Thread by @tribunaltweets

Good morning from Manchester and Helen Webberley (HW)'s tribunal. @Jeeeez17 tweeting in blocks through the day which is expected to be cross examination of her defence witnesses by the GMC's QC Mr Jackson (SJ)

HW's QC is Ian Stern (IS) and P stands for [tribunal] panel

The first defence witness is due to be Dr Vickie Pasterski (VP) a psychologist and this afternoon we're expecting Dr. Daniel E. Shumer (DS) a pediatric endocrinologist in Northville, Michigan, USA. We're currently running slightly late for a planned 9.30am start

Start at 9.52

Chair: Good morning all. Apologies for the late start due to Manchester rain
Panel have received Dr Boumans comments GMC expert witnesses (is d57)

IS: confirmed the expected expert witnesses and hope to complete both today. D29 has been produced by VP

C: Does that mean Dr Bouman could attend tmrw?

IS: Yes, I think so. He has to be completed on weds 29th or we’ll have a long wait for him to be free to return.

[We're waiting for VP who need to download an app]

VP affirmed at 10am

Chair: Good morning. Thank you for attending. Introduced VP to panel and QCs.
IS: Can you take up your 19 Aug statement, d29?
VP: It’s that one is 11 pages
IS: Have you signed it?
VP: Yes. I confirm they are true and complete to the best of my belief

IS: Covers 3 aspects of pat C assessment. Some psychological input into patients A, B and C You’ve commented on Dr Agnews statement re you.
VP: Confirms

IS: Your CV registered chartered psychologist, gender specialist, degree and Masters in US. PhD in London. Post doc at Columbia and NY State for 2 yrs. Recent posts summary as affiliated lecturer and clinical research psychologist in Cambridge UK...

IS: ..From 2008 are a consultant psychologist with a private practice at Harley St. You also supervise Masters and PhDs?
VP: Yes

IS: You were a module developer at The Laurels in Exeter. What did you do here?
VP: I was contacted by W Jackson to provide teaching on gender development so that the team could be singing from the same hymn sheet. Aimed to provide training over 2 days...

VP:..Basics on gender development conceptual framework.
IS how long have you been involved in gender incongruence?
VP: since 1995

IS: bp2 is a report on pat C already in records, bp3 is a letter dated 23 Nov 17 to the GMC in response to their request for responses. The tribunal will have read that. Do you wish this to stand as your evidence subject to cross examination? Confirmed by VP

SJ: Good morning all. Looking at 19 Aug 21 report dealing with your experience as described just now. [lots of background noise]
You’ve been involved in gender care since 95 as a trainee and professional with multiple MDTs. Also added about not just Columbia but also the..

SJ..psycho endocrine clinic at NY State uni. Would you accept that acquiring training is very important?
VD: Yes
SJ: training can be acquired many ways? Would you include academic study?
VP:Yes

SJ: But in the absence of a formal course do you agree that it would be important to identify who is practicing in this area and study how they work? Those better qualified than yourself?
Y Training from others is important

SJ Would you accept that there are a no of different roles you can play with individuals with TG issues and some are more complicated?
DS Yes

SJ Your academic and clinical practice shows just how specialist this area is?
DS It can be.

SJ Tribunal has to regard the people involved in prescribing for TG youth and adults. In the context of TG care, there are 3 important elements. Assessment, medical treatments and provision of ongoing support to assist with progress and development

VP Yes, re the 3rd you could offer the support but it’s up to indiv and families whether they take ongoing support or not
SJ Isn’t there a distinction between prescribing for adults and adolescents?

VP No I don't think so once puberty has started. Once in their gender role. No difference between a16yo and 40y old imo
SJ Do you accept that there are separate skills for assessment who presents with comorbidities? Dysphoria with gender incongruence?

VP Yes, but you need to distinguish between diagnosis and ensure no contraindications to treatments. Doesn’t need prolonged assessment.
SJ Prescribing?
VP Please repeat the question
SS Prescribing involves a level of expertise?
VP Yes

SJ Support may or may not be accessed, but I suggest that when dealing with peripubertal kids and when to start do you agree that there’s a greater need for support during the early phase?
VP All should be given support. No support is given for pre pubertal...

VP Guidance re identity is clear. Not before Tanner 2

SJ Where a patient presents with GD consequent to gender identity one has to analyse whether prescribing or whether there are other issues that need addressing?
VP Where needed, yes

SJ Whether assessing and prescribing, would you accept that it's important to have relevant experience b4 prescribing?
VP Yes, but everyone has to start somewhere.

SJ After training and gaining support from others, is it important that b4 one takes looks to c what peer review or support you might seek to support you that you're prescribing within ?
VP If they're qualified, they're qualified.. You don’t need to get support outside normal

..professional development

Oh.. it's been a long day and as there's no public session tomorrow I'm going to enjoy my chips and a beer and write the rest of today up tomorrow

SJ Although qualified isn’t partic expertise needed?
VP Yes, that’s why there are clinical guidelines

SJ But with the very young, isn’t it important to seek advice or supervision?
VP It varies per individual. In straightforward cases not necessarily but yes for complicated cases

SJ Re MDTs. Do you recognise an advantage if a patient is referred by a primary care Dr to an MDT, the benefit is those with relevant expertise can provide some element of care? Where all specialists can contribute?

VP Not all cases need all inputs, eg they’d need either a urologist or gynaecologist. You call on relevant clinical input
SJ You were identified as having particular expertise for assessment
VP Yes

SJ Another important person is specialist endocrine expertise?
VP It depends on the presentation of the case

SJ Where a patient has entered puberty very early and an age inside of clinical guidelines wouldn’t this trigger this is at the frontier of care and I should get expertise here?
VP If precocious puberty it's very clear you’d refer to endocrinology

SJ Much focus of the issue is moving from age to stage. Do you accept there comes a time when other issues become relevant, incl cognition, even though treatment might be indicated on purely harm reduction basis?

VP It’s a lifelong developmental process so you provide support. Importance of harm reduction as delays to treatment cause increased distress

SJ Re harm reduction, do you accept that you need to look at other possible ways to manage distress?
VP Yes, you discuss with patient and family
SJ Prescribing shouldn't be seen as the only tool for treating distress?
VP Rephrase the question please?

SJ What are the options, not just medical intervention, to reduce the risk of harm?
VP Not sure how else to do harm prevention as the accepted treatment is medical intervention. I don’t agree there's another treatment.

SJ It’s about the timing of prescribing and not just not prescribing per se?
VP It’s very clear when to prescribe. Understanding, family support, no contraindications, Tanner stage 2. All of this is laid out. If they fulfil the criteria it’s counterproductive to suggest ...

VP..you need a long disc re prescribing. Its very simple to determine whether to prescribe
SJ Do u not accept that it’s important to consider whether a child can consent? That they’re Gillick competent? Therefore age and development may be a contraindication to early prescribing?

VP That would present a difficult situation that I’ve never come up against. Only case I can think of was a case of precocious puberty in a girl with Downs syndrome. Team struggled to follow wishes of mother who didn’t want to intervene. But I’m not sure it’s relevant here

SJ Don't you accept that every case requires an evaluation of the implications of what may become lifelong treatment?
VP You have to establish that they understand according to their level of development. It’s not a contraindication when they start that they don't have the..

VP..cognition of a 25yo; if for their age they can understand the implications. It’s age-related understanding that allows prescribing. It’s not that they understand it how an adult would understand it. They’re in a lot of distress ...

VP ..It doesn't mean we don't go ahead with treatment for harm reduction. That question is not relevant
SJ I’m not saying they need 25yo cognition. Patient has to have a sufficiently full understanding of the implications of the treatment that’s proposed?

VP What do you mean by fully?
SJ The risks, dangers, fertility. Has a full understanding of the consequences
VP What do you mean by full understanding? There are different levels. How is this relevant?

SJ I anticipate you’ve been following the Bell v Tavistock case? And established case law re Gillick? The test of competence passed re consent to treatment?
VP Yes I'm familiar. You must have consent

SJ Yes, but consent is more nuanced. Are they competent? Parental consent may be important in life saving situations, but in these cases treatment should not proceed without informed consent
VP Yes. Consent is always assessed. Competence to consent is assessed

SJ Is it important to record this?
VP Recorded in writing or..?
SJ Recording the process
VP It’s implicit in going forward to treatment. I wouldn’t ask someone to sign consent to take blood pressure medication

SJ There’s a big difference with blood pressure treatments and blockers or hormones, no? They’re on completely different levels? You obviously assess capacity and related consent, and record?
VP Yes
SJ I put to you whether you have capacity to consent should be recorded?

VP I would agree with that

SJ Pat C is the focus of your involvement, para 8, re providing a diagnosis. “I can confirm HW consulted me for specialist involvement pat C and the development of his gender identity”. Can we underline, what is the particular experience that you..

SJ ..bring to making a diagnosis?
VP I provide a diagnosis and discuss the process of of transition, implications and whether there are any contraindications to going forward
SJ Your expertise is the required expertise?
VP My level isn’t always needed, ie for 13 y olds

SJ You as a chartered psychologist bring the required skills to carry out assessment?
VP Yes
SJ Within p10, correspondence with significant others: you had a dialogue with the family. What does significant others mean?
VP Family

SJ Not school or others with knowledge of the patient?
VP Yes, that’s standard practice
SJ Is it an evidence based exercise? To gain wider info re background and development beyond the family?
VP Can you rephrase the question?

SJ Are there other sources of information you regularly use for background info?
VP Could be care coordinators. For young people I regularly ask for letters of support eg from Cadets. But we only ask if patients give consent as it would be unprofessional to force them to disclose

SJ Looking at the nature of the process of getting more information, how do you go about it?
VP If someone has MH difficulties I would ask for records, letters from MH specialists, letters from patients re assessments they've had

SJ I’m not sure if it's referenced. What additional sources did you have for pat C?
VP I cannot tell you without access to the file

SJ Re 8 Dec and 21 Jan reports, is there a structure to your evaluation and assessment?

VP Yes. In this case 90 mins meetings in Harley Street. Inviting them to provide background info beforehand. Ask for narrative of their development. Primary presenting complaint and their goals, how to move forward, possible options. Discuss and make decision of how to move..

VP ..forward, could be PBs or cross sex hormones
SJ So possible options rather than a sense of agreement at the first mtg?
VP Yes, present all of the possible options. There aren't that many
SJ Re individual identity, part of the analysis is the strength of his identification?

VP Yes, always. This is my assessment
SJ Isn't there an evaluation of this statement?
VP Can you rephrase again?
SJ They may have a perception of their identity. You consider how consistent this is with other information?
VP The information comes from them themselves generally

SJ The other information you collect. This history is part of the evaluation as well as individuals and family’s history?
VP It differs from person to person. Some cases people don’t want to include others as they’ve already socially transitioned and don't want to bring others..

VP ..into this. It’s very individual. It becomes evident in whom they're involved on a daily basis. If there’s MH issues I would certainly ask for letters. In which domains have they socially transitioned already? Depending on their preferences I may or may not ask for support

SJ But that involves your expert assessment on whether to look outside?
VP It would be a breach of confidentiality to assess outside of the circle they’ve provided

SJ You may not ask for outside information?

VP Exactly. Eg if a diagnosis is made and there are no contraindications, I will suggest a treatment and how they go forward. Cannot ask every individual in their life eg a teacher who doesn't agree with transitioning. It's relevant to have other info re identifying possible..

VP ..problems in the future, eg in those not yet transitioned at school or work. I don’t give a lay person sway over a person's identity
SJ I’m not saying you would
VP Letters from family friends, schools, religious leaders. What’s their status, goals, obstacles, who they..

VP ..need to discuss with? If they want to include another person in the process I would include this, but if a family has started at a new school or college I would not out them

SJ In p?17 you conclude by saying I've investigated all relevant for diagnosis, discussed the possibility of comorbid adhd and they might want specialist assessment. Were you flagging up this might be something they should consider?

VP Yes, we agreed at outset they might pursue specialist assessment
SJ On p19 it’s not compatible if diagnosis was made. Shouldn’t an assessment be part of ongoing support and care?

VP Not all want to proceed. If adhd would make problems with compliance I would ask for specialist support. But if not, I would leave the decision to the patient and family and not withhold treatment

SJ Look at p22. You refer to questionnaire p171. Under the GI subheading, is this a document provided by HW?
VP Yes How do you feel about yourself? “I feel a bit in the middle. I see myself as a man sometimes, I see myself as a man with makeup on”

SJ Is that a statement you'd want to evaluate and make a more nuanced assessment of?
VP I would have discussions. But if they see themselves as a man, that’s it. There’s nuance as to how they see themselves. Being in the middle, their physical body not embodying their identity?

SJ It’s June 2016 and he was dressing like a boy?
VP Sure. It’s a young individual
SJ Looking at the section ‘What will you do if progress/treatment doesn’t go as you hope?’ Pat C says “I'm terrified of injections. If I can’t do it…” I’m not going to mention what’s written...

SJ ..next, but the panel can read the rest for themselves. As a psychologist, is this important to how the treatment plan should be managed?
VP In that the patient is afraid of needles? This isn’t a contraindication. We find other ways

SJ Please don't be so defensive. I’m asking how treatment is to be provided. Injections are worked out during treatment, so is this something that needs to be considered? Should it be flagged up as something to be considered?
VP I don't think so

SJ Presumably this is all recorded?
VP I take notes, audio recordings
SJ This is HWs? She’s the source of the information?
VP Yes
SJ All I mean is whoever has this information needs to factor it in.
VP Yes

SJ Pat C said “I think I'd like counselling” when asked about possible further support. This should be considered, no?
VP Yes, it’s offered. It was in this case
SJ If you were aware of this, was this something you’d recommend seeing this statement?

VP Yes, I offer contact details of those I work with regularly. It’s standard practice and is what happened in this case.

Short break for 15 mins to 11.20am
Return 11.24
Chair: Issue with not being able to see VPs face cause of delay

SJ Looking at Bp2, VPs report. Do you have it? Part of your witness statement?
VP Yes, I have it
SJ Within it you set out the background to you getting involved. A delay in being seen at GIDs in London, so seeking private bridged support. Was this your understanding, that...

SJ ..it’d be temporary support until the patient was taken on by Tavistock?
VP Yes, it’s how this would go forward, always
SJ He was at tanner stage 2. Was it to be confirmed by physical examination?
VP Yes, or by report

SJ Under psychiatric history u said been diagnosed with dyslexia and struggles w auditory processing
VP I used “reportedly” as this suggestion was by the mother. This didn’t appear to be a problem in my 3 hrs of assessment. It doesn’t mean they’re incapable of auditory processing

VP I used “reportedly” as this suggestion was by the mother. This didn’t appear to be a problem in my 3 hrs of assessment. It doesn’t mean they’re incapable of auditory processing

SJ Shouldn't this be picked up regarding capacity to consent? They have to sign quite a complicated consent form and need to be given info re risks and benefits. Doesn’t the consent form need to be tailored according to their abilities? If it's reported shouldn't it be clarified?

VP No. I determined they were able to consent
SJ To what? If patient is to be treated with PBs or hormones, were those issues something that needed to be flagged to the mother as possibly affecting capacity to consent in this patient?

VP I thought them capable. I suggested they could go on. There’s no evidence to suggest they shouldn’t start treatment if there were no contraindications
SJ Do you not accept that where a child is being asked to consent to this treatment, that this consent process should...

SJ ..take on board any processing issues?
VP Yes, and I covered this in my report
SJ Do you not accept, possible consent issues would need to be revisited in this context?

VP No. If someone needs specialist assessment, referral must come from a GP and be agreed by the patient. We can’t force the patient into expensive private referrals for specialist support, especially in terms of harm avoidance
SJ You flagged up ADHD...
VP The short answer is no

SJ Can I finish my question. My focus is on consent. That those need addressing in the context. Can they understand and absorb the information necessary?
SJ They could
SJ They should?
VP Yes, they could and should

SJ This is a dialogue and conversation that prescribers should have with the child?
VP Not necessarily. The prescriber can trust in my report. I make a diagnosis and recommend for treatment. Mine was PBs in this case. Then standard consent for making prescrips for med treatments

SJ Within dialogue in Dec and Jan, this wasn’t to be deemed as giving consent to these particular treatments? It was for HW to do final consent?
VP Yes
SJ HW should have a dialogue with child to make sure they have full understanding of the implication of treatment?

VP Yes, of course
SJ This dialogue should make HW sure that the child understands fully? Eg be of sufficient intelligence and opportunity to ask questions?
VP What do you mean by fully? Is it quantifiable?

SJ I’m looking at Gillick phrasing specifically. For all types [of treatment] is there sufficient understanding and intelligence to understand?
VP Yes, I would agree
SJ I suggest that process should be recorded?
VP How do you mean?

SJ It needs to be recorded so one can review how the process was undertaken? An audit trail as per all consent?
VP Yes. Although I should qualify that I’m not a medic so I don’t work with consent from a medical position

IS There’s been a whole series of questions on what a Dr ought to be doing. We should ask future drs on this. Can we move on?
SJ He will know that HW didn’t have the dialog with Pat C. She’s an experienced psychologist with relevant experience

P Think you’ve asked a number of questions . You could be going beyond VPs expertise and I understand why. Perhaps now move on to other matters?

SJ But she offers her view on prescribing practices? Yet I note your comments. Back to the report by VP, can see re pat A in p26 that patient is on PBs by GIDs. You’re expressing an opinion on their decision?

VP They have a policy on not prescribing cross sex hormones until age 16 which is too long being on PBs. Its outside standard prescribing for TG healthcare
SJ How do you manage acute distress, and at what stage and how long you’re on blockers? Is it always part of these cases?

VP Yes, it should be part of discussion
SJ You conclude in p27: balancing risks and benefits, the short term use of PBs is endorsed by most Western countries. What do you mean by short term?

VP [..] say never longer than 24 months. So between 6 - 24 months. This is generally enough time to assess whether their ready to take the next step
SJ But HW was going to put them on PBs for 4 yrs? The USA give implants that last 3 yrs? Where does 6 months come from?

VP Outside of TG care, prescribing of PBs is part of an ongoing treatment where there’s continuing assessment if they’re ready for the next step. It’s completely different in TG care where no support is given but they put you on these drugs for years.

SJ You’re not saying there’s no support within GIDs process?
VP They get very little support from GIDs. Appointments of 60 mins are regularly 18 months apart. Essentially they’re also discharged from CAMHSs once in GIDS
SJ No further questions

Chair: explains processes of tribunal to VP
IS: Please explain your understanding of an MDT
VP I’ve trained in many. I prefer to use interdisciplinary team, where people bring their own input to the team
IS Regarding consent and whether there was a bar to patients A and C?

VP They had the capacity to consent. They gave consent. I don’t know what you mean?
SJ In relation to consent, we know there's a document signed by the patient and parent in all 3 cases. Do you record capacity to consent?

VP It’s implicit in my practice, but I now ask explicitly and get them to sign it. And they get the opportunity to edit the report, the report comes from them too. From my assessment
IS Did you see anything in the records re poor assessment?
VP No

IS And the appropriateness of prescribing? Re pat C, tread carefully with language? Is there some sort of mental disorder or problems?
VP This doesn’t negate capacity to consent, although it can have an implications
IS How common are auditory processing issues?

VP I can’t say re auditory processing issues, but 10% are neurodiverse and many have dyslexia.
IS Do you have experience with these conditions?
VP Yes, but auditory processing was only brought up by the family
IS What do they mean?

VP I’m not an expert. It can have an impact. Remember it wasn't a formal diagnosis
IS Would you suggest a diagnosis if this was a real issue?
VP Yes, and I include a translator if English isn’t their first language to establish consent
IS No further questions

P I’m very much a lay person on adhd but one prev expert witness has said these kids can show emotional lability, concrete reasoning style, and impulsive decision making. This cld be important for capacity. So if there’s a suggestion of adhd clearly y’d want to take it seriously?

VP Yes. I determined they could consent. I had no evidence they had any of the symptoms you describe. And suggested they might want a formal assessment
P You found there were no concerns. But how would you assess these symptoms?

VP My judgement across time, engagement across 3 hrs. Patient and family reports and they didn’t say aspects of TG were impulsive
P In your analysis of all 3 patients, your evidence is that these were relatively straight forward patients?
VP I accept that

P My point is, given the broad acknowledgement that you have specialist expertise, does it take someone like you to assess whether these are straightforward cases? And that standard treatment is appropriate for these patients? Does the primary care dr require the input of...

P ..someone like yourself? To make the appropriate diagnosis and treatment?
VP You need specialist training and experience in GD. Diagnosis is very straightforward. It’s self diagnosis. I can’t know their identity. Practically anyone could say if there’s GD. But transition is...

VP ..what we're dealing with here and HW has the experience here
P I’m not going to ask about prescribing hormones, you did reference clinical guidelines on hormones for GD in the cross examination. What is the clin guidance u were relating to earlier? Is it NICE or Endo Society?

VP There are various documents but it is probably more complex than that. I wouldn't use 2017 docs. I can’t tell you any particular guidance I’d use
P But you described guidance? That you trust and believe in

VP I’d need to look up what I was referring to as I need to find the document [has a brief break to look] You need to keep up with the literature I’d suggest. [still looking] This is 2014, issue guidance, to be reviewed in 2024. There are various guidance eg Durham, Cambridge

P So it’s locally produced guidance?
VP No. It can be applied to anyone.. There are various documents like this one. I think the NHS issues. Ah.. Charing X GIC have issued guidance on prescribing
P When did they start?
VP I think late 1980s onwards

P So a paediatric endocrinologist will have had access to this doc in 2016/7
VP Yes
P Re consent. You went through a consent process with pat C and would go through one with any adolescent patient who had GD and was interested in transitioning. You see the patient, assess them..

P ..and recommend treatment for that patient and prior to this you’d explore capacity to consent before making recommendations
VP Yes
P But it’s still up to the prescriber to make their own conclusions re capacity and consent? It’s a 2 stage element?

VP Yes. A medic has specific drug discussions. I’m more general
P So Pat C, would you have explored blockers?
VP I’d have a general discussion but would leave the specifics of drugs to the prescriber as I’m not trained in medicine
Chair Any further questions arising from these?

SJ You’ve just been referring to clinical guidance and mentioned guidance in Cumbria and then Charing Cross but not given us any titles of the documents
VP I can do this for you. In any case the documents would need to be supplemented with new developments...

VP ..Royal College of Psychiatrists Oct 2013.
SJ So cr181?
VP Yes
SJ Is the Charing X guidance publicly available?
VP Yes. Look here from 2017 which will include an update from previous guidance

IS re capacity, how often do you see lack of capacity? For eg cognitive difficulty, or too young? Eg saw an 8 yr old with HW, we went through extensive discussions with picture books until they could repeat back to us about what would happen

IS How frequently do you see this?
VP I’ve not come across this

Chair: Thanks for attending VP

Then followed a long discussion about submitting evidence from pat A and his mother in a way that guarantees their anonymity. IS is keen for the public to hear the evidence as to why pat A went to HW, and why HW acted as she did. Nature of public and private testimony & GMC rules

discussed. IS stating it would be very unusual to read out a summarized version of private evidence.

P Lets have a decision another day.
Adjourn for lunch 1.30pm

Chair: Good afternoon. Thank you for joining us again, so early in the morning Dr Shumer (DS)
DS I have a request to have a 5 minute break for a professional call later [approved]

IS Looking at the age of prescribing, looking at pages 9-10 of your report of 22 Aug 21: You discuss why age is not a good cut off in p9.6. You prescribe to patients of 12 and beyond. Do you agree?

DS I was discussing the fact these are complicated decisions re when to initiate these medications. There are sources of distress, the developmental stage, so age isn’t the best criteria. On p24 we see your signature?
DS Yes

IS Your declaration?
DS Yes
IS Your 2nd statement of 25 Aug bears your declaration and signature?
DS Yes
IS Do you want these to be your evidence?
DS Yes

SJ: Good afternoon. Starting with your report, looking at p3, in the bullet points you list the material you had. Documentation re patients - what was this?
DS Patient records d4a-c

SJ p5 under your qualifications you reference being Fellow at Harvard, mentored by Dr Spack, 1st multidisciplinary team in the US. How long were you mentored by Dr Spack? You say “I’d like to run this by Norman”

DS I’m still in contact and he’s a mentor
SJ You still take the opportunity to call him for advice on difficult patients?
DS Yes
SJ Was he always helpful?
DS Yes

SJ On p5, basis for opinions, governing standards. In terms of WPATH, California and the Endo Society, does your experience help you decide what to take from each guidance?
DS Yes
SJ Did you evolve a clinical practice on how you approach patients in particular ways?

Ds We have 3 medical Drs Yes, it’s how we apply the standards of care
SJ You’re involved in formulating education and no doubt considering what you’ll leave behind you when you retire? There is an evolution of experience?

DS I consider myself to be one resource in how to manage GD, yes
SJ You’ve a Dr who wants to speak to you for advice, even today?
DS Yes but for a different condition
SJ Experience from one to another is an essential part of gaining expertise?
DS Yes

SJ on p9ii In the US providers come from a variety of specialisms other than paed endocrinology. Looking at the prevalence of GD dramatically increasing. When has this been over?
DS I’d say over last 10 yrs

SJ Is the majority of treatment in the US within specialist MDT units like yours?
DS MDT providers are still in the majority in paediatrics, perhaps not in adults
SJ So the majority are coming to specialist units?
DS The majority, but not all

SJ With primary care referrals you’re presumably satisfied they’d be competent to take on your training or they’d refer back?
SJ The safe prescribing of these medications is quite easy. Lists different specialities. But primarily, apart from family medicine drs, these are...

SJ ..primarily consultant roles?
DS Yes, they are specialist roles otherwise
SJ Could they engage with a centre such as yours about how they should prescribe?

DS To gain experience they could review care documents, have conversations, attend conferences, join email list servers to ask questions. There are lots of ways. Similar to HW
SJ So safe prescribing can be learned quite easily? Is that from the benefit of your experience?

DS I say this as a lot of folks do. It’s well laid out in guidelines eg Dr Rosenthal's documents. I don’t consider it overly challenging to gather exp without having a full fellowship of the Faculty of Endocrinology

SJ But some of the decision making is very complicated? You’ve said so?
DS Yes It’s one of the things. Perhaps an advantage of primary care is they have more experience of social questions but endocrinologists have more experience of hormone levels. It is complicated to help...

DS ..patients and families, to understand risk and benefits but you get good at this if you’re impassioned
SJ re training. In nearly all forms of treatments there’s no substitute for learning from experienced practitioners? Whatever the area of medicine?

DS If you think that’s an important part. It can be challenging as there’s a paucity of training. It’s an area that presents challenges as the numbers wanting to provide care may outpace the teachers available. This could be improved.

SJ But the point, if care is to be safely provided, is you need to look at how to gain expertise?
DS Yes, work with preceptors
SJ Without peer review or supervision, reading and going to meetings is only part of the learning process?

DS I understand what you're saying. When reviewing training I found HWs reading to be acceptable
SJ What do you mean by her training? Is reading enough?
DS Reading, listening to people, and talking about models of care, that’s what I meant

SJ You’ve emphasised passion. You say some people aren’t so good at working with patients?
DS Not with TG patients
SJ Do you think passion is important?
DS Yes
SJ But there still needs to be rigour? In assessment, treatment and monitoring?
DS Yes

SJ Simply because they work in a primary care model, they should not receive lesser assessment, review etc?
DS I agree. Also if comparing assessment by MDT (which might be unnecessary) or GP, I can’t say one is better than another without knowing the details of both

SJ re your services assessment phase. You remodelled your service to referral by self or primary care? As a paediatric endocrinologist, do you involve yourself in the assessment process? Or do you rely on others as Dr Klink does?

DS After the phone triage, there’s assessment by a social worker (SW). Others, if they’re less complicated and don’t need a prolonged assessment, I’ll be more involved
SJ What is the structure and detail of assessments before prescribing is considered?

DS As an example, a parent calls saying my kid says he’s TG for the past year and we’re struggling how to support him. We want to learn about medical interventions. The SW would schedule an assessment over 3 hrs and present then possibilities to the family. Or if a patient...

DS ..says he’s just about to start puberty, been living as a boy since age 3, and wants to talk about PBs, the SW might say meet with drs about PBs. Or a longer assessment after a triage call might go straight to drs regarding PBs

SJ So by the time of referral to a dr, the diagnosis has been made?
DS Yes
SJ It may have been made by a SW alone?
DS Yes
SJ Within WPATH isn’t there guidance on who is competent to carry out the diagnosis?

DS Yes, I think so. SW are able to do this in the US as mental health professionals.
SJ What qualifications do they need for that?
DS The majority of patients see a therapist, and they’re usually a SW. During a Masters degree they learn about this

SJ So they need a Masters?
DS I’m not aware of that
SJ Do they have specific training on mental health diagnosis?
DS Yes, like medical doctors
SJ At what stage is there an assessment of the young person’s mental capacity to consent to medical treatment?

DS It could be by the SW or the doctor that’s treating them. Asking what they know and don’t know about puberty, their gender identity, the possible options, medications

Break 2.14 - 14.32pm for DS’s telephone call

SJ In the context of the issue of assessment I’d like to refer you to papers including yours, C55. The paper titled Role of Assent in the Treatment of TG Adolescents (2015), one of your many focussing on a patient set out in the context of the report...

SJ ..Was this case dealt with in an MDT?
DS Yes
SJ Was one of the central issues the extent to which can he consent to appropriate hormone therapy with his intellectual challenges? (I’m not saying this applies to HWs patients here)
DS Yes

SJ The whole issue of capacity is something needing rigorous analysis?
DS It needs consent, which can sometimes be challenging
SJ So you need to check how well each patient can analyse complicated [?information]
DS Yes

SJ So you referred this patient to the hospital ethics committee?
DS Yes
SJ the process needed to be individualised for this patient
DS Yes
SJ So in the US are judgements sometimes made by parents alone if the child is thought not to be able to give capacity?

DS Parents know patients better than anyone so they have a huge role to play. They're very important. So in certain circumstances where there may be limited understanding, parents help us make the decision as a prov [?provisional] family patient team

SJ Consent depends on the primary consent of the child. Do you think a child should have the capacity to consent?
DS It’s hard to be absolute. If you think an intervention is life saving, eg chemotherapy, and the patient isn’t able to understand, that patient could receive the..

DS .. chemotherapy with the team explaining the treatment albeit with limited information to the child. You can view TG medicine in the same light. For some reason they’re thought of differently..Children may not have as much of a clear understanding of the risks and benefits...

DS ..But blockers would still benefit the child if people understand this to be in the best interest of the child
SJ Shouldn’t there be a discrete and individualised assessment of the ability of a child to consent?

DS The point of the paper is some circumstances are more challenging, and this is how went about them
SJ The next paper is Dr Rosenthal, who you know?
DS Yes

SJ Have you refreshed yourself on this? P31 Diagnostic and therapeutic possibilities: assessment. It is therefore essential that patients undergo a thorough assessment by a therapeutic provider. Do you consider your SW appropriate to undertake this?

DS Yes, it’s role of SW on the MDT in a triage call. I disagree it has to be a mental health provider where the diagnosis is more straightforward.
SJ In p32 analysis of 2014 review of papers and not giving cross sex hormones (CSH) below the age of 16. How far are specialist..

SJ ..units traversing from this baseline?
DS Yes I accept this
SJ In p34, there are controversies and barriers to ideal practice. And only limited safety and efficacy data avail to those below 12y of age for PBs and for CSH for under 16s?
DS Yes we’d love more data on these ages

SJ So then there was no data for under 12s, especially for gender affirming hormones?
DS He was looking at longer term outcomes. However there’s experiential data for these ages, but not rigorous data available

SJ Would you agree that those in the forefront of this study are looking at safety by stage? So are focussed on specialist units like yr own?
DS Can you restate the question?
SJ Those prescribing outside of the guidelines, that data is largely within specialist units like yours?

DS The largest units will have the data as they have the most patients, but I’m not sure of work that’s being done in other centres
SJ Would you say prescribing to under 14 is at the forefront of treatment? The frontier?

DS These patients get worried about delaying puberty to 16 and think this [is too late?] It’s not considered novel or at the forefront any more. One of the issues is delay in updating the SOC. You may hear from WPATH later as many feel their standards are outdated...

DS ..I anticipate the recommendations will look very different when the new guidelines come out
SJ version 8 is due soon. 2017 version 7 says age 16 for hormones. But you’re in a centre of excellence. So it’s those not in your centre who may find treating under 16s with...

SJ ..hormones to be novel?
DS I’m not sure
SJ re De Vries & Leibovitz’s paper. Do you agree with their analysis?
DS Can you be more specific?
SJ p43 on clinical management and interdisciplinary collaboration
DS I’m not as familiar with this beforehand

SJ Do you agree with the principles? Eg importance of MDT/interdisciplinary approach? The 6 Cs including care, compassion, commitment, communication and competence. Do you agree with them being important?
DS Yes

SJ The American Psychology Guidelines - are these the province of the SW?
DS Yes, although if the diagnosis of GD is very well known they’ll not be seen by a SW. The diagnostic criteria means the diagnosis is easy to make in a straight forward patient

SJ How long to satisfy oneself re capacity? How long can you suppress puberty with drugs? Possibility of missing the beneficial window ie there are good reasons to start early. But if they start puberty at a younger age it is hard to know how they can understand the implications.

SJ..There are no studies at which we know adolescents are able to make these choices
DS The origins of this dilemma is puberty causing dysphoria and which has long term physical and MH outcomes. So reversible PBs were thought to be a good option, eg give at age 8 to allow...

DS ..further maturation. From the Dutch studies in the 90s. The protocol still exists today
SJ This is a 2016 paper from when HW was prescribing. But there are concerns re the understanding of taking CSH?

DS I agree with the point they are making. That’s the job of the physicians, and for families to decide with the medics what to do
SJ So it has to be a tailored effort, to make the decision and consent?
DS Yes

SJ Going back to your report. Were you going to provide PBS & CSH, do you think it's important to have a treatment plan looking at how treatment will be provided into the future for this particular patient?

DS When we meet a patient, we discuss PBs, the patient and family want to discuss future decision making in the future. Allows further exploration of GI without the distress of undesired puberty. CSH may be desired so we outline that we don't have an age cut off...

DS ..All 3 of us, clinicians, child and parents make a care plan
SJ So there needs to be a vision of how planned care, starting with blockers, are to be delivered? And monitoring of progress is all part of the process?

DS There doesn’t have to be a final outcome. There’ll be discussions on gender identity, efficacy of PBs, desired goals, plans for next visit and its outline. Goals regarding the exploration of gender identity for the child between visits
SJ Monitoring is discussed?
DS Yes

SJ p12 of 24 of your report. Dr Klink you were already aware of?
DS Yes
SJ He’s underlined the importance of examinations and doing checks?
DS What examinations?
SJ eg physical examinations because of blockers

DS It’s hard with covid and doing remote examinations. You can do a pubertal examination. Although with some it’s obvious as they’ve started developing breasts. Also some may be traumatised by an examination. You can do it. Most would have a physical examination prior to...

DS ..gonadotropin releasing agonists [blockers; aka GnRH agonists]
SJ p13 of 24 focuses on capacity and consent. Is your practice that the process is formally documented especially with very young patients?

DS The risks and benefits of GnRH agonists are discussed and understood and we elect to proceed - it’s how I do it. Others may do it differently
SJ So even if it’s done briefly, there is a record?
DS It’s my practice

SJ Similarly, is consent simply noted in writing or is more discussion noted? What’s recorded?
DS It’s not a separate document but I have discussed risks and benefits including fertility and that the patient has consented

DS Yes, it’s my practice
SJ There’s a breakdown in communication. Patient started on PBs and wanted to go onto testosterone prescribed by HW, but then the Tavistock got involved and there’s a breakdown of communication...

SJ ..In cases where 2 providers prescribe, whatever the nature of the care, do you accept there’s a duty on the 2nd doctor to inform the previous ones?

DS It’s a hard question to answer as I recall there was an explicit request to not provide information to the earlier provider. So it’s a complicating factor on what would otherwise be reasonable practice. You need consent from parents in the US to transmit information

SJ Can I add, that if it’s known or possible that the hospital when finding out about the early testosterone prescription, it runs the risk of early communication breakdown with the patient?

DS My understanding is there had already had a breakdown of communication beforehand. And a subsequent communication problem with a bad email address. Initial problems with the initial consultant
SJ They didn't formally break, they just didn’t alert them to receiving further care

DS I agree that it’s not ideal and it must have been confusing for the initial provider at the time
SJ Dr Dean’s analysis was that before he got involved with new treatment, it would have been incumbent on communication with the previous provider..

IS [interjects] I thought he said there wasn’t a right answer?
SJ Wasn’t it “I would have a dialogue, even if I’ve not got the right information”?
Chair: "It would be a matter for the original clinician, but it’s what he would have done.."?

IS This isn’t appropriate for a cross examination
Chair: Do you want to look for his statement or defer?
SJ Would you have wanted to encourage the patient and mother to engage to encourage continuity of care?

DS It depends. If working in a co-management arrangement with providers, then yes. If they didn’t like the original providers then I wouldn't continue to engage with a provider they weren't happy with
SJ Moving onto pat B. Do you think there should be separate consent forms...

SJ .. between PBs and CSH?
DS I don’t personally use a consent form and document risks and benefits as discussed above
SJ Dialogue and discussions should be discrete?
DS Yes

SJ In terms of the model HW used for remote working, wrt consent, should this be done in person or by telephone or video, as if they were with you?

DS I don’t know if I have the right answer. Due to covid we have done more remote work so now I know we can give information in many ways. You can assess in more than one way. It doesn't have to happen in person

SJ But regarding dialogue? Do you mean video?
DS Yes
SJ Rather than email or telephone?
DS Yes
SJ So you can see them and pick up visual clues etc?
DS Yes, that’d be the intention
SJ You’re not going to settle for emails and phone call?

DS We’ve had a case here where the video link was challenging. I haven’t started an initial visit by email myself, I haven’t tried that.
SJ So you want person to person oral communication?
DS That’s been my preference

SJ In terms of record keeping, do you need regular reviews to see how patients' identities are progressing?
DS Yes. We make a plan at the initial meeting. It might be 3 months later
SJ Certain difficulties were raised in terms of the psychological assessment by Dr Pasterski?

DS You might have to refresh my memory re the specifics
SJ It’s a question re dyslexia and auditory processing of information. If raised as a possible concern, should they be specifically addressed as part of consent?
DS I think MH problems would need to be examined

SJ It’s a question re adhd not being seen within the 3 hrs of assessment but that it could be looked into separately by the family?

DS I don’t find it essential to have all of MH issues clearly treated but an understanding they need treatment for GD and the implics of treatment. For eg I have many patients with adhd & asd who are the right candidates for treatment despite this, as it is the correct treatment

SJ where issues of fertility hadn’t been addressed with the patient on starting blockers, should this be addressed before PBs are prescribed?
DS That’s an interesting question. The use of GnRH analogues doesn’t impact fertility by themselves if they’re used to pause puberty...

DS ..We would imagine normal fertility after stopping a GnRH agonist. They’re not equipped to understand fertility very well at this age. Which is why they’re good. We’re embarking on a pathway towards infertility. It’s a challenging question to know how to navigate that

SJ 4C in medical records p21 references age and who signs under what title. P27 dyslexia, p32 re fertility and at bottom of entry we fully discussed the role of PBs that would give us a chance to discuss which pub to have at around age 14. We didn’t discuss fertility...

SJ ..Should this be returned to?
IS [interjects} This is completely misleading! Why are you asking the witness the question?
SJ Subject to.. It was raised in an email dialogue but there was never then a direct conversation with the child about fertility wrt consent...

SJ ..And a form by email used for consent
DS The topic of analogues and fertility is complicated. So I certainly talk about how hormones can change fertility and how analogues are on a pathway that may lead to this.. So it's not necessarily egregious to not have a conversation...

DS ..about fertility, in order to have it later closer to adolescence
SJ In the context of the pathway, only a very few don’t go onto gender affirming hormones?

DS This is always changing. The younger people are teaching us more about gender identity. More are now non-binary although most people do elect to continue to hormones
SJ In 2016, would you accept that vast majority did move from GnRH agonist to g affirming hormones?
DS Yes

SJ So this underlines the need for detailed discussions about the implications on fertility of progression? It needs to be underlined?
DS Infertility discussion is more for the parents. Blockers allow maturation so that more mature conversations can happen later

SJ Discussions with parents, mum in this case: these should never take supremacy and take control of the process?
DS The patient and parent are both essential parts of the team making decisions, but at certain ages it’s more the parents asking questions than the patient

SJ But asking questions isn’t the same thing as making the decision. The most important person is the child?
DS I have the child present and I read this as the correct care from the documentation

IS: Looking at your report 9p12-21) where you set out your responses to the 3 patients and your conclusion. Has your opinion changed in any respect?
DS No

Break 3.44 to 4pm

P I have two questions. When did [paediatric] GD treatment within primary care start in the USA?
DS In the last 5 yrs. Before that it was all in secondary care. It may have been before that. I know it’s been longer for adults

P At your institution did you look at outcomes of GD management for those treated by primary care vs secondary care? eg the rate of drop outs?
DS No, I don’t have any research on this

2nd panel member: In an article from the International Journal of TG Health (2015) The Role of Assent in TG Adolescents, there’s a case study about a 14 y old with capacity problems which is taken for assistance by the ethics board. How exceptional is it for you to do this?..

[cont]..His adopted father indicated he had developmental delays, poor communication skills. Is this an exceptional case?
DS I don’t remember another case like this one. The majority of patients we feel comfortable making assessments. Where there are unmet psychological needs...

DS .. we get collateral information from psychiatrists, who may or may not be a member of our teams, about particular patients we find more challenging. Or we ask for additional consultations due to complexities

P For those who don't have additional complexities, do you generally find that you're confident in their capacity to consent?
DS Yes
P: The word courage in Scott Liebovitz’s article, noting that commitment was the 6th. What does courage mean here? Why is it included here?

DS My thoughts: One reason is the politicisation of TG care, esp in paediatrics. Even the premise of providing hormones is met with astonishment. Others understand this care to be life saving. We’re a deeply divided country that makes the work I do, and that of HW and the...

DS ..Tavistock illegal. Other states have no protections against discrimination against TG people. It’s controversial in some places, and as an advocate there'll be people yelling at both slides at the top of their lungs. It’s unique in medicine. Another reason is it’s a very...

DS ..important decision for young people and their families, regarding the outcome of their lives. So these are maybe what they’re alluding to

Chair Regarding the frontiers of providers. As per SJ and giving testosterone to a 12 y old. Shouldn’t this care be by a clinic like yourself or GIDs or California? How relevant is it for the frontier being done in this kind of clinic, by a GP?

DS When you have the patient in front of you it helps here. I might answer by personalising the question. If I had a child that was deteriorating due to a lack of testosterone, I might go to HW if I was in that situation. I think that it matters less where the care is done...

DS ..but more who is doing it. As I learned more about HW, I think she did the right thing with pat A as it seems like it was beneficial to Pat A. That’s how I’d answer
Chair Any further questions arising from these?

SJ Linked to the question on prescribing at the frontier of age 12, in your earlier evidence you indicated that you had prescribe that approach at that age?
DS Yes
SJ But this was with an MDT?
DS Yes. In the context of the clinic described earlier

SJ Where you have a patient that presents in a clinic, do you accept that when you are in primary care and you have limited experience (HW from 2015 onwards). That although you might want to help, your duty was to ask others more specialised to prescribe in this case?

DS It looks like she reached out to others, eg Los Angeles, and this was the basis of her comfort of prescribing, of risks and benefits. She could have accepted your argument not feeling comfortable prescribing without an MDT style and send you back to London with the risk...

DS ..potentially of worsening MH, or she could have prescribed for pat A with the potential of saving his life. Seems from my reading of the case, it seems like the benefits outweighed the risk and I agree with her position

SJ I suggest the positions are far apart/ within a short period so at the time she could have spoken with any of her contacts, eg N Spacks. Asked have you done all of these things? What data are you relying on? Instead of her making a decision in isolation. I would suggest she...

SJ ..only asked one person who's without relevant experience?
DS I’d suggest that the prior work she’d done had prepared her such that when that patient arrived she was able to make that decision
IS No further questions

C Thank you for today and last Fri Dr Shumer. We’ve finished in good time so no witnesses tomorrow except for Dr Bouman?
IS He is available in the am but not in the pm. But SJ is seeking not to sit tomorrow

Chair We’re not sitting tomorrow pm anyway
IS Dr Bouman must finish on Weds as we can’t adjourn to 7th Oct so if SJ feels his examination might go over Weds I will refuse his application

SJ I’m not seeking tmrw am for my profess engagement tmrw pm. Was expecting to hear VP tmrw and had further reports for Dr Bouman that I’ve not yet seen. Can we start at 9am tmrw? Cross examination now limited to Weds
C: What?

SJ No evidence in chief from Dr Bouman. Reality is I’ve planned not to have to cross exam Dr B until weds, but with this professional engagement.
C So 9am start on Weds? You're not ready tmrw?
SJ Correct

C re concern about one day for x examination. Are you confident this’ll happen in the time?
SJ Yes v confident
C that’s fine. Start at 9am tomorrow if Dr B can do that.
IS No doubt he can do that. I have asked him

IS re Mrs A / A situation. I think we’re in agreement that statements and their exhibits be read into open session and subject to anything identifying [not to be included] SJ wants it to be read in full so no omissions or precis by me and I agree to do that...

IS ..The only concession is where there's a submission of repeated information that will be left out
C Are you now saying you're happy that their witness statements go in?
IS no all of their evidence. All the material should be available to the public, ie statement any x exam...

IS ..or questions by the tribunal. We don't have a transcript yet and I need to see the terms described by the GMC. Can we agree bullet points? Although we don’t have the transcript yet

IS Dr Bouman is the end of the defence case
C Are pat A /mum happy with this?
IS I’m checking this and will get a statement from them saying this
C Anything to say SJ?

SJ I’m d/w Mr Stubbs. Use of phrases making public and seeing. Listening to it is public in open session. GMC agreeing to statements are read into the record rather than being provided by the public . So subject to deletions for repeats, or redactions of names...

SJ ..Other material isn’t being given to the public. Is only the reading out of this material [by IS]. Endorse needing a signed statement by both as the evidence will go into the public domain, and there’s obviously concern re vulnerable patients

C Who is checking if identity can be discerned from the material?
IS It’d be standard procedures. I’d read it, responsibility is on me. Invite SJ and GMC to submit any redactions and then provide it to you the panel

SJ duty lies with IS and defence. Been in this situation before. Redaction is for defence to agree and sort out rather than the GMC. Family will need to be content with what's being read into the public record.

C Outcome on Weds re what is going to be read. You’d like a decision from us now?
IS yes please
C We need to enquire about summarising answers. Summarising into 3 or 4 bullet points and the tenor of the answers. Difficult as don’t have the transcript...

C.. We're unlikely to have a transcript by weds but we agree in principle. Although pat A's mother was clear for anonymity so it's very important. This is oral evidence so it’ll be a record. We’d like to see what y’re proposing on Weds

IS It's d11,12,13 essentially, subject to redactions, plus their oral evidence. Very similar to reading out statements without additional cross examination material
C We’d like to know what it’ll look like and have consent from both parties before we give final approval

IS If there are any matters the GMC would like to exclude they should let us know
C same for the tribunal
IS Yes
C I see

IS We’re nearing the close of the case so will shortly going to submissions
C Hoping for written submissions which would help us as there's so much learning and it's such a big case
SJ Of course the GMC will provide a written submission...

SJ.. You anticipate there's the issue of taking time to do that. As you’ll appreciate you can front load this work, my learned junior is also in another long running case. We'll see where we get to by weds/thurs. If we finish on Thurs by reading the evidence, I can...

SJ ..envisage after 9 weeks of evidence that we will need to go back through the evidence. Independent of a working weekend, we’d need 2 days to prepare the written submissions
IS I'm content with that and it’s a work in progress. Tell me when you require it

Chair It isn’t right to give you a deadline

Not sitting tomorrow. Reconvene 9am Weds

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