CASE INFORMATION

Case ID: SFS-002
Case Name: Emily Robertson
Age: 32
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X24 (Sexual function symptom/complaint – Female)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient effectively 1.3 Uses a sensitive and non-judgmental approach 1.5 Explains medical information in an understandable way
2. Clinical Information Gathering and Interpretation	2.1 Takes a focused and hypothesis-driven history 2.2 Identifies psychosocial and medical contributors to sexual dysfunction
3. Diagnosis, Decision-Making and Reasoning	3.1 Considers differential diagnoses including physiological, psychological, and relational factors 3.4 Demonstrates clinical reasoning in evaluating the likely causes
4. Clinical Management and Therapeutic Reasoning	4.2 Develops an appropriate patient-centred management plan 4.4 Considers multidisciplinary management options
5. Preventive and Population Health	5.2 Provides sexual health education and preventive strategies
6. Professionalism	6.2 Maintains a respectful, patient-centred approach in discussing sensitive topics
7. General Practice Systems and Regulatory Requirements	7.2 Uses appropriate referral pathways (e.g., psychologist, sexual health physician, pelvic floor physiotherapist)
9. Managing Uncertainty	9.1 Recognises complexity in sexual dysfunction and tailors management accordingly
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies potential underlying conditions requiring further assessment (e.g., endocrine disorders, mental health issues)

CASE FEATURES

Primary complaint: Sexual dysfunction (low libido and discomfort during intercourse)
Contributing factors: Psychological, relationship, hormonal, and physical considerations
Importance of sensitive communication: Patient may feel embarrassed or reluctant to discuss
Exclusion of underlying medical conditions (e.g., depression, hormonal imbalance, medication side effects)
Multidisciplinary approach: Consideration of counselling, pelvic floor physiotherapy, medical treatment options
Patient expectations and concerns: Reassurance, education, and appropriate follow-up

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Emily Robertson, a 32-year-old female, presents to your general practice with concerns about her low libido and pain during intercourse over the past six months. She explains that she has never had this issue before but has noticed a gradual loss of interest in sex, which is now affecting her relationship with her partner.

She describes feeling guilty and frustrated because she wants to feel closer to her partner but struggles with arousal and discomfort during penetration. She has noticed vaginal dryness and states that she sometimes feels a burning sensation after sex.

PATIENT RECORD SUMMARY

Patient Details

Name: Emily Robertson
Age: 32
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Ethinyloestradiol-levonorgestrel (COCP), one tablet daily

Past History

No significant medical conditions

Social History

Occupation: Marketing manager (high workload, frequent deadlines)

Family History

No family history of hormonal disorders or significant mental health conditions

Smoking

Non-smoker

Alcohol

Drinks socially, 1-2 times per week

Vaccination and Preventative Activities

Up to date with cervical screening (last test 12 months ago, normal result)

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I feel really embarrassed bringing this up, but I’ve been struggling with my sex drive, and it’s starting to affect my relationship.”

General Information

(Freely Given if Asked Open-Ended Questions)

Noticed low libido and discomfort during sex in the past six months.
Feels frustrated and guilty because she wants to feel connected with her partner but struggles with intimacy.
Still loves her partner and feels emotionally connected, but the lack of sexual desire is causing tension.
Work has been very stressful over the past year, leaving her mentally exhausted most days.

Specific Information

(Only Given if Asked Direct Questions)

Background Information

Sex feels different—less enjoyable, sometimes painful.
She doesn’t feel as ‘in the mood’ as she used to and doesn’t understand why.
Has never had this issue before; in the past, she had a healthy sex life.
Feels pressured to be intimate, even when she doesn’t feel like it, which makes it harder.
No history of sexual trauma or abuse.

Pain History

Pain only occurs during intercourse, mostly at the vaginal entrance but sometimes feels deep discomfort.
Describes the pain as mild to moderate burning or a raw feeling.
Pain is worse when penetration starts but eases slightly after a while.
No daily pain or discomfort when not having sex.
No unusual vaginal discharge, itching, or odour.
Has noticed vaginal dryness, which wasn’t a problem before.

Menstrual and Hormonal History

Periods are still regular, but she has noticed they are lighter than before.
No hot flashes, night sweats, or other menopause symptoms.
Has been taking the combined oral contraceptive pill (COCP) for 10 years without issues.
No history of polycystic ovary syndrome (PCOS), endometriosis, or thyroid disorders.

Psychosocial Factors

Work stress is overwhelming—she has tight deadlines, long hours, and pressure from her boss.
Feels drained by the time she gets home, so intimacy is the last thing on her mind.
Her partner has been supportive, but she can tell he’s feeling rejected.
Occasionally has negative thoughts about her body—feels like she’s not as attractive as she used to be.
Worries that if this continues, it will damage her relationship.
No past history of depression or anxiety diagnosis, but admits to feeling low, overwhelmed, and emotionally distant.
No history of trauma or sexual abuse.

Lifestyle and Medication History

No significant weight gain or loss.
Exercises irregularly but used to go to the gym twice a week.
No major dietary changes.
Does not smoke and drinks socially (1-2 times per week).
No recreational drug use.
Not on any other medications or supplements, apart from the COCP.

Emotional Cues

Appears embarrassed and hesitant when talking about her symptoms.
Speaks quietly and avoids eye contact when describing the impact on her relationship.
Tears up when discussing her fear that her partner will lose interest in her.
Visibly relieved when the doctor reassures her that this is a common issue.
Nods and listens attentively when the doctor explains possible causes.
If the doctor suggests stress may be contributing, she admits she hadn’t thought about it that way before.
If the doctor suggests changing her contraception, she seems hesitant but open to the idea if it might help.

Patient Concerns and Expectations

Worried this is a sign of something serious—is she losing her hormones too early?
Afraid her partner will become frustrated and pull away from her.
Wants to know if there is a medical cause and whether it can be treated.
Concerned about long-term impact—will this issue be permanent?
Looking for practical advice—wants to know what she can do to get her libido back.

Questions the Patient Might Ask

“Is there something physically wrong with me?”
“Could my pill be causing this?”
“Is there any treatment for this?”
“Will this go away on its own?”
“Would seeing a counsellor help?”
“Is this common in women my age?”
“Could this be an early sign of menopause?”
“What tests would you do to check if something’s wrong?”

Escalating the Scenario Based on the Candidate’s Approach

If the candidate fails to show empathy or sensitivity, the patient will become more withdrawn and hesitant to share further details.
If the candidate only focuses on physical causes and ignores stress/relationship dynamics, the patient will not feel like her concerns are being addressed.
If the candidate acknowledges emotional factors (e.g., stress, relationship pressure), the patient will open up more and engage in the discussion.
If the candidate reassures her that treatment options exist, the patient will feel more hopeful and motivated to follow recommendations.
If the candidate dismisses her concerns, she will feel discouraged and may resist suggested interventions.

Final Patient Reactions Depending on the Consultation Quality

If the candidate provides a thorough and compassionate response, the patient will say:
“Thank you, Doctor. I feel a bit better knowing this is something we can work on. I’ll try what you suggested.”
If the candidate is vague or dismissive, the patient will hesitate and say:
“I guess I’ll just wait and see if things improve… but I’m still worried.”
If the candidate provides an overly medicalised response without addressing emotions, the patient will remain doubtful and ask:
“So you think this is just stress? That doesn’t seem like the whole answer.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, exploring biological, psychological, and social factors contributing to her symptoms.

The competent candidate should:

Approach the discussion sensitively and non-judgmentally, ensuring the patient feels comfortable sharing personal concerns.
Use open-ended questions to explore the nature, onset, and progression of symptoms.
Identify biological factors, including hormonal influences, medication use (e.g., combined oral contraceptive pill), vaginal dryness, and dyspareunia.
Assess psychological factors, such as stress, fatigue, mood disturbances, anxiety, body image concerns, and previous trauma.
Explore relationship factors, including emotional intimacy, partner expectations, and any associated distress.
Take a comprehensive medical and gynaecological history, including menstrual cycle changes, previous gynaecological conditions, and contraceptive history.
Ask about social factors, such as work-related stress, sleep patterns, and lifestyle habits affecting libido.

Task 2: Provide a differential diagnosis based on the history.

The competent candidate should:

Consider biological causes, including:
- Hormonal factors (e.g., COCP-related libido reduction, thyroid dysfunction).
- Genitourinary syndrome of menopause (GSM) (less likely at this age but consider in light of vaginal dryness).
- Chronic pain conditions, such as vestibulodynia or vaginismus.
Explore psychological contributors, such as:
- Stress, anxiety, or depression leading to reduced libido.
- Body image concerns or performance anxiety.
Evaluate relationship factors, including:
- Emotional connection and intimacy issues.
- Unspoken tension about sexual expectations.
Exclude other medical conditions, including diabetes and chronic illness, which may contribute to fatigue and reduced libido.

Task 3: Explain your management plan to the patient, addressing her concerns and discussing possible interventions.

The competent candidate should:

Validate the patient’s concerns and reassure her that female sexual dysfunction is common and treatable.
Discuss modifications to hormonal contraception if suspected as a contributing factor.
Provide education on sexual health, including the role of lubrication and arousal in reducing discomfort.
Offer psychosexual counselling or referral to address emotional or psychological contributors.
Encourage stress management strategies, such as relaxation techniques and improved work-life balance.
If indicated, discuss medical treatments, such as vaginal oestrogen for dryness (off-label in younger women) or other hormonal options.
Ensure a multidisciplinary approach, considering referrals to a psychologist, pelvic floor physiotherapist, or sexual health specialist.

Task 4: Discuss referral options and follow-up as part of a patient-centred approach.

The competent candidate should:

Offer referral to a psychologist if significant psychological distress or relationship issues are identified.
Consider pelvic floor physiotherapy if vaginismus or pelvic pain is contributing to symptoms.
Provide guidance on sex therapy services for structured support.
Discuss a review plan to monitor progress and adjust management if needed.
Address safety-netting advice, ensuring the patient returns if symptoms persist or worsen.

SUMMARY OF A COMPETENT ANSWER

Uses a patient-centred, sensitive approach to history-taking.
Identifies multiple possible contributing factors, including biological, psychological, and social influences.
Provides a structured differential diagnosis, prioritising common and reversible causes.
Develops an appropriate, individualised management plan, addressing both physical and emotional aspects.
Discusses realistic treatment options and referrals while providing reassurance.
Ensures appropriate follow-up and safety-netting for ongoing support.

PITFALLS

Failing to establish rapport or creating an environment where the patient feels judged.
Focusing only on medical causes while ignoring psychological or relationship factors.
Not considering medication effects, particularly the role of the combined oral contraceptive pill.
Providing a one-size-fits-all approach, rather than tailoring management to the patient’s needs.
Failing to offer multidisciplinary management, neglecting psychology, pelvic floor physiotherapy, or sexual health services.
Not addressing patient concerns directly, particularly fears about long-term sexual function.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about symptoms, ideas, concerns, and expectations.
1.3 Uses a sensitive, patient-centred approach to discussing sexual dysfunction.
1.5 Explains medical information in an understandable and reassuring manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused history, identifying key symptoms and psychosocial contributors.
2.2 Uses clinical reasoning to interpret findings and identify possible causes.

3. Diagnosis, Decision-Making and Reasoning

3.1 Considers a broad differential diagnosis, including medical, psychological, and social factors.
3.4 Recognises complexity and the interplay of multiple contributing factors.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an evidence-based, patient-centred management plan.
4.4 Incorporates multidisciplinary management, including counselling and physical interventions.

5. Preventive and Population Health

5.2 Educates patient on sexual health, arousal, and stress management strategies.

6. Professionalism

6.2 Maintains a respectful, non-judgmental approach when discussing sensitive topics.

7. General Practice Systems and Regulatory Requirements

7.2 Uses appropriate referral pathways for psychological, sexual, and pelvic health support.

9. Managing Uncertainty

9.1 Handles diagnostic uncertainty effectively, considering multiple contributors.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises when further investigation is required, including hormonal or psychological assessments.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD