Thread by @tribunaltweets

Good morning. I will be tweeting today from Helen Webberley's Tribunal @RachelWilde13. Proceedings scheduled to start at 9am, but might be delayed until 9:30

2 new documents received from defendent - D58 and D59. Exhibits D30, T31, D45, D46, D57

We have Nigel Westwood (NW), Dr Walter Bouman (WB), Ryan Donoghue (RD), Angus Macpherson (AM), Ian Stern (IS), Simon Jackson (SJ), Sewa Singh (SS) clerk

Chair anxious to complete HW evidence today. IS questions to WB. Examining Doc D31 - WB's CV. WB is currently President of WPATH. Questions re reports on patients A,B,C. Doc D30 on patient A, WB confirming truth of document. Doc 45 - patient B - WB confirms statement of truth.

IS confirming that all the evidence WB has provided are statements of truth on which he is willing to be cross examined. SJ cross examines WB. SJ - do you accept that the considerations that need to be undertaken before hormones are prescribed are going to be different for a 16+

than for a pre pubertal child. WB - no I don't. I cannot see the difference between a child of 15 a day before their 16th birthday and the next day. The diagnostic process is the same for both. The average age for diagnosis is 11/12. The age of the patient doesn't matter.

The treatment is also the same. IS - so in this context do you think it is a matter of puberty stage not chronological age. WB - yet puberty stage is the important thing. If a trans person is pre-pubertal you cannot say they suffer from gender incongruence.

WB - it is about age and stage. One 15 year old is not as mature as another one. It will have to be your own clinical judgement. WB - I have not prescribed for 12/13 year olds, but if I were in HWs position I would do the same as HW. IS - but do you agree that the diagnosis of

competence is different. WB - the signed consent form is the evidence that the patient has consented. WB - in my experience/evidence there is no difference of a different outcome if we have seen the patient 2 or 20 times. Some children have had this gender dysphoria from 3 years

WB - if the patient is trans there is no benefit in carrying on for 2 years (no difference in outcome). IS - practitioner must take time to ensure that the patient can consent and also that everyone involved with the patient has all the information and understands it

IS - questions must be more focussed. WB - whole consent process won't come into play unless you have a trans person. I take into account all the psychosocial issues every day. SJ - should a discussion take place before prescription that the person understands the treatement

and can consent. SJ - does obtaining consent mean more than sending in a signed form? WB - patients have to wait so long. At the first appointment I do everything including taking consent for hormone treatment. SJ - for someone over 16? SJ - Psychoanalysts say you must have

a multi disciplinary team? WB - I've thought about that and I don't think that this is the model that serves our patients best. It is outdated and a tick box. What do our patients need? I have developed our service in Nottingham which consists of trans health specialists

We have a team of nurses and child adolescent psychiatrists and other clinicians who have done further training. We all work to the same treatment pathway. I wouldn't call that a MDT. We do discuss between each other - for example this person has severe autism.

Compared with GIDS it is very different which I think is very inefficient and makes patient wait longer. I have always wanted a one stop shop. For 85-90% of the patients it is very straightforward. Patients are socially transitioned. Why would I want them to see anyone else?

WB - when I started to see trans patients I began to see that there was no difference between the trans patients and me. Unlike with psychiatric patients which I saw which obviously had mental health problems. Trans patients don't want to talk about treatment - its straighforward

SJ - are you all prescribers? WB - all of us are prescribers in the early days including nurses. Now our team is large we have juniors. Juniors do not prescribe. No endocrinologists in the early days. We now have 4 part-timers. We make sure everyone has an endocrine screen

Especially older people who need an endocrine screen and may have other health problems. We don't pretend we are fully qualified physicians. SJ - so the training process takes the juniors to the point of being able to prescribe. SJ- what is the route to being able to prescribe?

SJ - what are the initial qualifications of the prescribers and what training do they have? WB - they take a nurse prescribing course having done enough hours of treating trans patients. We have 3 nurses who have done that course. We have 1 nurse with a masters and can also refer

patients for surgery. At the beginning it was an apprenticeship model we were all learning. SJ - do you agree it is essential to have that apprenticeship training? WB - for myself I would say no. I saw my first patient and had to get on with it.

WB - my first patient was a TW, I had to prescribe female hormones for her. I asked my colleagues what I should prescribe - they advised and I asked a GP to prescribe. Then my colleagues said take bloods. Then I read and read. No one knew anything about trans health care

at the beginning there was hardly anything. SJ - do you agree that talking with colleagues is an important part of the learning process? WB - yes, if you have colleagues you can talk to. Otherwise you need to find out more on your own. I was lucky to have 2 senior colleagues

SJ - do you accept that once you have decided on a diagnosis it is appropriate for a written treatment plan to be provided? WB - we write to the GP to tell them what we are going to do. Tell the patient - any problems, contact me. SJ- one thing about training -

do you agree that WPATH and BAGIS offer training opportunities? WB - yes I agree that WPATH does. In terms of BAGIS - they offer one meeting a year, that's all. Seeing lots of patients gives us a good idea of what trans is. Patients are marginalised, I see lots every day.

Trans patients are badly treated by society and by the NHS. SJ - you are familiar with Dr Klink (DK) aren't you WB? Do you have respect for him? WB - yes I have respect for DK, although he is younger than me. He was keen to be the expert witness to make a plea to UK colleagues

not to get stuck on 16 years. There is a consensus globally on 14 years. With the proviso that you have to look at stage as well as age. I have reached out to colleagues globally re minimum age for cross sex hormones - in exceptional issues 12 ages is the youngest globally.

SJ - you said that was in exceptional cases? WB - well I wouldn't think that was for the general population. SJ - I am trying to get some clarity, what is the consensus within WPATH - is it 14 or lower? WB- guidelines not set in stone, can be used flexibly. I see people in

distress every day. And in most cases the distress does stop. SJ - prescribing below the age of 14 - is that being done in specialist centres? WB - yes SJ - and in those centres are these a MDT approach? WB - yes, in some yes. I don't agree with an MDT approach. Its inefficient.

I don't know what they have in Amsterdam. In GIDS they have an enormous team. SJ - the other hospitals you have mentioned, they are centres of excellence where they have the necessary experience and learning to prescribe in exceptional circumstances. Do you accept that?

WB - well whether that is one person or 10 in the team, I don't know. In Nottingham we don't see people below the age of 16. The prescribers take on the responsibility for prescribing. No one else. SJ - I don't disagree but lets move back to patient A. With patient A

I accept they presented in a distressed state. Do you accept that the prescriber must be able to ensure that the child has sufficient knowledge and understanding of the treatment to consent to it? WB - you take consent from the patient in front of you. SJ - patient A had

been prescribed blockers already. But wanted to see HW to get cross sex hormones more quickly. Do you agree that HW had the responsibility to ensure that Patient A could fully understand the treatment to be able to consent? WB - many patients go abroad for treatment. This means

they cannot go to the NHS if anything goes wrong. Its terrible that this happens. Its not congruent with providing good care for our patients. Puts the patient and their family in a very difficult position. SJ - my question was not based on whether GIDS was right or wrong

but whether the decision to prescribe should have been done in conjunction with them? WB - this is never going to happen. I cannot make it work with GIDS, although I have tried. Won't communicate with me. Polly Carmichael (PC) says to me it is all very complicated. No interest in

collaborating with me. You can say HW should do this or that, but it isn't possible. SJ - in terms of the provision of care, for shared care agreements, to ensure consistency of care, for the prescriber to contact the GP more than just some emails to ensure that the GP

is comfortable in prescribing. WB - we do do that in Nottingham. But when we started we didn't do that. Its all in one letter to the GP with the signed consent form. SJ - do you have some academic papers that you were provided with? Paper C55? By doctors Leiberwitz and

de Freis(?). 'Gender Dysphoria in Adolescence' is the paper. WB - I editted this paper. SJ - authors are underlining about when it is appropriate to start - today there are no studies about when it is appropriate to start these treatments. Underlining the point about the need

for caution. Presentation may indicate prescribing, but the child may not have the psychosocial understanding. WB - its stage not age. You have to have the child before you to make the decision. SJ - moving on to record keeping. In the context of your clinic - is the process

recorded of every appointment with the patient and what happened. WB - you don't write down everything, it's just what you want to know. I asked patients if they are trans, when it started, when puberty started, what their treatment plans and wishes are. I given them a consent

form after giving them the information. For straightforward patients, 45 minutes. Do it all in one go. SJ - do you write down what you said with the patient? WB - not all of it, only what I thought was relevant to write down. eg risk factors, health issues that type of thing

IS - I am unclear what GMCs position on Patient A is. Is the GMC saying that despite suffering from GD, Patient A should not have been prescribed hormones? It's really that the GMC bring the case, they accept the patient had GD, so what is their case? I've raised the point.

SJ - one must look at this in the context of Patient A and Patient A's mother. GMC made it clear that there was to be no challenge to their evidence. To what extent am I meant to put my case that WB should not prescribe to Patient A? WB said he does not prescribe to this cohort

I am happy to put the GMCs case to WB. I am here to assist the tribunal. (audio is going in and out which isn't helping). P - SJ is saying that there is no need to put Patient A's case to WB, as he does not prescribe for this age group. SJ is happy to do this if needed.

SJ - I have set out the steps I think WB should go through before prescribing and in essence WB has said none of these are necessary. P - tribunal's view is that we have asked each of you to set out your case as you think most appropriate. If there is a sense that matters

haven't been covered, then that is something for the tribunal to consider. SJ - to WB. Can I take you to your report in relation to Patient A pg 2 where you set out the allegations that HW faces in relation to Patient A. One of the issues that the GMC raises in terms of what

is necessary to have taken place before the prescriber prescribes is for an adequate examination to have taken place. For patient A - you did not obtain an adequate medical history. You make the point that medical tests eg blood pressure have been requested but not whether they

have been obtained. WB - interesting discussion amongst paediatricians. Something particular to paediatric endocrinologists, they want all the nitty gritty. You have to ask yourself - what is more important that the patient suffering from GD is treated or whether they end up

1 cm shorter or not. I pose that there is no absolute necessity to do this. We don't do it. SJ - I am not suggesting this is a long, but Dr Klinks evidence sets out the process to be gone through. WB - there is no evidence that doing these medical tests leads to any better

outcome or not. SJ - I put it to you that before prescribing gender affirming hormone to a 12 year old that you go though a full examination and diagnosis. Do you accept that? WB - no I don't. The waiting times are so long - 6 months for a bone scan. SJ - are these the

necessary steps or not? WB - medical tests yes. Psychological tests no. A trans doctor knows a patient is trans. It isn't necessary. SJ - before one prescribes one has undertaken a full assessment of a 12 year olds competence to demonstrate they have sufficient understanding

of the full outcomes and consequences of taking these hormones? WB - my understanding that this was done. As a doctor you always assume competence among your patients and you would not write down if you think they were cognitively impaired. In this case, patient A, fairly

straightforward. This patient was an identical twin. SJ - move on to patient B. In terms of the history, there was a meeting with HW on 11th August 2016, in the notes on patient B there is a letter to the GP where HW says she has fully discussed the side effects with patient B &

they understand them and consent to them. But the consent form wasn't signed until a month later. It would have been good practice to go back to the patient and check they really understand before signing? WB - we don't do that in Nottingham. We do it all in 45 minutes.

This isn't a short case at Patient B has been seen by several CAMHS clinicians in the past. We just wait for the consent form to come back. We have all the letters etc ready to send off when the consent form comes in. SJ - against the background in relation to patient A

I repeat that although this patient was older and in the cohort that you treat, that the same assessment and formulation of plans should take place. WB - I think pat B was more complex than Pat A as he had depression which was treated by Dr Walters. I spent most time on this case

I was worried that Dr Walters would stop the testosterone. You can learn a lot from looking at the referral letters. I would pose that a lot of the mental distress that this patient had was because they were put in an impossible position between the NHS and HW. This patient had

the highest risk of suicide. SJ - does this example underline the need for the process of engagement between all those involved in the patients care - HW should have a wider dialogue with all the practitioners. WB - no, we have patients from all around the country. Very few

patients have mental distress. Assessment and care of mental distress must take place locally to where the patient lives. We have to assess if this makes a difference to our prescribing, just like for any other prescribing like for diabetes for example. SJ - do you accept that

there is a difference between prescribing for diabetes and prescribing for gender affirming hormones. Because a prescription for gender affirming hormones is part of a whole package of care. WB - but that isn't what happened. HW took bloods etc. SJ - but unless you have evidence

of continuity of care, you want to ensure that a patient doesn't fall through gaps in care. WB - I don't agree. This is similar to other prescribing. As a trans healthcare service patients seeing a doctor for prozac isn't something we can get involved in. SJ - what is your

experience of GPs prescribing for GD patients. WB - my experience is that most GPs are very supportive of us with supporting tests and care. 90% of GPs are compliant with this. Sometimes they ring and say 'I have never seen a trans patient before' and we always give them advice

there will always be a small percentage of GPs who refuse to do so. We then give patients the prescription, and advise patient to find another GP. SJ - do you accept that a prescription written from your specialist centre has an authority that a prescription from HW would not

have? WB - I don't know. I consider HW to be very experienced in trans healthcare. I think HW has a very good name. SJ - one of the GPs in this case, was unsure of HWs expertise. Moving on to Patient C. SJ - do you have a copy of Dr Pasterski's report (VP)? WB does not.

SJ - within the assessment by VP, 2 things flagged up. VP says this - patient has been diagnosed as dyslexic, and mother has said possible ADHD. VP says patient was polite and attentive throughout assessment. VP did not think patient C had ADHD. VP diagnosed GD and recommended PB

SJ - do you think in terms of Gillick competence that those were indicators that a more thorough assessment should have taken place? WB - lets not make this more complex. Have you ever met a person with ADHD? If a person can sit for 3 hours then I would be flabbergasted if they

had ADHD. VP is very experienced and I would rely on her expertise. Yes the report had spelling mistakes. The problem I have with psychologists is that every single thing has to be explored before prescribing PBs. I don't agree it - isn't necessary. It doesn't impact on the

treatment for GD, whether the patient has autism etc. The outcome will be the same. SJ - says patient C 'struggles with auditory processing'. So when this is flagged up to the GP, then a more focussed and thorough examination and personal contact should be undertaken before a

patient signs the consent form? WB - are you now suggesting there should be another form to consider just consent? SJ - I am putting to you that rather than rely on email with the mother, there should have been a personalised evaluation via a conversation takes place WB - no, the

process was gone through and the consent form was signed. And young trans people have many disadvantages vs cis. A medicalisation of young people who are otherwise functioning fine. SJ - moving on to your comments in relation to patients A/B/C. Thank you, no further questions

IS - I want to cover 2 issues if we may. The first is some suggestion that Dr D says he is not an expert in treating patients under 17. Where does your expertise come from for treating trans patients over and under 16. WB - initially I trained as a general adult psychiatrist

in the Netherlands. Never saw a trans person there. Came to Nottingham to specialise in old age psychiatrists. I was always comfortable in prescribing medical treatments. Then started training in sexology and psycho sexual therapy. Then I started a psycho sexual clinic for older

people. 2006/7 I came across a few trans people. After 10-12 years of older age psychiatry I wanted a new challenge. Asked medical director if any other opportunities, offered GD clinic. Really sold on it after visiting clinic. I though trans people were being treated terribly

people were marginalised. My colleagues taught me how to sort out the hormone treatments, reading, getting involved in WPATH, going to conferences etc. Being part of the professional network. IS - you treat people who are 16 and over, and not able to comment on those under 16

can you comment on this? WB - I have tried to establish a more fluid relationship between GIDS and us. In medicine we work with models and diagnosis, diagnosis critieria for a 12-13 yr old and a 16+ year old. In Belgium they are moving towards a more pubertal diagnosis

once puberty sets in, if a patient still has GD it is cruel not to treat them. IS - diagnosis is not different between a plus or a minus 16 year old. You see referral letters for younger patients? WB-yes we refer them onto GIDS. This does not serve our patients well.

IS - when you receive referral letters for an under 16 yr old does it set out the criteria for referral? WB- the best referral letters are the shortest from GPs. eg this patient has been struggling with GD. These are the most straightforward cases. From psychiatrists, the most

complicated and difficult. We ask patients how their gender developed - I always played with boys, wanted to play with 'boy' toys and wear 'boy clothes'. IS - has material been looked at by you for younger patients? WB - narratives for all patients are remarkably similar

the concept of people making up a narrative. I think we are experienced enough as clinicians to know when a patient is telling you porkies. I run the WPATH journal - international journal of transgender health. All the submitted manuscripts come into me. 200-300 a year. I

allocate to the various reviewers we have. We have 125 clinicians around the world to undertake a systematic review of guidelines. Hopefully will be published next year. IS - you believe that version 8 will reflect that gender affirming hormones should be started at 14. Have

you been involved in the discussions about this? WB - no. IS - Do you have oversight of the material they produce? WB - yes I do because I am a colleague of the non binary group. All members have to vote on all chapters. IS - page 7 of your CV where you set out your book

publications. We can see that many of them are around transgender health care. What material have you come across to write those books? Are you familiar with the needs of those under 16? WB - yes from the books. Field is not as broad as you think it is. Not hard to have a good

knowledge of it. IS - Your view of HW. What you consider to be her competence? What do you rely on? You say you have read through all the patient records and referrals. WB - many many referrals from patients who have been under the care of HW. At least 10's of them. IS - you have

found nothing wanting? WB - yes, patients have been very complementary about her care. IS - in relation to any question you have been asked by SJ in there anything in relation to what you have said about HWs treatment of patient a/b/c that you wish to alter? WB - no. Trans is a

natural variation in the population. P - a few questions. Dr Westwood (DW). Capacity assessment - having done this type of work for a while I am aware that psychologists/psychiatrists use different instruments to assess competence. WB - no nothing like that exists for trans

DW - so assessment of capacity is left to the clinician? WB - yes. DW - why hasn't there been research about what age a person can reach competence? WB - to put it simply there isn't an absolute answer to that question. It's not about the age, but the stage. DW - how would you

design such a study? Very difficult. When you take histories from your patients, all very similar describing a history of gender incongruence from a young age. So do you see adults who could have benefitted from earlier intervention? WB - yes there are a lot of problems.

eg if a transman grows breasts and vice versa. TW will have a body and voice of a man. Bad for their self esteem. An interesting question as that rarely comes up. Surgery then needs to take place to remedy these. If you block a transgirl early the penis doesn't grow so this means

it is harder to make a vagina later. But for some people the GD is so overwhelming that they have to transition. Or they commit suicide. There are ramifications of not treating. DW - to clarify, you say it is complicated. If a doctor has a young transgender person in their

surgery, is it incumbent on the doctor to take all of the risks and benefits into account? WB - I think it is an impossible task and no one would be able to do that. At the end of the day you have to go with you gut feeling. Is it in the best interests of this patient, or not?

Some patients will be able to stick it out longer than others. You need to make that assessment on a daily basis. DW - evolving nature of trans healthcare. We used to talk about GI disorder, now it is gender incongruence. Moving from a psychiatric to a somatic(?) diagnosis

GD hasn't changed, but our thinking about it has. How is Soc 8 keeping up to date with this changing landscape? WB - 10 years from now we will not be having these discussions. Some colleges more equipped to have a route for a special training scheme or others. The RCP could do

that as well. There will be a recognition that you don't need to train for 6 years to be a trans healthcare physician. GPs would be well equipped to do this as they see many patients all day every day. Especially as there are an increasing amount of trans people. DW - one last

question. If a doctor treated GD as a psychiatric condition, from next January will not be a psychiatric condition. Can a doctor vary from the rule book or not? WB - interesting and complicated question. ICD 11 is ready and published. Some countries eg USA have refused to use.

No appetite in the US to take GD outside of DSM 5 because of health insurance. It is going to depend on which country uses which manual, this will be a difficult situation. One country thinks it is a psychiatric condition, another does not.

Chair - one area of questions to ask about. You have formed an impression of HW because of the number of referrals you received from her to your clinic in Nottingham. WB - vast majority of patients referred by their GP, but most referrals stating that they have also been under

the care of HW. Chair - so it is in that context that you could been able to assess HW care? Chair - on that basis you formed a view of HW transgender practice? You offer educational facilities at your clinic? WB-not as a general rule. On occasion for a large group eg for GPs

but we don't have the bandwidth so we don't do it routinely. Chair - so an individual GP cannot seek training from the Nottingham centre? WB - no, for individuals can come and train with us on a one to one basis. Shadowing if the doctor was senior enough.

SJ - Dr Bauman talking about training opportunities, if you had been approached by HW would you have been able to offer her an opportunity to learn about adult transgender medicine? WB - yes but not young people, adults.

Process discussions about the reading of the statements of Patient A and Patient A's mother.

Back at 2:30

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