Thread by @tribunaltweets

Good afternoon. @katie_sok here for today's session of the Helen Webberley tribunal. Afternoon session to resume at 1.30pm. Tweets will be added to this thread in batches in due course.

As a reminder, HW is Helen Webberley, SJ is Simon Jackson QC Counsel for the GMC, IS is Ian Stern QC Counsel for Dr Webberley, P stands for the Tribunal Panel and Dr D stands for Dr John Dean

Please ask if any abbreviation or shorthand is unclear.

To confirm all attendees were dialed in remotely today. There were two observers from the public at the MPTS building, myself and a student taking a Gender Studies course.

Resuming with qu’ns for Dr D. Chair: We have qu’ns from the tribunal. I’m going to start.
[discussion of more camera issues, attendees that can’t see each other]

Chair: The service agreement of the Tavi sets the age, circa 16 yrs, as the earliest age for Gender Affirming (GA) hormones, or that was position in 2016/17.

So with patient A, who is on blockers at aged 11, presumably one can accept that A was an exceptional case for GA hormones at such early age? [Not sure if he meant to say blockers here] Can you make a comment on that? Is that young for blockers after a diagnosis?

Dr D: Falls outside my area. Don’t see people under aged 17.

Chair: You can’t assist us from your experience about GNRH for adolescents?

Dr D: Traditionally prescribed when fairly advanced through puberty. But there is an alternative approach at younger ages where determined by Tanner stages (my understanding). That protocol is that when reach Tanner 2 they would be put on a blocker with aim that reduces

the Gender Dysphoria distress and delays 2ndary sex characteristics.

So x-sex hormones at 16 not before, not seen it happen earlier even if that is part of early intervention programmes

Chair: so early intervention has no impact on when GA hormones are given?

Dr D: Protocol says no hormones pre 16 yrs. That would be whether say GNRH at age 14 or whether at an earlier age such as 11.

Chair: Don’t want to make you feel uncomfortable but this AM you said 2 years was the max. should be on blockers due to issues with bone development etc. So 2 years about right time?

Dr D: I did but prefaced my comments that my exp. was working with adults. In people under 16 I would always seek advice from specialist. My evidence relates to my exp.

Hypo-gonadal state w/o sex hormones present can have impact on bone mineral density, lipids …. no. of issues with low testosterone or low estrogen.

I mentioned concern about height. There is evidence now that height might be significantly affected by earlier testosterone but also evidence to contrary but certainly there are metabolic consequences. In adult practice would be 2 years.

Note I would be making referral for delayed puberty at about age 14/15.

Chair: Where was the Tavi or UCLH‘s treatment going if they start blockers at age 11 and broadly the position is you should be on them for no more than 2 years but 4/5 yrs to age 16?

Dr D: The circs that pertain to adults on GNRH for 2 yrs+ are familiar with me but I’m not certain for a younger age. My perception is that it is undesirable but outside my expertise, I can’t say

SJ: I thought Prof B addressed this in his evidence. I recollect that he said patients are started at young age because of their then presentation. They review prior to age 16 or perhaps about 15.

Dr D: The intent with blockers is to give young person relief from dysphoria and allow them time and space for reflection.

I wouldn’t characterise starting at 11 as not having a plan. There is a plan. Personally, I would be concerned with these for 4 yrs if [it was] my child but I would expect the specialist endocrinologist to explain to me why this is ok

IS: I did ask Prof B that question [gives ref]

Chair: Some extremely high %age of adolescents that get blockers go onto GA hormones, plus 97%. So, what is the point of managing a psychiatric position for so long if going on to GA hormones?

Clearly the clinic has got to manage the adolescent’s health psychological and psychiatric but only until resolution to gender dysphoria (GD) namely, by GA hormones taking place so, why don’t clinics get on with it (to be brutal) and administer GA hormones earlier?

Is it to do with capacity and consent? By consent, I mean recognition by patient that this is the path they wish

Dr D: Not unusual for ppl. unfamiliar with this area but I must point out gender incongruence is not a psychological issue. [think he says it’s a neurological condition but not sure]

There are differences in young people with reported higher levels of fluidity in gender identity and this can happen rapidly compared with adults.

I think in young people, part of the rationale for this programme is to allow the patient time to achieve to some stability and consistency in their long term goals rather than move rapidly

One of the issues that is so difficult is the changing views of some patients. Equally others remain clear and consistent. But not poss. to predict who will continue to require treatment. So don’t go quickly because of this uncertainty

Older adolescents are more stable with goals and where sever GD more likely to persist in goals to transition but not easily predicted. That’s my understanding why no rush.

Chair: it’s a matter of determination of MDT/clinician and adolescent as to whether pitch of consistency is achieved. If informed wisdom of MDT/clinician is that he is stable and consistent with desire to continue then…..

[SJ interjects] SJ: Dr Klink identified need for delay. Danger in looking in isolation e.g. postulating if Patient A & the mother decides … psycho-social maturity not good enough at e.g. 12yrs even if stable

Chair: I’m not suggested young person (YP) or family determine, I'm understanding decision is to whether or not particular YP has arrived at point of stability and consistency. That’s the moment when the clinician will be considering prescribing the next stage….

I’m not saying dependent on patient or family, its the conclusion of clinician based on info they have

Dr D: I’m sure clinician would not endorse irreversible intervention if doubt by the YP concerned. But generally, shared decision making between clinician/patient/family as how to proceed.

Again speaking of adults, where they are very clear, still on occasion those goals change (happily rarely) but they experience regret commonly because the psycho-social burden of transition outweighs benefits (internalised t-phobia)

But sometimes gender identity changes for no obvious reason.

Chair: Thinking of the Tavi, CL clinic, the Vancouver clinic and evidence from Northern Ireland…
Patients A, B and C seem to me outside this environment, one way or another, ‘outsiders’. Looking at them broadly:

A didn’t want long wait for GA hormones
B who was 16yrs didn’t want blockers as it was too late
C was upset about delay for 1st appointment
So these are outside the care you are extolling in the Tavi and elsewhere?

I get this from two passages in the defence’s report, Dr Schumer para 9.7 his report D32 “beware the only legitimate team”. Dr Paterski says the need for a supplemental service is immeasurable from the letter to GMC.

So if there are patients who are outside GIDS or Vancouver clinic, what about then? Is there not a role for a supp. service to cater for those people?

Dr D: Yes as long as the care being offered is consistent with authoritative guidelines. Its undesirable to say there is one way of doing it. I think within that though there are still guidelines that give frameworks which are based on published evidence within which you can work

But whether in private [setting] or NHS if use those guidelines no reason for clinicians not to provide [not to provide another service is what I think was said here]

We may disagree best approach partic. in an area of limited clinical evidence. That is more the case for YPs than adults but does impact adults to some extent.

Eg with asthma where limited evidence, professionally, personally I prefer cautious approach. [Not sure why asthma used as example here]

Unwise to use interventions where there is not evidence of effectiveness/safety but it’s a personal, clinical judgment

Chair: So clinician uses professional judgment?

Dr D: I think use caution where no evidence

Chair: Ok thank you. Dr Nigel Westwood (Dr W) now has qu’ns

Dr W: Good Afternoon. I’m a lay member of the panel as is the Chair (lay in terms of medicine). I have 3 qu’ns.

Dr W: Refer to page 83 para 12. [We don’t have access to the bundle] In a gender identity practice I expect as a min. clinical record would include a statement re. capacity and failure to include this for patient KJ (believe this means patient A)

falls below standard expected of a specialist. You go on to say that there is no info to suggest A lacked capacity for interventions.

Dr W continues: I assume you are familiar with Bell vs. Tavistock judgment?

One finding was that consenting to blockers necessarily involved dialogue as to what might happen next because most go on to GA hormones.

Therefore the findings of the judicial review (JR) were the capacity ax must include what might happen next. Don’t know if you accept that JR view?

Do you agree or not that HW when assessing A for testosterone prescription, was entitled to rely on the fact the patient been seen by Tavi 5 months before and had consented to puberty blockers (PBs) and therefore consented to what might happened down the line?

Dr D: Assessing capacity for the use of PBs and hormones should include looking to the future, looking ‘over the hedge’, that is my firm belief for many years before the JR (I also note that judgment is under appeal).

But in answer to the qu’n about whether HW can rely on the capacity & consent ax for PBs at the Tavi to imply consent for testosterone, no I do not agree [This is a firm no from Dr D]

There should have been a discussion re. the likelihood the person would continue to desire hormones… That should have happened… It seems highly unlikely that dual consent is given for both. Certainly in my practice, PB consent is not adequate for consent to use testosterone

DR W: 2nd qu’n. HW witness statement has not been tested yet [i.e. not cross-examined by tribunal] but let’s relay on what she states…

[rely*, typo!] “it is my usual practice to only record consent where [didn’t quite hear but think this was that HW only records consent where there are issues or its not given]”

[DR W then supplies some references to bundle, ?D20 page 62b para F]

[IS interjects] IS: It’s not reasonable for a Dr to evidence consent through a signed consent form with attendant info sheet? Then for 3rd parties looking at that to make an inference this included ax for capacity.

What sort of clinician would accept a signed form if they had doubts?

Dr D: So there are examples where patients have signed and its clear they did not have the capacity because info was inadequate.

I’m not suggesting that is the case here but in GP practice and Sexual Health, Reproductive medicine and in adult practice, clinicians do not write “patient has Capacity to consent”, it’s not routinely documented

But in this area with limited evidence base, with well-known qu’ns and publicity it would be good practice and prudent to document capacity.

It has been drummed into me working in an MH trust that you must document that ppl. have capacity. I understand generally other Gender clinics do state capacity as well as patient signing consent form.

An affirmation statement that 11 yo has capacity to make this decision is appropriate and to not include this is below the standard of a specialist in this area. That is not for a moment to doubt that many lack capacity but it should be documented.

DR W: you were asked by SJ where duty lies for communication to take place between care providers, in our case HW was involved with A but A also had own GP and Tavi/UCLH involved
You said prescriber responsibility …. [cant hear]

Dr D: ‘do no harm’ also an issue here – potential here with 2 dr’s prescribing for same problem, not unique, e.g. sexual health clinic where confidential nature means info not routinely shared to the GP

Dr W: Want to see if your opinion changes. Dr Young was Patient A’s GP, Prof B at the Tavi. HW evidence says Young and Butler were not willing to work collaboratively. See email dated 7 .6. 2016

Mother of A says Dr Y isn’t aware patient is on testosterone as he against prescribing.

Again HW evidence has not been tested... but she stated she attended WPATH [conference?] in Amsterdam in June 2016 where she met Prof Butler. HW: “I spoke to Gary B and he made it clear we could not be friends or colleagues. He said I could not attain the specialism he had”

So they had closed doors to her.
Does that change your opinion in any way as to what HW should have done? Re. prescribing testosterone while under care of Tavi?

Dr D: No it doesn’t. Human affairs are messy, clinicians must form their judgement based on clinical guidelines and Regulator guidelines. I would not have prescribed Testosterone

Should have discussed with A, found an alternative provider or moved away from the Tavi. Ultimately, safety of patient is paramount. 2 dr’s working w/o knowledge of each other’s care is not acceptable

Dr W: 3rd and final question [cant quite hear] …psychopathologising of transsexualism… thinking has moved on …. GD ‘F code’ as MH disorder will cease and will move into a sexual health issue.

You said in your evidence that gender incongruence is not an MH disorder. Seems consistent with evolution of this area. If not an MH disorder, where does the GD arise from? Is it not because denied GA therapy and in absence of that problems follow as in limbo?

Dr D: Yes that is a compassionate ax. In ‘ICD 11’ we have ‘gender incongruence’ and the word disorder has gone.

Dr W: Agree ‘disorder’ had been dropped.

Dr D: responses to gender incongruence vary. Intolerable for some. Others exp. less distress and make adaptions to get on with life w/o professionals involved.

We see those with health problems as a consequence but not in itself a disorder, it certainly for most ppl. has adverse consequences. Not everyone will seek interventions.

Some delighted to be just affirmed and do not want or need medical interventions. It is very important that patients have the opportunity to consider all options, with time to consider. This will improve well-being and reduce bio-psycho-social health issues .

Triadic therapy (PBs/Hormones/Surgery) was seen as a conveyor belt with almost the expectation that can’t offer treatment if not willing to go to the end. That is not the contemporary approach now

Sometimes goals may change as they go on e.g. want surgery to begin with then change and vice versa. Matter evolving over of significant period of time.

I don’t get sense we hold people back. NHS gets caught up with serious delays but the days of delaying treatment to ‘jump through hoops’ are no longer not contemporary practice

DR W: Thank you. No more questions.

[Another panel member Dr Theva now takes over to ask Dr Dean questions]

Dr Theva: How does a clinician make a decision in best interests of patient? E.g. A and there mother are in front of you.. how are you deciding?

[their*!]

Dr D: 1. it’s patient wishes, you listen and respect their autonomy. So, we need to assess their capacity to understand and the Mental Capacity Act assists us here

Recommends to us ways we can try to max the opportunity for the patient to communicate the decision. Most patients will know their best interests so we have to have grounds to disagree.

2. Is the family involved? Listen to their views. Again being careful individual is not being influenced.

How much further than that? See Bell v Tavi ruling. I have to say the days of requiring people to provide evidence form 3rd parties…. Used to be a statement required eg from friend or employer – no longer.

Non-maleficence i.e. causing no harm also relevant. Bio- psycho-social ax might lead us to see the risks of a patient’s choice. We explain in a way the patient gets

Patients entitled to take risks and make unwise decisions. Whether we agree and wish to be a party to that is professional judgment.

Then beneficence is relevant i.e. doing good for the person. Have to weight all these.
Largely patient driven. Ideally in YP it should involve parents but not always but might have to change my approach if courts decide its required in all cases from parents.

Dr T: if objectively decided she has learning points before she can make a decision, what should she do?

Dr D: if patient has not understood then take action to change this. Suggest videos, handouts or engage someone with skills to communicate eg if patient has autism might need specialist

Dr T: Clinician should be able to justify her decision in either case?

Dr D: yes certainly, and document carefully where some uncertainty in the area... Seek MDT or ethics committee in some cases

Dr T: Do you think HW was not able to justify her decision in A’s case?

Dr D: I felt HW fell below the standard other than where IS has pointed to new info I wasn’t aware since my original report.

Dr T: How should this patient have been managed?

Dr D: Um.... given this is outside my exp. as GP or parent of child I would say important for all clinicians involved to overcome their difficulties for the good of the patient and then work together or one should withdraw.

Dr W: you mentioned ethics committee. From Bell judgment one of the contentions was that Court of Protection might be involved here. Let’s say there is a scale with, on one end, no consultation and then Court of Protection at other end. Ethics committee in the middle.

In practice, are you seriously suggesting that a Dr with a special interest in transsexual care should refer to ethics committee?

Dr D: there is a wide spectrum of cases. Most don’t need MDT. But where there is significant disagreement among professional and or family and they are stuck then…. one approach to resolve

Court of P not sure … these are health issues but that is for illegality

[Dr W thanks Dr D and hands back to Chair]

Chair: Over to advocates. IS first

IS: I cant see you Dr Dean! Forgive me [camera issues]
You’ve made it clear time and time again that you have no exp. of ax for under the age of 17yrs. So on what basis are you responding? Is it what you think ought to be done? Or based on some sort of guidance?

Dr D: The opinions I’ve given are based in part on guidelines, policies, research publications, clinical exp., discussions with colleagues over 20yrs on similar issues. I have expressed views as a GP too and I continue to work today with many GPs supervising them in this field.

IS: Others who are prescribing?

Dr D: yes in adult practice, I don’t supervise those doing under 17s

IS: do you know GPs prescribing?

Dr D: Yes 2 in Exeter, 6 in local Gender teams, 1 in Cardiff, 4 in Merseyside

IS: you were asked about patients being held back? And the delays to get appointments. Adults don’t have hoops to jump through but younger patients do?

Dr D: yes and great frustration for YPs but causes distress at all ages. A lot of cross people out there. Justifiably so.

IS: GPs assess capacity on adolescents and children automatically as they go. That’s one part of the consent process?

Dr D: Yes

IS: this is based on all info available?

Dr D: Yes

IS: that may include material from UCLH, parents, whole range?

Dr D: Yes

IS: so HW would be entitled to look at this and take into account, wrong not to?

Dr D: Yes we must also must take into account there may have been a time lapse or change in capacity. But ax of capacity must be in relation to the intervention. GA hormones not same as GNRH

IS: Yes but she can look at all the material, actually is obliged to?

Dr D: Yes

IS: Not recording capacity is ok for adults?

Dr D: No, I do it for adults and this should be done in gender practices. Not usually in general practice. Think this is also the case in NHS

IS: So “Ive assessed capacity” doesn’t mean you got it though right does it?

Dr D: No of course not, informed judgement

IS: recording it doesn’t mean its been done or done adequately?

Dr D: I would agree

IS: so important that clinician assesses patient has capacity for the intervention in question?

Dr D: yes I’m sure sometimes done and not documented, good practice where this a controversial decision, essential to document

IS: “good practice” or “prudent” you mean prudent on behalf of the practitioner?

Dr D: I think for the patient and the org. you work for too. Unusual to [just] write down when not been done. But I have no doubt as to the conscientiousness of HW

[Hard to hear but believe Dr Dean says this last sentence despite commenting -vely on her not documenting patient capacity as standard]

IS: In this case no practitioner says they have not worked to WPATH guidelines. Are you familiar with Northern Ireland practice?

Dr D: No

IS: Some might say quite strict? E.g. every adolescent goes through CAMHS

Dr D: yes interesting point given I am saying not an MH issue. WPATH written for worldwide audience. In the UK the 4 jurisdictions have independent policies

IS: WPATH guidelines are said to be interpreted by those in NHS clinics and those in Amsterdam and USA?

DR D: Yes not going to be treated the same in different places but general principles are adopted in my view in those countries

IS: And the experience of the CL clinic is as a General Practice or called ‘family practitioner’ in America providing exactly the sort of service where they can bring in more complex support?

Dr D: Yes similar to UK. Big difference though is that 11% of the patient population at the CL clinic are gender diverse people. Whereas 1 or 5 in a thousand in the UK… but may be greater but people don’t disclose

IS: Exactly, depends where you live. CL clinic is in New York

Dr D: yes in an area that is LBGT+ friendly

IS: Can I assist with an issue the Chair asked? See Bell v Tavi judgment para 22 to 30. In 2011 PBs only available age 16 or older but it changed in 2011 with the Early Intervention study. Given to 12 to 15 yr olds in mid-puberty

Dr D: Yes sorry that was my understanding too. Not all going into the earIy intervention protocol though

IS: 161 patients referred by GIDS for PBs that some YP could be on for up to 5 years from age of 10. So I think that answers the Chair’s question.

Dr D: yes

[IS hands over to SJ]

SJ: You were asked by Dr T about the issue of knowing what are best interests. When looking at best interests, over what period of time do you need? E.g. now vs. mid term vs. long

Dr D: that clearly has a bearing. If intervention decision has no long term consequences than look at immediate time period. But where there are long term impacts of the intervention you do think about BI over time. E.g. reproductive options, fertility

We provide detailed written information for patients to read and consider over time before completing consent process

SJ: Re DR W’s qu’n, you said patients are entitled to make the wrong decision. Where it’s a child or adolescent does that position still hold?

Dr D: wrong decision is in eye of beholder…. Unwise decisions…. Mental Capacity Act applies… 16+ when thinking of fertility, pregnancy…

Gillick competency applies… accepted that ppl <16 may have capacity to consent, albeit this is being challenged by Bell [which is under appeal]

It’s important that competence at <16yrs is considered. Not a process I’ve had to go through in this field. Done so in terms of contraceptive pill for 13yo who was sexually active.

If I was in this situation I would take advice from specialists with YPs

SJ : Ive no further qu’ns.

[Chair thanks Dr D for his evidence and the several times he has attended. Reminds Dr D that case is ongoing and should not be discussed]

Chair: With Dr Kierans tomorrow at 9.30am

[SJ interjects to raise a matter]

SJ to Chair: Your language on occasion when posing qu’ns to Dr D… you described patients as ‘outsiders’. A didn’t want to wait for hormones, B didn’t want blockers, C upset about delays – none of these factors would cause anybody to think they are outsiders.

Dr D has confirmed that many angry, cross people... And you then said, with respect, that they had fallen foul of the system. A was re-assimilated to Tavi….
[cant quite hear next bit]

SJ continues: “Beware the only legitimate team”, Schumer.

Dr K made clear on a no. of occasions e.g. for B, that testosterone didn’t alter psychological presentation. These problems are quite separate and distinct. Testosterone should not be seen as answer to GD.

Concerned I’ve failed to call evidence on these issues if that’s the view you’ve formulated.

Chair: thanks, thats helpful. I did say ‘outsider’ because of the situation of A, B & C but if not good word I withdraw. It was only to categorise together for Dr D to opine. Anyway thank you, I’ll reflect upon that and take it into consideration

IS: I don’t agree with him. The wording is always difficult, I still make errors but nevertheless… GMC say their case is not that Tavi is the only legitimate place for trans adolescents and then there was reliance on Dr K for B … um Dr K is psychologist in NI.

Dr K has not seen any docs in this case save the Bouman(?) reports. She’s not been directed by GMC to review … but she does have Dr Pasterski’s report.

I’m not clear what the position is? Tavi is not the only option? Is the answer the KOI system [Knowing our Identity system in Northern Ireland]? What is the system the GMC say?

SJ: I’ve not said KOI system. GMC case is based on evidence from Dean, Agnew & Klink for MDT approach. GMC has made clear its not against private practice. The question is whether the respondent met the standard for good medical practice.

[Chair thanks both advocates. Hearing adjourned at c. 3.25pm. Return @ 9.30 am tomorrow]