Thread by @tribunaltweets

Good morning from Day 31 of Helen Webberley's tribunal. @Jeeeez17 will be posting tweets in bunches through the day covering the cross examination of Dr Kieran

A reminder that we don't have access to the legal bundle of the case against Dr Webberley (HW) who is represented by Ian Stern QC (IS). Counsel for the GMC is Simon Jackson QC (SJ) and Dr K is Dr Kieran. P stands for Panel member (of which there are 3)

Dr K (AK) is Clinical Psychologist at the NHS KOI Children & YP GIDS clinic in Northern Ireland

Session started 9.34

P: Further docs were received overnight which are AKs response to Dr Baumans report on patients B and C. We also received defence doc from Health and social care board - review of pathways of GIDS

IS So we’re continuing cross exam of Dr Kieran. My learned friend might have something to add after these new docs and I’m happy for this to happen

SJ Yes it's important to discuss these new reports and I feel she shld b able to discuss these before being cross examined on them

P: good morning Dr K. Thank you for returning and preparing your responses. SJ is going to take you through these reports so we’ll start with that now

SJ: First lets go to your report of 7th sept commentary on Dr Bauman on patient B. Under the heading you set out the background to pat B but go on to say “there are a no of emotional problems incl poor self esteem leading to poor functioning”.
How would these affect functioning?

AK: It depends on the extent of distress. You need to look at impact on daily functioning eg on education, social and family relationships. Problems indicate a need for a thorough MH assessment to ensure all aspects of mental distress are being addressed.

SJ: Looking at suitability of treaments now

AK: An assessment needs to be comprehensive including MH assessment eg a reduction in school grades you’d need to look at other possible reasons as there are many possibilities.

AK: Only after exploration can you be confident that addressing correctly.

SJ: When taking a medical history your point is that one assessment isn’t sufficient nor is looking at historical material alone?

AK: There’s so much to cover: development of gender identity, body image, all relationships, MH. background development, history of emotional difficulties, difficulties in function in all areas of life. Also thoughts about transitioning: their knowledge and expectations to..

AK: ..ensure accurate information as they have often received misleading information. And their understanding of the above. All of this. You cannot do this in one session in my opinion.

SJ: Dealing with the developmental history and possible ASD and possible CAMHS involvement. All at KOI have to continue to engage with camhs?

AK: It would help a lot as KOI would work with camhs and look at whether further assessment was need re concentration and whether we’d need to modify how we interact with a patient eg on the presentation of information.

SJ: Would this include modifying re capacity to consent?

AK: Yes, esp attention deficit. You need concise info, short sessions, give it more times, more clarification. So it doesn’t prevent treatment, but u need to ensure you provide info that suits cognitive style & [?ability]

SJ: Regarding realistic hopes of transition eg removing a social skills deficit?

AK: Issues of feeling diff from peers, of inclusion & friendships. They often hope that with transitioning their social difficulties will be resolved.

AK: Some of that can be helped ie what’s realistic here with making physical changes. But if you have ASD transitioning won't resolve all of these difficulties although increased body confidence might help. So social skills training could be addressed.

SJ: patient B has significant MH probs incl sub misuse and self harm.Also a dissociation from treatment and disengagement of treatments impacts?

AK: This reqs an assessment of the history of disengagement and reasons why has this happened. Is it practical eg travel, or a problem of r’ships with staff? How cld you improve conditions to support engagement as transitioning can bring up its own tricky issues that need support

SJ: In psychological assessment, your role isn't to assess their gender identity altho they may need space to explore their identity. But it’s up to them to define that for themselves?

AK: Only they can determine their own identity but there are lots of issues to consider eg their identity might still be in development, their sexuality and the interplay between these. There might be social diifficulties with not fitting in with peers as a girl or boy..

AK: identity could be more as non-binary or gender fluid. They might need to explore what aspects of transition they desire, eg they might just don’t want breasts but not want to take testosterone. It’s about ensuring they take the steps right for them.

SJ: You refer to patients information guidance at Dr B’s clinic? Is that for adults?

AK: Yes, it is for adults. It isn’t common they'd see under 18s (??)

SJ: National and inrternational guidance say you should study presenting difficiculties thoroughly?

AK: This comes from their website I think. If their presenting difficulty is distress w gender this should be thoroughly assessed

SJ: But this doesn’t mean constant assessments recurring but a process at KOI of patients should pass through. Hoops to pass through. So how much assessment is enough?

AK: This is very difficult to answer as each patient is different, has a different history and family history, will be at different stages of understanding of their own gender identity and possible treatments. So it’s very individual.

AK: There are certain aspects need exploring based on wpath; exploring all of these topics is a minimum. You might also need to consider adhd, asd hearing voices etc . And why most guidelines don’t have a set no of sessions so patients don’t expect a set number but a range.

SJ: You say in your experience it is too simplistic to say that problems are secondary to GD?

AK: Young people’s lives are complex with a list of sources of distress, eg bullying, trauma, neurodevelopment, early experiences, problems in the family or trauma. You cannot assume that all of distress is due to GD and you cannot assume that treating the GD will resolve all..

..of distress. They may need other inputs

SJ: Your notes on remote signing of consent. With no direct contact there is no way can you can be sure about consent?

AK: Only by discussion can you sense how well they understand information esp that you’ve relayed to them. It isn’t about getting a signature but about demonstrating they understand the information

SJ: Moving onto 3J re MDTs and WPATH on feminising/ masc hormones: treatment needs to be part of a coordinated treatment incl psychosocial issues?

AK: my understanding is it’s a holistic assessment and all areas of patient need addressing and not just the GD. A network approach of all the people involved with joined up thinking is in the best interests of patients

SJ: You suggest that if you’re working outside of WPATH guidance you should inform patients they’re being treated outside of guidance. How should this be reported to patients and recorded?

AK: this should be disc with the patient and family eg WPATH suggest this but in yr case because of xyz I suggest we do this treatment. Discuss it and make detailed notes. If writing a report you shld add the guidance, discussion and reasonings why particular decisions were made.

SJ: re patient C and your report of 8 Sept. Again re the psychological assessment (which was also covered with pat B) covers assessment of suitability and timing of treatment and an evaluation of their ability to understand

AK: Re appropriate timing you need to consider functioning, stability of MH. They don't need perfect MH but shouldn't be in crisis. They might want to delay blockers cos exams are coming up and they don't want to deal with side effects. So there are lots of reasons

AK: You want to be sure a new intervention is timed properly, that the abililty to understand and capacity to give informed consent. These are discussions to be held over a period of time, assessing their decision making capabilities.

SJ: Re explanation of additional factors incl ADHD. You agree w Dr Bauman’s observation that it isn’t a contraindication to treatment but that you’d want to access further cognitive assessment, and want to explore their impulsivity

AK: Yes, part of ADHD characteristics is impulsive behavior and decision making. You need to explore if decision making is affected this way. That it’s not impulsive and has been considered thoroughly

SJ: Re patient C and the issue of fertility. This wasn’t discussed with the patient but with their mother. You say this isn’t adequate imo? You say if not discussed that this is a material failure of care?

AK: Yes, it’s a failure of informed consent. Fertility needs to be considered right from the beginning even if PBs are considered reversible and discuss the consequent CSH impact at the beginning. Also if you want to preserve fertility this takes a while and needs organising and

AK: referral asap so it doesn’t delay the starting CSH after PBs. So discussion should take place prior to beginning treatment and be sure as starting the treatment pathway leads to CSH in most cases. It has to be discussed.

SJ: You say professional guidance eg wpath and endo soc of 2017 reflect the clinical consensus at a period of time, that these will change but that you shouldn't ignore them

AK: Yes, it’s obviously an area of med development so guidance will change over time. But wpath are clear what factors need assessing, so even if specific pathways may change the broad topics ie covering inf consent and undertaking a thorough assessment, will not change over time

SJ: no further questions at this point

IS begins his cross examination:

IS: I may go back over things we’ve already discussed, and if that’s the case I apologise. Thank you for your reports too. What is your experience of dealing with remote assessments before covid, say from 2014 to 2020?

AK: Like many psychologists we didn't do this routinely. We did do telephone reviews but always interspersed with face to face meetings. It was not a sole method

IS: Are you aware of other countries using online method?

K: ? sure other countries use this method. My opinion is this cld be thorough if using eg face to face with other methods. In KOI online was a mixed experience during covid. Some people struggled with online but others enjoyed it. So you need to tailor the method for each patient

IS: As you're not a medical dr you don’t have experience of starting and dosing medication?

AK: No. but I am part of the discussion process. We have an endocrinologist that does that in our service.

IS: You’re working 30 hrs a week between 2014-20. Was this 5 days a wk?

AK: Over 4 days a wk

IS: There’s no breakdown of your patients avail on the internet. Is there any information?

AK: There’s a small amount of info online on the Northern Ireland website and our leaflet

IS: does this talk about nos? Eg numbers on PBs?

AK: I’d need to access records as this type of information might not be publicly available. We have about 80 referrals a yr. I can’t say how many go onto endocrinology. Also we help/refer camhs with those who might not be referred to endo.

AK: It’s not comparable to the Tavistock as we’re smaller but I do have lots of experience

IS: roughly how many of patients referred are children and how many adolescents?

AK: The vast majority are adolescent. Only quite small nos are under age of 12.

IS: What approx is the number of new patients you see a week?

AK: Approx 1 approved patient per week, at a new referral mtg. A minimum of 1. But other Irish clinics fed into this mtg so it might be more

IS: I’m trying to assess your level of experience as you say you’re very experienced? Have you been to WPATH and Endo Soc conferences?

AK: Yes, I’ve been to both wpath and Endo Soc conferences. I was a member of epath or wpath at some stage but am not now as joined UK society

IS: How many conferences have you attended? Did the Tavistock hold conferences?

AK: I’d need to look at record of CPD. Tavistock were conference events as well as providing clinical supervision.

IS: You’ve not done any research other than your PhD?

AK: No I’m more interested in clinical work and am part of a very small team. I recruit patients to research instead.

IS: Looking at referral nos to GIDS in 2009 14 referrals to adult gids In 20,19 132 referrals. You haven’t been able to see any new pats since March 2019?

AK: KOI had 33 referrals in 2014 and ?53 In 2019. Referral rates have been pretty steady. This is accepted referrals as some are refused. 70-80 per yr is my understanding of numbers. I can get this info for you if u want. The service started in 2014 so was a smaller no that yr

IS: You had 59 child & adolescent referrals in 2018/9. So the maximum you’ve seen is around 300 patients?

AK: I’d rather not guess numbers

IS: But you wouldn't have seen all of these personally?

AK: I would have seen them all at least once. We all meet all the patients at some point on their journey, esp those on physical treatments. For eg I might meet them in the endocrine clinic

IS: So you will have seen them after they started on hormones?

AK: Can you clarify the question please?

IS: You would have seen them after starting hormones?

AK: Yes

IS: What’s the approx no you’ll have seen?

AK: I cannot give you information on my level of contact from memory

IS: You say it’s important not to conflate children with adolescents who are not mini adults. Obviously they all have human rights though?

AK: Yes

IS: So they’re entitled to Treatment just like adults?

AK: Yes

IS: When you say that the brains of children & adolescents are different, are there studies to show brains are different in trans children and young people? (? to trans adult brains??)

AK: Which document are we referring to?

IS: On p4 of report on patient B you say: brains, bodies and identities are still developing. How is the brain developing?

AK: Cognitive abilities are still in development until age 25. Esp the frontal lobes. So it’s not complete until then...

AK: These regulate emotions and deal with making decisions, others perspectives and impulsivity

IS: You mean cognitive development as well as aspects of identity development are still developing?

AK: Yes

IS: Does gender identity remain stable in most individuals?

AK: Many feelings change during puberty. If GD persists or worsens in puberty it is more likely that a gender identity will continue into adulthood

IS: So you have to have assess gender identity and ASD and assess these continuously? But not cis counterparts?

AK: No. You don’t just assess stability of identity but their understand of treatment and explore any factors that might be conflating their gender identity distress.

AK: This isn’t to prevent treatment as the goal is fully supported treatment, having had sufficient time for them/us to explore and address other problems that contribute to gender distress

IS: You’re having a debate here. You have differing views to Dr Bauman?

AK: I’m confused as what he’s said doesn’t match with how the Nottingham centre works . I can’t comment on this disparity. But with my patients I’m not assessing their gender identity as I can’t do that. But they need to understand the options and variety of way to express their

AK: gender identity eg those that don’t want any medical treatments. They must have access to all possible options.

IS: You’re trying to transcend your patients? Do you understand what I'm trying to do?

AK: Things can become polarised into supportive or not. We are supportive

IS: It’s not a criticism of Bauman and their website. Here we have cis people of whom we don’t assess all their issues eg their cognitive processes, autism in order for them to get treatment. Do you understand how TG people feel?

AK: Yes, but we’re assessing treatments with significant risks eg infertility

IS: Yes, but no one would assess their identity?

AK: We don't question that

IS: Talking generally re NHS protocols there are extensive delays and hoops to get through. To misquote G Stein “A trans is a trans is a trans” Why do I need to go through these hoops to prove who I am? How people feel. Is this an acceptable view?

AK: We do need to prioritise the views of service users & we try to include their voices throughout KOI. It’s a challenging dynamic with young people where not understanding their identity is hurtful (hence we support the use of pronouns/advocate in schs/ affirmation essentially)

AK: But we also have to ensure enough reflective space to explore treatments and capacity to consent. It takes time to develop relationships where you can affirm but also question them. I apprec that some may feel it is more a questioning of their identity, which is unfortunate

IS: This transcends KOI but I'm discussing it as a general issue

AK: Yes, but KOI is my reference point

IS: Is there any scientific evidence that shows that KOI results are better?

AK: It’s very difficult to explore as there haven’t been other processes (?). We have followed the staged process of treatment and I’m not aware of other methods.

IS: what about Callen Lorde or treatment in Canada?

AK: I don’t know about CL and cannot comment on Canada

IS: Comparing models of care eg CL in New York. And the outcomes of various models. I accept it’s difficult to do research on these models but surely it’s possible?

AK: Yes, we could assess if there are v different models but I don’t believe there are any available at present and we follow the European and WPATH model.

IS: Do you follow up your patients into adult services?

AK: No. We don’t follow them through to adult services.

IS: It’s not a seamless service into adults?

AK: No, it hasn't been commissioned as a seamless service into adults and there’s no continuation

IS: Do you typically give hormones at age 16?

AK: Yes

IS: When do they go up to adult service?

AK: Usually a referral at 17.5 yrs but they’re not actually seen until well past 18 because of the waiting list. Their cases are kept open until they’re taken up as adults but now if people are stable we refer them to endocrinology service at 18.5 if they’re stable

IS: Do you continue to see them at age 16-18?

AK: Yes, as we want to monitor impact of treatment

IS: To clarify, you’ve not been provided with papers in this case?

AK: Correct

IS: So it’s your interpretation of Dr Bauman's report?

AK: Yes, I’ve tried to raise general points rather than be very specific as I've not seen records

IS: If I say I believe there are issues with your report, please bear this in mind: you didn't have all the information when writing it

AK: That's fine

IS: Doc 24B re pat B: From Dr Bauman’s “report what the outcome has been” Psychiatrist continued the testosterone and discharged them from MH but they had an appt at Leeds. p3 which says “resolution of all distress with physical intervention despite being on testosterone” ??

IS: As you gathered patient B was 16+ when started GA hormones after a lengthy history of being denied affirmation. Denial of which typically causes distress does it not?

AK: Would agree but I’m not aware if their identity was affirmed or not, or whether it was denied by others

IS: Is this typically true in general?

AK: Yes it is.

Panel: I’d like to point out that Dr Bauman wasn’t sent all of the records either in all fairness

AK: Yes, I agree. Not being affirmed would be v distressing for that young person

IS: He felt that he wasn’t listened to. Testosterone doesn’t cure all ills does it?

AK: No

IS: They can still experience distress?

AK: It depends upon all the circumstances. Eg a family that was previously unsupportive could receive help to support the family member

IS: We don't know what would have happened if patient B had not been prescribed testosterone?

AK: Correct

IS: I want to ask you to say “testosterone is not a cure”. What is the treatment for GD if not testosterone?

AK: It’s not the case that testosterone will resolve all distress re GD as it cannot change everything despite its impressive masculinizing effects eg it won't resolve social anxiety

IS So it depends upon the resolution of social anxiety?

AK: We all develop unhelpful mechanisms in order to cope with distress and these often remain even when the original source of distress has ended

IS: no further questions

P: Let's have a quick break and return at 11.15am

Session restarted at 11.19am

SJ: You were asked about yr membership of wpath or epath and I think in an earlier session you said you used to be a member?

AK: Yes. My m'ship ceased in about 2017. I didn’t renew it, not for any partic reason & decided to join the British assoc

SJ: Did you attend wpath meetings?

AK: No. not apart from conference

SJ: Were you a member of EPATH?

AK: Yes, I presented at a conference of theirs in Ghent, in 2016 I think

SJ: I asked about the Tavistock conference and whether this was internal or ext training?

AK: Yes. I would need to look at my records but I reg went to their conferences. I recall attending clinical work (family days and clinics as part of induction) and also 1 or 2 conferences

SJ: Were these international or national conferences?

AK: International I believe

SJ: moving to the reports and whether the assessment process was focussed on identity rather than treatment. Can you expand on this?

AK: Yes, it’s not possible to really assess if someone’s really M or F or non-binary and it’s up to the person to explain their identity. So discussions should be supportive and how they experience this. Is treatment right for them?..

AK: What are the options, the realistic and achievable results of treatment, is the timing right?

SJ: Some TGs aren’t seeking treatment . What proportion in your experience want support or guidance and not physical treatments?

AK: Note that also some do originally want to physically intervene but change their minds. There are all sorts of possibilities. The majority do want to access physical treatments so do progress, either with us or the adult service.

AK: Those who don’t want to access physical treatments were more likely to move to camhs or stay with us a shorter time

SJ: So those who didn't want physical treatments can still access support from KOI?

AK: Yes, we are more than just a physical treatment service, eg we run group work and family support

SJ: No further questions

P: Does IS have further questions before the panel asks some?

IS: No

Panel: I have a profound question stemming from your statement on p8 of your report (c17) It’s usually stated that although it’s recognised that GD isn’t a MH disorder, our experience is that many patients require ongoing support for MH difficulties or relationship issues.

P: I’m a lay person who knew nothing about GD before this started. My understanding is there’s been an evolution in thinking about GD. WHO had gender dysphoria in ICD10. But now it's referring to a spectrum of transexual that now described as gender incongruent, which will..

P: move into the classification of sexual health. There’s been a maturation of thinking here. I’m hoping you can help me.

If GD isn’t a MH disorder and certainly transexual isn’t, then what is it that gives rise to this depression and risk of suicide?

AK: Our society continues to be very gendered and binary, there are societal expectations of prescribed gender roles which are very damaging if they don't follow them. Also minority stress of growing up where you feel that you don't fit in.

AK: When it comes to puberty it isn’t just gender expectations but also physical changes that don’t feel right for you, which can be very distressing. It's a complex mix of biopsychosocial.

P: So a complex biopsychosocial model based upon the gender people perceive you to be, and doesn’t fit you? Whole of society shifts away from the binary and getting away from the binary [ would help?]

AK: Some are v happy within their skin, some only need affirmation and correct pronouns, but others really struggle

P: But this cohort that really struggle with their identity, why do you say that gender affirming treatment isn’t the cure?

AK: Treatment can resolve a lot of GD but the reality is that they’ll continue to live in a body that they were born in, rather than the one of their acquired gender. So they’ll always come up against issues in future, eg around sexual r'ships, medical issues.

AK: So you hope you will be less dysphoric but issues will always arise at some point: certain scenarios or triggers. You’ll always have had the hard life experiences before transitioning which can also have an impact. So GD can still be an issue in the future

P: They also present with behavioural or emotional difficulties in the future. So it’s not a panacea. Follow up into adult services. What is the degree of satisfaction with those who went through treatment and what relief did they get?

AK: I would say that the majority had a high degree of satisfaction if well informed and supported as part of a holistic package. People are delighted with the changes..it makes a massive difference to their quality of life. It’s why I’m so passionate about physical interventions

P: Given that GD is a consequence of societal expectations of a binary world and incongruence for some, coupled with early intervention having a huge advantage in secondary sex characteristics, is early intervention important and does delay cause problems?

AK: Early intervention is important and unnecessary delay can exacerbate distress. But we know for some that GD does not continue. Social changes or physical changes of puberty or developing sexual feelings resolves GD for some. The GD will not persist which makes this v complex

AK: We need to be prompt as soon as the gender identity has been consistent and persistent and able to make informed consent. There are risks with early intervention: it also impacts on future surgery so there isn’t a simple right thing to do in this area..

AK: Which is why it requires such expertise, thorough assessment and an MDT

P: When you were talking to SJ you said the majority of clients generally go on to treatment which contrasts with GIDS where 80% didn't want to go onto treatment. Of those who did have PBs the vast majority progress. Is your experience consistent?

AK: Do you mean consistent with us or adult service treatment in those closer to 18 as we felt the adult protocol was more suitable for them? There is consistency there.

P: Do you have any questions arising from the panel’s questions?

IS/SJ: No

P: Thank you for your help Dr Kieran. Thank you very much for your evidence, time and your reports

IS: Just a point re Dr Butler. He may have been talking about the distinction between child and adolescent desistance? 80% but less for adolescents. We can check his evidence about this

SJ: Dr K is the GMCs last witness therefore subject to finding out her statistics and submitting these down the line this concludes the GMCs case

P: From wk 1 or 2 Mr Jones was going to find out if there were handwritten notes from Mr Stratton. Do you know if anything was found?

SJ: No further records were found after enquiry is my understanding

P: So you close your case subject to these 1 or possibly 2 additional inputs SJ?

SJ: Yes

P: How will you conduct the defence IS?

IS: I seek to raise matters of law in writing this afternoon that arise at this stage. Then should we have an early lunch? I’ll provide the document to you and Mr Jackson so you can deal with them on Mon am. They should take no longer than one day.

IS: Then HW gives evidence (prob 2-3 days of questions from SJ) which will take us to at least the end of next week.

Then Dr Bouman Mon & Tues, then we have Dr Schumar, Patient A, Patient A's mother and Dr Shumer is back on. So dates have been arranged

P: So there are matters of law before calling your client which you’ll finally set out in writing for us? We just want to confirm a few issues. Then send them out. Prepare to argue this afternoon but appreciate that SJ may not be happy with this. So we might proceed

P: Serve this document on SJ and then on the Panel. It has to go through the GMC as per up to now. So confirm you just want 30-40 mins to confer with your client and then send it and start your journey

P: We’ll need to see the document before deciding how to proceed. Is 1pm too early for you IS?

IS: No

P: What about you SJ? Do you want it to be later?

SJ: I can read it and have a view by 1pm, but obvs I don’t know how long this doc is nor how many points it covers so will be unable to assess it now. I can see there are benefits to proceeding this pm but the GMC will probably want to reflect until Mon if more than a short doc

P: Let’s adjourn until 1.30pm then to include a lunch break too.

Adjourn morning session at approx noon

@threadreaderapp please unroll

@threadreaderapp unroll please