Thread by @tribunaltweets

The session is now resuming with Simon Jackson's (QC for the GMC) examination of Dr. Helen Webberley's decision-making re. Patient B who was 16 years old when first referred to Dr. Webberley, in 2016.

[Thread No. 2]

SJ: Can I take you back to p.446 on Patient B. Against background of issue of how possible changes would be managed and desirability of managing them within MDT with specialist endocrinology input...

SJ ctd: You deal with issue of commencement with analogues and then say: 'we could also swap to injections to T as well, but the one big issue is who will do the prescribing, will your GP be happy to do this?' Is this in context of increased dose?

DW: You can increase T, it can be done in smaller doses.
SJ: So it's not resistance to principle of injections, it's just the practicalities of it, yes?
DW: No, it's important balance b/w what patient desires and thinks is best for them and what doctor thinks is best.

DW. I thought gel was better but what I was saying to patient is if we get your GP on board then we this will help when we do move to T injections...this is a way of negotiating and decision making together and that's the way I always worked.

SJ: But this is not a negotiation, and not in context of F2F discussion with patient or MDT, this is not in context of a shared care agreement.
DW: I don't agree.
SJ: There is a further prescription we can see that is without any direct dialogue/meeting with patient...

SJ: We can see now in April a further prescription of testostone gel.
DW: You can see lots of back and forth with patient during this time whilst we get GP on board.
SJ: But do you agree planning of this could have been agreed at the outset?

DW: GPs are anxious about providing care for patients. I tried to get GP on board to help.
SJ: But with this patient you made statement that service you provide is akin to a GIC but you do it more quickly. There is a missed opp to include specialists; your dilemma was cost...

DW: I don't think having consult with any of the people Dr Klink was talking about such as occ therapists, paed endos, psychotherapists - all this would have had an additional cost to the patient. The best thing for this patient at this stage was me, patient, mother and GP.

DW. I don't accept this was a missed opportunity.
SJ: In terms of taking on a psychologist etc to help the patient, to deal with competing pressures on patient to come to terms with the medical issues and impact on patient, the stresses and strains on patient psychologically..

...and socially, that is what an MDT would have provided.
DW: I'm not seeing stresses and strains on the patient. I'm seeing a patient asking for more Testosterone and saying there is an improvement. Had tried suicide.

DW. Patient had said CAMHS was useless. For me at this stage to say, the cost will be this to discuss the stress you might feel if you don't get injections from your GP would have been unacceptable.

SJ: p. 445 "the physical changes that haven't changed for me (ie. lack of masculination, i'm still being misgendered) are causing me stress", said Patient B. I'm suggesting management of that anxiety, and if we do this the cost is X, the patient and mother had anxiety...

IS interjected - what is causing the anxiety? Is it lack of progress or GP not complying?
SJ: It's a combination of managing the anxiety that was present and GMC says it would have been better to manage this anxiety within MDT as Dr Klink outlined?

Panel Chair: The question is whether you properly managed Patient B's anxiety at this stage. Can you answer?
DW: Broadly 3 options. Could have referred patient to counsellor or psychologist to manage stress of practicalities when to apply gel, he wanted quicker masculinity change

DW: And he wanted injections. What I did do, is say 'hello patient B, I hear you have had highs and lows. I think it's best you have PB injections to reduce oestrogen'.

DW: I did not choose option 3 to increase his dose, didn't refer to MDT for psychology bc I didn't think they could help this particular stressor, but opted to contact GP to get them more involved.

We are now moving onto Patient C.
Chronology first.
SJ: Within report of Dr Klink, p.149 of bundle [I don't have this], an entry in Oct 2016 this patient contacts or emails GenderGP setting out history of patient.

SJ: A 10 year old patient living as a boy and going thru puberty. A process of communication with response from you, DW, expressing concern about difficulties patient had been experiencing. A series of emails that led to...

SJ: On 8th Dec, a note from you, DW. You referred Patient C to Dr Pasterski, who soon after saw Patient C. And in Jan 2017, Dr Pasterksi reports...
DW interrupts, to add details.

DW: In December I ran joint clinic with Dr Pasterski.
SJ: Would you accept that this joint meeting would be the kind that is more of an MDT situation?
DW: 1st meeting with patient, there were 3 people. 2nd mtg family therapists saw him for 5 sessions. Then he saw Prof. Butler.

SJ: Would you agree that meeting with Dr Pasterski (psychologist) was analogous to MDT with people with different expertise together?
DW: Yes.
SJ: Was this an assessment of whether patient had long standing pattern of GD?

DW: Language is always difficult. Long standing issue for the patient was gender incongruence. The actual taking steps to change gender appearance was fairly recent. His GD was not apparent. He wasn't showing distress at delay bc his mum had intervened.

DW: He wasn't suffering GD. Patient referred to GIDs July 2016, mum said long waiting list, so sought private care whilst on GIDS list.
SJ: Is that an example of using other mechanisms to help children deal with stress and anxiety associated with their gender incongruence?

DW: The family wanted to explore his gender incongruence. Mum wanted to explore what was going on in child's earlier life in case there were issues. So this MDT-like meeting with Dr Pasterski, her specialism is out of my reach, to consider psych issues.

SJ: If we look at Dr Pasterski's report, p. 192, I won't read out for reasons of sensitivity, but one can see what a patient is saying in relation to various issues as to how the patient identifies as a certain gender...

SJ: The final para talks about gender presentation and taking steps to change it, but are there things he says that raise questions about how he was viewing his identity?
DW: I'm not entirely sure what you mean but I'll try to answer..

DW: Because of the problems transgender people face in society, sometimes there is another reason instead of a more challenging social reason, for their gender incongruence. So very often families say do you think it's bc of this or that, can we explore it...

[DW a bit difficult to follow but think is saying that it's society's lack of acceptance of trans people that is causing the distress].
SJ: Patient's statement deals with primary statement of physical gender. But there could be other reasons for this patient's g-incongruence.

DW: This is an example of puberty blockers being used well - Dr P said this patient is good candidate. Patient talks about difficult gender history, bits of the body that should be cut off or should or should not be there - these are typical 'gender identity expressions.'

DW: As Dr Pasterski says PBs will help give the patient time to 'say, yes I still don't want female puberty to start, I'll have another injection' or 'I'll see what happens when female puberty resumes'. This patient had real issue with chest development. A good candidate for PBs.

DW: It's difficult to discuss issues of discomfort with patients without PBs because pubertal development causes gender dysphoria. The more puberty continues the less able they are to access gender affirming care or puberty suppression.

SJ: I want to return to the document yesterday to do with Prof Hindmarsh's complaint. Series of bullet points saying 'I do not understand'. Last bullet a brief statement I want to look at you in context of assessment.

SJ: "Psychiatric processes are unnecessary, paediatric endocrinologists are unnecessary - transgender health care has changed" - your statement. One of the issues I have put to you is that the relative brevity of your psych assessment of patients compared to approach adopted

...elsewhere. You have rejected that approach. But with Patient C you involved Dr Pasterski to assess this patient with a view to commence blockers.
DW: Yes.

SJ: You recommended Patient C is a good candidate for puberty suppressing. Criteria under W-PATH guidelines needed to be met and you said it had. Patient had demonstrated long lasting GD with increasing intensity, has worsened with onset of puberty...

SJ: Is this the basis on which you felt the patient would have time, on PBs, to think? What about nuance to presentation of gender identity, is that something that would fall into category of issues to be explored going forward separate from any decision to prescribe PBs?

DW: You said my reports were too brief, which led you to look at Dr Pasterksi's report. There is no guidance that says there is better outcome if you have assessments lasting this long or more frequently. Any assess. of a person's needs or diagnoses if you like shud be relative.

DW: I guess we are moving onto question of ADHD alongside Gender Incongruence - we need to be sure not to force assessments. We need to tailor care and assessment, and when I say assessment i mean of patient's needs...

... rather than ticking boxes to show what has been explored in patient history.
SJ: The reality of so called tick boxes and we have just looked at concluding para of Dr P's recommendation and Dr P in order to recommend suitability for PBs would need to establish criteria...

...from W-PATH was fulfilled, yes?
DW: Yes.
SJ: But the guidance says there needs to be time to look at all this. That short para I quoted from Hindmarsh correspondance indicates your approach to treatment of this cohort is...

...driven by patient wishes, reduce the amount of time for investigation, and not include psychological input or psychiatric assessment.
DW: I am not sure I suggested there was no guidance but there is no evidence there is better outcomes if you have this many sessions ...

SJ In fairness you did say that.
DW: I said psychiatric assessment was inappropriate. We must move away from thinking that gender issues is a psychiatric issue to be assessed though there may be separate psychiatric illnesses alongside.

DW: The issue is that Gender dysphoria doesn't go on hold during assessment and it's hard for patients to endure assessment processes that go on for too long. It's a tailor made approach. I strongly disagree I just give what patients want.

DW ctd I give them what they need, according to my expertise.
SJ: In terms of involving Dr Pasterski for Patient C, what was the driver for this? Was it the age of patient?
DW: I want to move away from concept of assessment.

DW. I want to look at what patient was thinking and wanting. In my practice I don't use word 'assessment'. "I hope we will find you someone to talk to who has experience in gender issues and the other issues" - this was my response to first email Mum had sent.

SJ: Re Patient A too, you felt Patient A didn't need 'assessment' - were you using Dr Pasterski to give you the mean to start prescribing?

DW: This patient A had long standing persistent idea of their Gender Identity. [Doesn't mention Patient C].

SJ: Turns to psychiatric history of C. Has dyslexia and struggles with auditory processing, potential ADHD (not diagnosed but Mum thinks). Should this not be part of the support package that I suggest would have been available in an MDT?

DW: ADHD not a psychiatric illness, so need to be careful. If there is an issue of another variable or things about their lives that might be related medical issues but what Dr P said after 3 hours of discussion, the patient was polite, engaged and reasonably able to concentate.

*concentrate.
DW: There were no concerns that this young chap had any deficit to his attention or capabilities.
SJ: If there were any issues associated with his attention deficit doesn't this come into issues of ability to consent?

DW: Yes. There have been patients with neuro diversity issues, autism or autistic spectrum and they pose real issues. You can put them thru lots of counselling etc but making decisions is very difficult. With this patient no issues impacting capacity to consent.

We are now going to break for lunch.
SJ wants to move into further issues of consent re. Patient C after the break.
Adjourned until 2pm.
[End of Thread 2 and my fingers are suffering!]