Select four (4) from the following list:

Ash Patel, aged 36, presents for a follow-up after being diagnosed with primary syphilis. Ash is a non-binary person who is sexually active with multiple partners of various genders. They are concerned about disclosing their diagnosis and unsure how to approach partner notification. Ash reports no symptoms apart from the healing genital ulcer and completed a single dose of IM benzathine penicillin as treatment last week.

Medications: Nil (recent benzathine penicillin G IM)

Allergies: Nil known

Past history: No prior STIs, no chronic medical conditions

Social history: Works in hospitality, non-smoker, drinks alcohol socially, supportive peer network

Examination findings: Healing ulcer at the base of the penis, no discharge or lymphadenopathy. No other skin or mucosal lesions.

What are the most appropriate next steps in Ash’s ongoing care and public health responsibilities? Select four (4) from the following list:

Imani Okeke, aged 60, presents for a general check-up. She is a transgender woman who transitioned over 30 years ago and underwent vaginoplasty at age 35. She has not seen a doctor in several years. She is not on hormone therapy currently, having stopped oestradiol 5 years ago. Imani is sexually active with a cisgender male partner and experiences occasional discomfort during intercourse.

Medications: Nil

Allergies: Nil known

Past history: Vaginoplasty (age 35), hypertension (diet-controlled)

Social history: Lives with partner, retired, non-smoker, no alcohol use

Examination findings: Normal general exam. External genitalia consistent with neovagina. No external lesions or erythema. Digital exam reveals narrowed canal with tenderness at the introitus.

What are the most appropriate next steps in Imani’s care? Select four (4) from the following list:

Finlay Rowe, aged 27, presents with new genital ulcers and a low-grade fever. He is a transgender man who is sexually active with both cisgender men and women. He reports unprotected sex with a new male partner 10 days ago. He has been on testosterone therapy for 3 years and has not had gender-affirming surgery. Finlay is concerned about STIs and says the ulcers are painful and affecting urination.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: Acne, no previous STI history

Social history: Works in hospitality, non-smoker, drinks socially, lives alone

Examination findings: Three shallow, painful ulcers on the vulva, no discharge. Inguinal lymphadenopathy present bilaterally. No other skin or mucosal lesions noted.

What are the most appropriate next steps in diagnosis and management? Select four (4) from the following list:

Rowan Lim, aged 55, presents for a sexual health check-up. They are a non-binary person who underwent bilateral mastectomy and hysterectomy 10 years ago. Rowan is sexually active with one cisgender male partner and does not use condoms. They have not had STI screening since before their surgeries and are unsure what preventive care they still require. They are not on any hormone therapy.

Medications: Nil

Allergies: Nil known

Past history: Gender-affirming surgery (top surgery and hysterectomy)

Social history: Works in academia, non-smoker, drinks socially, monogamous relationship

Examination findings: Normal general examination. External genitalia appear healthy, no discharge or lesions. No lymphadenopathy. No cervix present.

What are the most appropriate steps in Rowan’s sexual health care? Select four (4) from the following list:

Jamie Carter, aged 33, presents with genital pain and swelling. Jamie is a transgender man who began testosterone therapy 4 years ago and has not had any gender-affirming surgery. He reports tenderness and swelling of the left labia over the past 2 days, with some redness and increasing discomfort. He is sexually active with cisgender women and uses sex toys, but does not always use barrier protection. No fever, dysuria, or systemic symptoms.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: No prior STIs, regular testosterone monitoring

Social history: Lives with partner, no smoking, occasional alcohol, employed full time

Examination findings: Localised erythema and fluctuant swelling on the left posterior labia majora consistent with a Bartholin gland abscess. No regional lymphadenopathy. Atraumatic digital rectal exam. Afebrile.

What are the most appropriate next steps in Jamie’s care? Select four (4) from the following list:

Logan Daniels, aged 22, presents requesting contraceptive advice. Logan is a non-binary person assigned female at birth and currently on testosterone therapy for the past 18 months. They are sexually active with a cisgender male partner and are not using contraception. Logan reports irregular spotting but is unsure if they are ovulating and is concerned about unplanned pregnancy.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: Acne, no prior pregnancies, no STI history

Social history: Lives with partner, student, drinks occasionally, non-smoker

What are the most appropriate next steps in Logan’s contraceptive and sexual health care? Select four (4) from the following list:

Beau Kelly, aged 29, presents with recurrent urethral discomfort and dysuria over the past 3 months. Beau is a non-binary person who underwent phalloplasty with urethral lengthening 2 years ago. They are sexually active with multiple male partners and use condoms inconsistently. Beau has been treated for presumed urinary tract infections twice in the past but cultures have been negative.

Medications: Testosterone undecanoate IM every 12 weeks

Allergies: Nil known

Past history: Gender-affirming surgery, prior chlamydia infection (treated)

Social history: Works in design, drinks socially, non-smoker, no recreational drug use

Examination findings: External phallus well healed, no erythema or discharge. No tenderness on abdominal or genital exam. No inguinal lymphadenopathy. A digital rectal exam is declined.

What are the most appropriate next steps in Beau’s management? Select four (4) from the following list:

Eli Zhang, aged 20, presents to discuss concerns about sexual function. Eli identifies as agender and has been on testosterone therapy for 12 months. They report reduced libido and difficulty with genital arousal despite being in a supportive relationship. Eli is sexually active with one partner (cisgender man) and uses condoms consistently. They feel anxious about their body during intimacy but do not describe pain or trauma.

Medications: Testosterone enanthate IM every 3 weeks

Allergies: Nil known

Past history: None

Social history: University student, lives with partner, no alcohol or drug use, non-smoker

Examination findings: Vitals within normal limits. No clinical signs of androgen excess or deficiency. No genital abnormalities noted on external exam (with consent).

What are the most appropriate next steps in Eli’s care? Select four (4) from the following list:

Sasha Novak, aged 46, presents with concerns about painful intercourse and bleeding after sex. Sasha is a transgender woman who had vaginoplasty 15 years ago and is on oral oestradiol. She has not seen a doctor in over 5 years and has not been sexually active until recently. Sasha expresses anxiety about being examined but wants support.

Medications: Oestradiol valerate 4 mg daily

Allergies: Nil known

Past history: Vaginoplasty, no prior STI history, no hormone-related complications

Social history: Works from home, lives with partner, non-smoker, occasional alcohol

Examination findings: External exam deferred by patient request. No visible discharge or skin lesions. Sasha consents to urine testing and swabs.

What are the most appropriate next steps in Sasha’s assessment and care? Select four (4) from the following list:

Quinn Shepherd, aged 31, presents requesting a routine sexual health check. Quinn is a non-binary person using they/them pronouns and has had chest surgery (top surgery) but retains their uterus and ovaries. They are not on hormone therapy. Quinn is sexually active with multiple partners of various genders and uses barrier protection inconsistently. They report no symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in hospitality, drinks socially, no smoking or drug use, lives with friends

What are the most appropriate components of Quinn’s sexual health care? Select four (4) from the following list: