Start with an open question

Begin with open questions about Amal’s symptoms and priorities.

“Can you tell me more about your period pains and how they affect you?”

If sexual concerns arise, allow silence and give time.

“You say you’re worried about not being able to have a physical relationship. Why do you feel that way?”

Co-construct the agenda:

“What would you hope we can achieve in this consultation today?”
“Are there particular worries you’d like me to help with?”

Time-efficient data gathering

Sensitive open questions are efficient because they allow Amal to disclose what feels most important and help build trust.

Explore:

• Pattern, severity and duration of period pain.
• Impact of period pain on college, mood and daily life.
• Recurrent UTI symptoms and frequency.
• Any fever, persistent infection or urinary retention.
• Sexual concerns, painful sex or fear of future intimacy.
• Emotional impact, shame, anxiety or trauma symptoms.
• Family and cultural context where relevant and with consent.
• Concerns about confidentiality and disclosure.
• Concerns about her younger sister.
• What support Amal already has.
• What she wants help with today.

High-yield questions

Period pain

• “When did the painful periods start?”
• “How severe is the pain?”
• “Does it stop you going to college or doing normal activities?”
• “Do you have heavy bleeding?”
• “What have you tried for the pain?”

Urinary symptoms

• “How often are you getting urine infections?”
• “What symptoms do you get?”
• “Have you had fever or felt very unwell?”
• “Have you ever had difficulty passing urine?”

Sexual and relationship concerns

• “Are you worried about pain with sex?”
• “Has this affected how you feel about relationships?”
• “Would it help to talk about what support is available before any future sexual relationship?”

Emotional wellbeing

• “How has all of this affected your mood?”
• “Do you feel isolated or worried about talking to anyone?”
• “How are things at college?”

FGM and family context

Ask gently and only with consent before deeper exploration:

“Sometimes period pain or urine infections can be linked to changes after procedures in childhood. Is that something you feel able to talk about today?”

Explore family or cultural experiences if relevant to her symptoms and if she is willing.

Sister and safeguarding

• “You mentioned your sister. What are your worries about her?”
• “Can I explain what I would need to do if I’m worried about someone under 18?”

Functional, psychosocial or contextual assessment

Explore impact on:

• College and academic performance.
• Mood and emotional wellbeing.
• Relationships and intimacy.
• Family expectations.
• Isolation.
• Future plans.
• Fear of disclosure.
• Safety for herself and her sister.

Useful question:

“How do these symptoms affect your life at college and your mood? Has it made you worry about future relationships?”

Explore ideas, concerns and expectations

Amal may be seeking pain relief, reassurance, confidentiality, help with intimacy concerns, or clarity about what happens if she discloses FGM.

Ask:

“What are you most worried might happen if we talk about this?”

“What would feel like a helpful first step today?”

Revisit goals during the consultation:

• Pain relief.
• UTI support.
• Emotional support.
• Safety for herself and her sister.
• Clarity over confidentiality.
• Relationship and intimacy concerns.

Recognise and respond to cues

Watch for cues such as:

• Hesitancy.
• Downcast eyes.
• Reluctance to discuss relationships.
• Shame or embarrassment.
• Avoidance.
• Protectiveness about her sister.
• Fear about authorities or disclosure.

Respond gently:

“I sense that there might be things that are hard to talk about, and that’s okay. I’m here to support you and won’t judge.”

If she fears disclosure:

“I can explain clearly what stays confidential and the situations where I may have a duty to share information, especially if someone under 18 may be at risk.”

Useful consultation phrases

“I understand this is a sensitive topic and I want to help.”

“I know that other women have gone through similar experiences.”

“Sometimes pain with periods or water infections can be linked to changes after procedures in childhood. There is support available if that’s the case.”

“Your symptoms suggest a possible link to scarring or changes from your past experience. I want you to feel comfortable to share what you want, but also to understand your options for support.”

“Given your concerns about confidentiality and your wishes for your sister’s safety, I can walk you through exactly what happens next.”

Consultation flow and signposting

1. Start with Amal’s main concern and agenda.
2. Explore period pain and urinary symptoms.
3. Ask about impact on college, mood and daily life.
4. Explore sexual concerns and fears about intimacy if raised.
5. Ask sensitively about FGM-related history, with consent.
6. Clarify concerns about confidentiality and disclosure.
7. Discuss her younger sister and safeguarding duties.
8. Explain possible links between symptoms and past FGM.
9. Offer management options and referrals.
10. Agree follow-up and ongoing support.

Do not leap straight to safeguarding. If Amal starts with menstrual pain, acknowledge it first:

“I hear the periods are really painful and that’s been hard for you. How are you coping?”

Summarising and checking understanding

Summarise in short, clear sections.

“You’ve been having painful periods and repeated urine infections. You’re also worried about intimacy and about what might happen if you talk about FGM, especially because of your sister. We can help with the symptoms, and I’ll be clear about confidentiality and support.”

Check understanding regularly:

“Does what I’ve said about the reasons for the pain and what we can do about it make sense? What questions do you have?”

Data gathering self-check

Before moving to management, the trainee should know:

• Pattern and severity of period pain.
• Frequency and severity of UTIs.
• Whether red flags are present: heavy bleeding, fever or urinary retention.
• Whether symptoms may relate to FGM-related scarring or anatomy.
• Impact on mood, college, relationships and intimacy.
• Amal’s understanding and preferred language around FGM or “cutting”.
• Her concerns about confidentiality.
• Her concerns about her 16-year-old sister.
• What support she wants today.
• Whether safeguarding advice or referral is needed.

Assessment domain mapping

Data gathering

• Menstrual symptoms and impact.
• Recurrent UTI symptoms.
• Sexual and intimacy concerns.
• FGM history where volunteered or sensitively explored.
• Psychological, social and family impact.
• Sister-related safeguarding concerns.

Clinical management

• Pain relief.
• UTI advice and possible referral.
• Specialist FGM services.
• Psychological support.
• Safeguarding referral for younger sister.
• Documentation and NHS Digital FGM Enhanced Dataset discussion.

Relating to others

• Trauma-informed listening.
• Culturally sensitive language.
• Managing silence and cues.
• Transparent explanation of confidentiality limits.
• Shared decision-making.

‍

Prioritised differential diagnosis or clinical reasoning

Given the presentation, the most likely causes include:

1. Dysmenorrhoea secondary to FGM-related scarring or adhesions.
2. Primary dysmenorrhoea unrelated to FGM.
3. Urinary tract infection, potentially secondary to altered anatomy from FGM.
4. Genital tract infection.
5. Endometriosis.
6. Psychological distress or trauma-related pain amplification.
7. Renal or urological pathology unrelated to FGM.

Avoid assuming all symptoms are due to FGM, but consider its possible physical and psychological contribution.

Clinical reasoning script

“Your period pain and urine infections may have more than one cause. Sometimes symptoms like this can be linked to scarring or changes after cutting, and sometimes they are due to other common conditions. We can treat the symptoms and also offer specialist support to understand what is happening.”

Red flags and risk assessment

Assess for:

• Heavy bleeding.
• Persistent fever or infection.
• Urinary retention.
• Severe or worsening pain.
• Recurrent infection not improving.
• Significant psychological distress.
• Risk of further harm.
• Safeguarding concerns relating to her sister.

Seek urgent or specialist help where indicated.

Decision points

Key decisions include:

• Does Amal need urgent assessment for infection, urinary retention or heavy bleeding?
• Are symptoms likely related to FGM-related scarring or altered anatomy?
• Does she need referral to specialist FGM services?
• Does she need urogynaecology referral for recurrent UTIs?
• Does she need trauma-informed psychological support?
• What information must be shared about her sister?
• What can remain confidential?
• Does the safeguarding lead need to be involved?
• What follow-up is needed?

Management priority

The management priority is to provide safe, holistic and culturally sensitive care that addresses:

• Period pain.
• Recurrent UTIs.
• Sexual and intimacy concerns.
• Emotional wellbeing.
• Confidentiality and safeguarding.
• Specialist FGM support.
• Follow-up and advocacy.

Management options

1. Pain management

Offer pain relief options, including:

• NSAIDs.
• Paracetamol.

Use BNF guidance where appropriate.

Also discuss practical period-pain measures:

• Warm packs.
• Rest.
• Healthy routines.

2. Bladder care and UTI advice

Offer bladder care advice, including:

• Hygiene.
• Hydration.
• Cranberry products.

Consider further management or referral if UTIs are recurrent or complicated.

3. Specialist FGM services

Offer referral to specialist FGM services for assessment, advice and support.

Explain what the service may help with, including symptoms, anatomy, sexual concerns and support planning.

4. Psychological support

Offer psychological support or counselling, including trauma-informed therapy.

This may help with:

• Anxiety.
• Shame.
• Fear of intimacy.
• Trauma-related distress.
• Isolation.

5. Sexual health and intimacy support

Offer discussion of future sexual health in a supportive way.

This may include:

• Sex education resources.
• Support around first sexual experience.
• Advice about pain, fear and communication.
• Referral or specialist support if needed.

6. FGM charities and support groups

Signpost to:

• Forward UK.
• NSPCC FGM helpline: 0800 028 3550.

Offer advocacy or culturally appropriate support if Amal wishes.

7. Safeguarding referral for younger sister

Explain that because Amal’s sister is under 18, there are legal and safeguarding duties.

Explain this transparently:

“I want to be honest with you. I will respect your confidentiality as much as possible, but because your sister is 16, I have safeguarding responsibilities. I can explain exactly what information may need to be shared and why.”

Involve Amal in the discussion where possible, unless safety or law requires action without consent.

8. Documentation and NHS Digital FGM Enhanced Dataset

Have a confidential discussion about documentation and the NHS Digital FGM Enhanced Dataset.

Explain honestly:

• What will be recorded.
• How her data is used.
• What this means for confidentiality.

9. Urogynaecology referral

Discuss possible urogynaecology referral for recurrent UTIs where appropriate.

10. Follow-up

Offer follow-up for:

• Pain control.
• UTI recurrence.
• Emotional support.
• Specialist referral progress.
• Safeguarding discussion and questions.
• Sexual health or intimacy concerns.

Personalised plan

Tailor the plan to Amal’s priorities and fears.

A personalised plan might include:

• Immediate pain relief and UTI symptom management.
• Specialist FGM referral if she agrees.
• Trauma-informed counselling referral or signposting.
• Written information in her preferred language if needed.
• Advocacy or community support through an FGM specialist organisation.
• Clear explanation of confidentiality and safeguarding steps.
• Safeguarding referral regarding her younger sister.
• Follow-up appointment to revisit questions once she has had time to process the information.

Example phrase:

“Given your concerns about confidentiality and your wishes for your sister’s safety, I can walk you through exactly what happens next and make sure you have emotional support during this process.”

Shared decision-making

Support Amal’s control and autonomy wherever possible.

Ask:

• “Which part feels most important to focus on first?”
• “Would you like written information to take away?”
• “Would you like support from a specialist FGM organisation?”
• “Would you prefer an advocate or someone you trust to be involved?”
• “Would it help to have another appointment to talk through this slowly?”

Be clear that safeguarding duties may limit choice in relation to her sister, but involve Amal respectfully in the process.

Safety-netting

Advise Amal to seek urgent help if she develops:

• Heavy bleeding.
• Persistent fever or infection.
• Urinary retention.
• Severe or worsening pain.
• Symptoms that make her feel acutely unwell.
• Worsening emotional distress or feeling unsafe.

Ensure she knows who to contact and how follow-up will be arranged.

Ethical, legal and safeguarding considerations

Demonstrate familiarity with:

• Female Genital Mutilation Act 2003.
• Mandatory reporting for minors.
• Caldicott principles.
• Safeguarding pathways.
• Confidentiality and its exceptions.

Key principles:

• Respect Amal’s autonomy and dignity.
• Be transparent about confidentiality and limits.
• Share information only where legally required or necessary for safeguarding.
• Make actions justifiable and proportionate.
• Involve the safeguarding lead.
• Seek senior advice if unsure.
• Document thoroughly.

Documentation points

Document carefully:

• Amal’s symptoms and impact.
• Language used by Amal to describe FGM or “cutting”.
• Physical, emotional and sexual concerns.
• Red flags assessed.
• Confidentiality discussion.
• Safeguarding concerns relating to her sister.
• Information shared and rationale.
• Advice and resources provided.
• Referrals made.
• NHS Digital FGM Enhanced Dataset discussion where relevant.
• Follow-up plan.
• Senior or safeguarding advice sought if applicable.

Common unsafe management plans

Avoid:

• Promising absolute confidentiality.
• Ignoring the safeguarding implications for a 16-year-old sister.
• Using judgemental or culturally insensitive language.
• Forcing Amal to disclose details before she is ready.
• Treating the case as only dysmenorrhoea or only UTI.
• Ignoring psychological distress and intimacy fears.
• Failing to offer specialist FGM services.
• Not documenting safeguarding reasoning.
• Acting alone if unsure rather than seeking senior or safeguarding advice.

Follow-up and coordination with other professionals

Coordinate care with:

• Practice safeguarding lead.
• Local FGM clinic or specialist FGM services.
• Urogynaecology where appropriate.
• Psychological support or trauma-informed therapy.
• Patient advocates.
• FGM charities and support groups.
• Safeguarding services where required.

Follow-up should review:

• Pain control.
• UTI symptoms.
• Emotional wellbeing.
• Relationship and intimacy concerns.
• Referral progress.
• Amal’s understanding of safeguarding steps.
• Ongoing support needs.

Learner checkpoint

Have I balanced Amal’s confidentiality and autonomy with my safeguarding duties in a transparent, compassionate and proportionate way?

‍

Relevant guidance areas 

• FGM information and safeguarding.
• Dysmenorrhoea, UTI and endometriosis assessment.
• Trauma-informed consultation skills.
• Confidentiality and safeguarding duties.
• Documentation and information sharing.
• Specialist FGM services and support organisations.

NICE guidance

• NICE: Urinary Tract Infection.
• NICE: Endometriosis.

BNF references

• BNF: British National Formulary, including analgesia guidance.

GMC, DVLA or safeguarding guidance

• UK Government FGM Safeguarding Guidance.
• Female Genital Mutilation Act 2003.
• Mandatory reporting for minors.
• Caldicott principles.
• Safeguarding pathways.

RCGP and SCA resources

• RCGP SCA Toolkit.

Patient information websites and support resources

• NHS FGM Information.
• Forward UK.
• NSPCC FGM helpline: 0800 028 3550.
• FGM specialist organisations or advocacy services where available.

Relevant research or educational references

• Sociolinguistics of Simulated Consultations.
• Linguistic and cultural factors in MRCGP examination.

Key principles to remember

• Start with Amal’s story and symptoms before moving to safeguarding.
• Use open questions, silence and sensitive language.
• Ask permission before deeper exploration of traumatic issues.
• Consider FGM-related scarring, primary dysmenorrhoea, UTI, genital tract infection, endometriosis and trauma-related pain.
• Explore physical, psychological, sexual, social and academic impact.
• Explain confidentiality and its limits honestly.
• Safeguarding duties apply where a minor is involved.
• Offer specialist FGM services, psychological support and trusted organisations.
• Document carefully and seek senior or safeguarding advice if unsure.
• Maintain Amal’s dignity, autonomy and trust throughout.

Transferable learning for future cases

In sensitive consultations involving trauma or safeguarding:

• Build trust before asking detailed questions.
• Let the patient choose language where possible.
• Do not promise confidentiality without explaining limits.
• Balance autonomy with safeguarding duties.
• Offer practical support as well as legal explanation.
• Use specialist services and safeguarding leads early.
• Document the reasoning behind information sharing.

Supervisor or examiner lens

A supervisor or examiner is likely to look for:

• Sensitive, non-judgemental communication.
• Recognition of FGM-related physical and psychological complications.
• Exploration of intimacy, mood and social impact.
• Clear explanation of confidentiality limits.
• Safeguarding action regarding the younger sister.
• Appropriate referral to specialist FGM and psychological services.
• Thorough documentation and escalation if uncertain.

Final learner takeaway

In FGM-related consultations, trust is built through sensitive listening, honest confidentiality discussions, holistic care and proportionate safeguarding action.

‍