Thread by @tribunaltweets

24th September resumed at 4:20pm to hear witness- Dr Schumer (DS).
Witness affirms he shall tell truth.

Chair - Afternoon and introductions. See how far we get, but we'll look forward to seeing you as early as possible on Monday afternoon Dr. Shumer.

IS points to DS's C.V. and asks for him to give us the highlights.

DS- N.W. Uni. Medical school Paediatrics- Vermont. Paediatric endocrinology at Boston. Harvard school of public health - Michigan.

DS cont...Child and adolescent gender clinic -we provide care for gender non-conforming children and adults.

IS- Clinical interests-sex specialists, research o gender dysphoria, various institutional positions what role do you play.. fellowship curriculum on pdtc endocrinology

continued..IS - Medical director at the comprehensive gender services. Organise educational sessions related to gender identity. Ethics commt 2018-present at paediatric endo soc.

DS- Investigational review board -bodies that review research -suggest modifications to proposals.

IS- Book chapters -pg 6. One of the book chapters with Norman Spack who was at Boston children's Hospital-
DS- Medical director when I was training there.
IS- Approx how long have you been dealing [with this area]
DS- Residency on graduation in 2012, then Boston under N. Spack.

IS- August 2021 -doc pg,4 para 5 3/4. 600 patients received gender care - you've personally evaluated 300 patients with gender dysphoria.

DS- Model borrows from WPATH and Endo Soc. Transgender young people with gender dysphoria -pubertal suppression and hormones.

IS- I want to ask you please, relating to this statement, 4 areas.
1- prescribing -whether or not it's the sole area for paediatric endocrinologist to prescribe?
2- How GP's prescribing works in America?
3- Assesments- how that works?
4- multi diciplinary teams (MDT's)

IS- Age of starting pb's/hormones. to give more assistance to the Tribunal.
In bold -a variety of specialists -not just endocrinologists.

DS- I understand why ENdos were at the forefront. Dutch Ds were noting going through that wrong puberty made it harder for them as adults.

DS- Endo's had experience with medication for precocious puberty. Analogues for surpression. Use isn't particularly complicated. Routinely prescribed for other reasons, eg. birth controll or low testosterone levels. Learning how to prescribe isn't challenging.

DS- The most important thing is that a practitioner should have interest in working with Transgender and gender diverse youth. Champions in the States are adolescent endocrinologists, GPs also working in the filed. that's a positive thing.

DS- A lot of endocrinologists are not well suited -adrenal gland or thyroid experts- they will be lost or uncomfortable addressing trans youth.

DS- Frankly many of the best providers -I say best as they are affirming - are not endocrinologists. Their passion influenced them to learn to use these medS.
If I was referring patient out of my area these would be factors I'd be looking for. Not necessarily that they're endos

DS- There are GPs who's practice provides this care to patients efficiently.

IS- Is there any bar to prescribing these medicines?

DS- No. There is not.

IS- Are there qualities in GPs which makes them suitable for this work?

DS- There may be skills. A GP may have a quality potentially that they can maintain a relationship with the patient and take care of the whole patient in addition to their gender needs.
When the Dutch model was proposed, youth with GI disorder were considered as a rare condition.

DS- There is now a different prevalence of gender identity - one out of every 200 in my Country in a recent study. So common- as we have seen- that then becomes the purview of general practices.This kind of care will continje to shift further through primary care.

IS- 4000 on a waiting list in the UK.

DS- Not surprised.

IS- What constitutes a multi-diciplinary team? MDT?

DS- The goal of an MDT is, is a way that a patient is receiving all their care, assessments, managements that they're getting - all the care they need on their journey.

DS- This might include school staff, community liason...Composing an MDT can vary.
It shouldn't be understood that the people who organise their team should be happy with the way they're delivering their care. (not sure if that makes any sense- but that's my notes)

IS- This is like a 'hub & spike' type of operation.

DS- Referral had to come from patients community health association. Perform tests and lengthy meetings. Then recommendations /offers to see medical specialists.

DS- The positives and the negatives?- Negative was that patients often felt they were jumping through hoops. But in my mind it was overkill. The patient would be deteriorating in their mental health.
They knew from the beginning that for eg, hormone blockers or testosterone was..

..DS-..something they wanted to talk to their Dctrs about, and that conversation conversation leading up to that point was not helpful. I wanted to remove some of these access barriers to care.
That they don't need a second referral from a specialist...

..DS-..Triage includes what the patient [has in mind]. Paediatric endocrinologists would see patient about options and the side effects. If there were unmet psychological needs we would refer to specialists in their area, but that wouldn't necessarily effect their care.

IS- Single telephone call for triage?

DS- Yes.

IS- You've been doing that for about 6 years now?

DS- Working well for us. I feel confident and competent that I can turn to specialists help when needed.

IS- At iii) in your report, you say not restricted to [ 16yrs].

DS- Historical changes. I believe 16 was the age of consent in Netherlands at the time. Goal was to have some idea that a young person could make a decision. This was pretty novel.
Several things have happened that have made us reconsider -...

...DS -..The process of developmental progress - [so, with a patient ] Testosterone is known to be potentially very beneficial but we're waiting for a date on the calendar.
Also the period of time on puberty blockers and effect on bone mineral density.

Still DS - It's become clear to many children and families that they will prefer to live as more masculine, for eg, as they are watching their peers go through puberty.
These are tools in our tool kit now that we can use them when the need arises.

...DS- There is no reason to use drugs before the age of normal puberty. Average age of puberty is 11 for girls and 11.5 for boys. For insistent persistent patients- it becomes more reasonable [to consider treatment earlier].

IS - It's 5pm. Aware of time.

IS talks about options to get hold of Doctor Schumer on Monday. It is agreed that he joins the tribunal again at 1:30 on Monday.

SJ to DS- Is the document - Structure and stages, is that set out in a way that patients are made aware of?

DS- It's ...more on the website. I can refer you to the website. Send a link to IS.

Chair winds up. Monday will begin with Doctor Pasterski at 9:30.