Thread by @tribunaltweets2

Good morning and welcome to the misconduct hearing of Dr Michael Webberley (co-founder of Gender GP)

This is @Wommando live tweeting and today we expect to hear from one of the GMC expert witnesses, Dr Richard Quinton (RQ).

Catch up here:
threadreaderapp.com/thread/1508423…

The GMC counsel are Simon Jackson QC (SJ) and his junior Ryan Donohue (RD).

(RD was the GMC counsel in Dr Adrian Harrop’s case which we reported last Oct)

The counsel are attending online and the 3 tribunal members are in person.

MW is not present and has no counsel.

Abbrevs:
GGP: Gender GP
GMC: General Medical Council
MW: Dr Michael Webberley
RQ: Dr Richard Quinton
AK: Dr Alanna Keirans
MPTS: Medical Practitioners
Trib: Tribunal
VE: Voluntary Erasure
Chair: Leader of Trib members
GD: Gender Dysphoria
TG: Transgender
PB: Puberty Blockers

We begin. The clerk checks connections with SJ and RD who are accessing remotely.
Chair: Good morning and apologies we didn't have the prompt start we wanted. SJ are we in a position to call RQ or other matters?
SJ: we're ready to go with RQ

RQ is remotely accessing and connection checked.

Clerk takes RQ through affirmation of truth.
The chair introduces himself and the tribunal members.

Chair: can I say this, please do remember at any stage you want a break let us know.

SJ: Dr Q can you confirm you have your reports available and start with part 3, the expert bundle?
RQ confirms this
SJ: and part the Medical records for all patients?
RQ: yes

SJ: if we start with your reports by way of introduction, we can see you've done a no. Of reports, 7 in all. First the BMH report, (18 patients), then individuals the TG patients which are 7.

SJ: Can you confirm you were instructed by GMC to provide your opinion on endocrinological treatments on these patients?
RQ: yes
SJ: here you set out your qualifications. Can you set out your main clinical practice as an endocrinologist?

RQ: I qualified in 1998, Consultant 1999, my practice covers the spectrum of endocrinology. Always had interest in male and female disorders and fertility...
SJ: when would an Endo prescribe testosterone?
RQ: to a man who a proven case of hypogonadism.

RQ: blood tests are required for hypogonadism diagnosis and other things must be checked *lists)
SJ: you say you may get a low indicator of testosterone and the tests, what would be the process for low testosterone?

RQ: I'd look what other info is available to get a full picture, blood counts are the first thing. Is there history of fracture, unwanted breast, testes that haven't decended, cancer treatment, brain cancer? I would always want blood tests repeated in a standardised way...

RQ: if testosterone is low is it because of the signal from the pituitary gland?..
RQ: if you have low testosterone and high LH FSH, it means your testes are failing.

Any illness in men and women, the reproductive access tends to shut down. Women's periods tend to stop eg

RQ: the low testosterone is indication of underlying illness that needs treating
SJ: how is the testing conducted?
RQ: a lot depends on LH and FSH...if high we have a diagnosis immediately if the latients doesn't have diabetes, etc. I'd write to doctor and say give testosterone

RQ: if its slightly low I'd write and say its unlikely this man is hypogonadal and I'd be saying to disregard the possibility.
SJ: in terms of physical assessment is that important?

RQ: very important and certainly if you have low testosterone and low LH and FSH...(too fast)
SJ: if one diagnoses hypogonadism, what treatment, is that prescribing?

RQ: treat all men whatever age, mh, disability with testosterone...only reason not to if they have active prostate/breast cancer of want fertility...
SJ: what then is the treatment plan for continuing meds and monitoring?

RQ: it's a very interesting Q. If you believe the hypogonadism to be true, it will be lifelong. Most ppl feel better but if a patient says they don't feel better, still using viagra, my answer would be I'd like you to carry on and important for blood count and bone density.

DQ: We monitor blood count, monitor bone density, monitor testosterone...
SJ: in terms of setting dosage/monitoring?
RQ: testing would be routine at intervals. You start with average dose and then monitor and adjust.

RQ: If it's a gel you adjust the pumps, if injected, the dose is filled and adjusting the intervals.
SJ: you've set out practice on NHS, is it also routinely avail in private sector
RQ: Testosterone is widely available in private sector

SJ: are you aware of people who go outside the NHS?
RQ: yes some come to me, some I can reassure and say this isn't hypogonadism (HG), some I can't reassure.
SJ: I'd like to look at provision of testosterone (T) via Balance My Hormones (BMH) by MW

SJ: We can see patient summary and a health questionnaire repeated for all patients. We see personal info at the top, questions about GP and box 'please indicate services interested in'. We see some boxes for men and women (lists)

SJ: can you go through them and the difference
RQ: first I will say I feel it's terrifying without a diagnosis made and there's already a shopping list of treatments the patient can decide from..

RQ: Growth hormones should *only* be prescribed by consultant Endo..it is not something that should remotely appear on a shopping list for the general population

RQ: ...the assumption is the testes were normal to start with and fertile...what on earth are you doing giving testosterone, this will lower sperm count and fertility.

RQ: estrogen is important to men as well as women, for bone density and libido, but if too must T you can overload system and more of that T gets metabolised into estrogen which will cause breast development.

RQ: we know that T treatment in excess causes fluid retention and some of his writings he's using the drugs to mitigate fluid retention.
SJ: when you say he?
RQ: Dr Webberley, he's causing a problem with one drug and using another drug to try to resolve it..

RQ:.. and that could drop the bone density. I mean, Wow that is balancing, a tightrope act and trying to fool the human body. I'm not a betting men but I know who will win on that.

Chair: where would you use this?
RQ: there's absolutely no where theyd use that other than body builders and its called 'stacking'. There's no clinical indication at all to use that.

RQ: (too fast) it just happens the best treatment for gynecomastia if you're a man is surgery but cant get on NHS....T for women, post menopausal women find their libido isn't what it was and their on HRT and T can sometimes assist

SJ: with BMH, what indication does it give to you what the patients have ticked?
RQ: It suggests these patients are self selecting and deciding treatment without diagnosis. MW is prepared to deliver whether in patients interests or not.

SJ: Next 'health habits, personal safety exercise' is that an indicator of anything
RQ: it's off two alarm bells, is this someone who is in a lifestyle to augment effects of weight training, the other is we do see a condition that you've driven yourself so hard & have induced HG

SJ: anything else on this questionnaire here?
RQ: if you've lost morning erections its likely to have HG and an important Q...have you ever had trauma to testes is an important Q.

RQ: The Qs fall into 2 categories...they're not unreasonable Qs but not sure why some of the Qs. What's missing is the top end of problems. Then there's all sorts of nonsense questions and not relevant and don't why they're asked.

SJ: (reads our more Qs about letting GP know) Is this a regular theme
RQ: I'm astonished that that question is even being asked. It would be indefensible Hormone treatment without involving GP....I'm astonished the option to 'do not contact GP' is there

SJ: what if the patient doesn't want the GP alerted?
RQ: I would say almost impossible position if long term treatment. A long term treatment involving blood count, you could generate all kinds of secondary tests...

RQ: and treatments if the GP isn't allowed to be contacted. It is utterly unacceptable that you don't contact GP.

SJ: can you address this statement about a consent form for T
RQ: although he speaks of raising T levels, the ref range he quotes, is way over any I've ever seen. I've never seen an upper limit like that, he's basically invented an upper level of normal.

SJ: is that relevant to testing?
RQ: wel, effectively he's missed the patient, he's said he's putting levels at upper normal, in fact he's not, they'd be above normal. That's a deliberate misleading statement.

RQ: in terms of monitoring if you are going to ram T level that high you're increasing risk of red blood count too high. If you're going to do an irresponsible thing you need to check blood count.

(RQ is taking the tribunal through various possible side effects of T treatments and the very least evidence says T helps depression.)

RQ: MH seems to terrify patients into treatment and talks about risks that aren't there.

SJ: (reads consent forms) if we go through each, I understand prolong TRT reduces sperms count and fertility
RQ: if you think someone has normal fertility at baseline it invalidates HG in the first place. This suggests he's knowingly treating men who are not HG

RQ: if you're a man who starts out with normal T levels and started on MW levels, your fertility will definitely reduce and testes will definitely reduce, not possibly, DEFINITELY.

RQ: It can take up to a year for hormone access to return, that's a huge underestimate of 'may or may not' with dose he's recommending.
SJ: ...thoughts regarding consent?
RQ: it's misinformed consent. It's consent based on misinformation which is not consent.

RQ is having difficulty in finding documents and we are breaking for 15 minutes to do this.

While we are in this break, I'd like to make clear some new abbreviations:

HG = Hypogonadism
T = Testosterone
Endo = Endocrinology

We return. The clerk checks connections.
SJ is looking at referenced results of T
SJ: can we go back to your report, you note these levels would not be considered abnormal. Next we see referenced test with same observation and not considered abnormal.

SJ: Putting into context, any diagnosis of HG what brief obs do you want to make
RQ: the results are overwhelmingly consistent with normal levels and NOT HG

RQ: increased lower body fat, that's an alarm bell, men with HG don't complain with lower body fat.
SJ: before the BMH forms, is there anything you want to say?

RQ: T was normal range, FSH levels not raised and what is of interest is the fact his haemoglobin has dropped from previous and why on earth that's suddenly happened.

SJ: if we look at July we see MW signed off and sets out a treatment plan and 5 times prescriptions. What obs do make before prescribing?
RQ: there's no diagnosis and there is no consideration given whatsoever to lifestyle...this is very young, ignoring haemoglobin..

RQ: the treatment plan is stacking...and then we've got estrogen blocker to stop HCG and fluid retention.
SJ: when we looked at the form which talks of TRT and estrogen control, can there be different drugs to stack, or is this an identified routine way of doing it?

RQ: in order to answer fully I'd have to be a doctor violating GMC guidelines working with athletes. From what ppl write on the internet this is the standard way of stacking.

SJ: what do you see from tests?
RQ: (too fast)....he has stonking levels of T, again the upper end of male range and he's up 42.5. MW has done what he said on the tin and T has soared

SJ: further results, can you comment on T there?
RQ: again, these are the upper end of normal range, the estrogen level remain normal but we don't what that's doing to bone densitity. There's no blood count check so the most important test hasn't been done.

RQ: this was not someone who had primary gonadal failure. MW has done the tests but not used them.
SJ: can you comment on these tests?
RQ: again I'm wondering what is going on with this guy.

RQ: He was anaemic and noone reacted to that and now on masses of T...does he have another disease we don't know about? (missed) then there's a drop of cholesterol, the good type, somethings happened to this level and associated with heart risk.

RQ: We see this with excessive T and steroids.
SJ: then let's deal with your summary where you set out the combo which is 'stacking'
RQ: MW describes this differently but it is 'stacking'

The Chair is clarifying a few questions
RQ: his SHPG level is unbelievably low, just unbelievably low...when do we see these really low levels? Usually in men abusing androgens...and the cholesterol is stonking low.. a lot of androgen that may not be T.

RQ: why has the liver function gone off? Could it all due to T or are there some anabolics in the mix.. there's weirdness there that deserves a proper doctor to have looked at and considered.

RQ: Also, we've no idea what the test timings are in relation to these injections...
SJ: does care need to be carefully audited?
RQ: yes moreso if you're trying to prescribe what you know to be a higher dose and he said from the outset that's what he'd do...

RQ: there's no thought process
SJ: about taking history...in summary what is important in obtaining history from Patient
RQ: you need history to confirm diagnosis of HG, both history & examination needed. No examination and history is tickboxes, history isn't there for diagnosis

SJ: here's your summary where you say MW has done LH and LS tests
RQ: I think he didn't order those and they're only here because by good fortune the GP ordered them. MW had no thought if ordering them.

SJ: what should have been frequency of dosage?
RQ: everyone is different but that dose would be expected to last 3/4 weeks...he's given it every 5/7 days which is double the dose for a man with HG

SJ: The important of the clinician being in contact with patient?
RQ: these blood tests may as well have never been done as there's no reaction from MW, no meds changes or even acknowledged. Monitoring for tick box purposes rather than safety.

SJ: I want to move on to consent for Testosterone Replacement Therapy (TRT) we've already addressed this
RQ: yes he's invented these levels.
SJ: that concluds all the Qs I want to ask in relation to that Patient. I want to look at Patient H

RQ: is it worth mentioning that for hormone treatment, if they're deficient, with things like diabetes we don't sign consents for these, we explain the treatment and benefits...

SJ: in context of HG would there be a structured consent form
RQ: nothing like that...it really needs treating, nobody would do a do a consent form for insulin, etc

SJ: if we can also go to this patient's questionnaire...'may we contact your GP' and the reply 'NO' in capitals 'DO NOT CONTACT GP'...and 'are you currently on hormones', they say no, then they enter they want the same as the last patient?

RQ: yes and potentially worse...this is dominoes pizza with all the toppings.
SJ (too quick)
RQ: Could this be someone who's exercised so much they have developed HG or are they looking to buff themselves up more?

SJ: it says roaccutane is present
RQ: roaccutane is a treatment for acne and comes with suicide risk. I'm not a dermatologist. If someone is getting bad acne it suggests they've got high T levels. In the same way children pre puberty don't get acne.

RQ: the assessment has been discredited and not used in clinical practice, eg. 'do you feel tired after lunch'...it sought to identify men at risk if HG, its been discredited.
SJ: The patient asks 'I hope you'll be able to help me', can you confirm these refs

RQ: that's T, and HCG and estrogen blockers and he's looking for hormone growth and this would be stacking PLUS
SJ: can I go back to report...looking at chronology we see in Dec 2017, Patient completes questionnaire, then bloodtests, can you comment?

SJ: on the basis of the test wha5 reason for intervention
RQ: None, this man was normal.
(Missed)
RQ: I wonder if this was actually a consultation or MW just doing his own little note, maybe just MW reflecting what patient had written. A desire for fertility and T is an oxymoron.

RQ: it's almost exploitative, this is a vulnerable person was a difficult stage in his life and instead of help he gets banged full of hormones. There's no indication for it based on history and blood tests

RQ: the patient believes they need the hormone cocktail and despite evidence to the contrary were gonna prescribe it to him
SJ: (reads about 'open mind' about treatment

RQ: that statement basically says this man is not HG but well give a bit of at to keep him happy. It's covering one's back statement.
SJ: does that regime address this patient

RQ: the regime is not what he initially said. He then goes into the full dose stacking regiment and it's like he's reverted to type and... what can I say...it's just incredible.

SJ: and then you say despite convincing evidence of HG, anything more you want to say
RQ: one feels this is a vulnerable adult taken advantage of and put a risk. By treating stuff that isn't there and not treating stuff that is there

RQ: this man in NO way had HG and needed other intervention, lifestyle and MH, and had asked for stacking regiment and that's exactly what he was prescribed without the hormone growth. Doesn't seem patient had any benefit and not at all surprising.

SJ: do you find any MH assessment?
RQ: no none at all. The other thing to say is MW is a physician, we have our own specialities, we're meant to form a holistic assessment as well and there's a total absence of that.

SJ: whats your summary of treatment plan and follow up
RQ: he's misdiagnosed patient with HG and failed and hasn't even used a HG treatment, he's used body builders stacking. He's failed to recognise patients mental health, vulnerability issues.

SJ: Here about standard of care...can you summarise his practice in relation to this cohort seeking hormones?

RQ: His practice was to give the customer what they wanted even if not in their best interests. Treatments he used were extreme and invalidated. Failure of diagnostics and therapeutics and I think failure of humanity.

SJ: (missed)What problems can be caused?
RQ: all we have is what seeps out of bodybuilding community and we see men who are infertile, testes have shrunk, hormonal access has shut down, they won't recover without stopping but even they do stop there's a nasty phase of cold turkey

SJ: Your criticism of MW you endorse in your report
DQ: yes
SJ: Second cohort are the TG patients, we'll need to look in your report now to start. (They find pages)

SJ: We see a summary of patient S. Can I pick up your experience dealing with GD patients, both minors and adults and you set out what your remit is. We're going to come to a convo about MDT's, for the lay ppl how should we understand an MDT?

RQ: it came from cancer treatment, that there were several doctors and specialists, surgeons, paediatricians, specialist nurses, radiographers, that's your full cancer MDT...that led to the looser concept of MDt applicable to many other aspects of medical care.

RQ: One of these is TG care, they may not be in same room. Therell be gender specialist, usually come from mental health backgrounds, consult psychiatrists, senior Psychologist, then you also have endocrinologist and a specialist nurse...these would be core members of MDT...

RQ: increasingly, counsellors can have a role, important all individuals communicate regularly
SJ: in terms of coordination, does there need to be a structure and responded to by MDT or in context of primary care,

SJ: how do the models work, where does responsibility lie for MDT to take place?
RQ: the Gender doctor who is assessing the patient and making diagnosis.
SJ: and what's your experience of overlap between gender specialist and person doing prescribing?

RQ: eg, in responsible private practice and many gender MDTs there's a clear separation between who's doing assessment and who initiates prescribing. A clear separation. Where I work that operated for many years without an Endo and I was the first...

RQ: not every patient will necessarily have my input or will be discussed with me, that's just a marker of where Northern gender used to be and how it's changed over years. Most gender clinics and certainly in private sector there is a clear separation.

SJ: What's your experience of MDT with adults and children.
RQ: my adults is based on experience, my experience with children is based on a few things, Drs at the Tavistock and second is an Endo meetings once a year, finally as an adults Endo...

RQ: I get to mark my colleague's paediatric homework as it were. Patients who've outgrown the Tavistock will then be transferring to an adult Gender Clinic .
You then say you help with cisgender children, expand?

RQ: if you're a child with a inherited problem, gonads may not function or go through puberty late and you will then get referred to paediatric clinic, or older you'll go to joint clinic...I have a national profile in puberty, these children are non-trans but issues with puberty

SJ: who would be prescribing
RQ: i wouldn't be prescribing anything to under 13 EVER, from 13-16, it may occasionally but with full discussion with paediatric colleagues. And even with agreement, under 13 just wouldnt go there.
SJ: why your reasons,

RQ: the cut off is 16, no physician is trained to look after children, not trained to prescribe to children, not even aspirin.

Chair: your opinion that a physician can't prescribe to a child under 13, is that your own view or is that a view from your knowledge of practice of medical community or are you referring to formal guidance?

RQ: interesting question. In terms of guidance there's surprisingly little....and it's impossible for an adult physician to prescribe safely and responsibly to a minor without paediatric support.

RQ: Because I'm hyperspecialised in puberty disorders, I'm sitting in a joint clinic I'm happy to prescribe treatments with agreement of paediatric colleagues.

SJ: Is that others practice?
RQ: Almost certainly leave that entirely to paediatrics
SJ: in prescribing hormones to cisgendered minors, do you have to address issues to do with competence of patient to understand treatment?

RQ: yes and actually not everyone with puberty disorder is a minor, its rare but will see an adult who's never been through puberty every few years which is extraordinary. At all ages there's the issue with competence.

RQ: In an extreme case I've been involved where it went to the family court in terms should a non-mimor lacking competence receive treatment when the family weren't in agreement.

SJ: how is competence addressed with children?
RQ: most cases the family want what is best for their children and everyone is involved in the discussion, child, parents, colleagues, issue of Gillick competence rarely arises...

RQ: because that's where the child is considered without parents knowledge. In general the family are fully intertwined in decision making. Sometimes the child doesn't want to know and says leave it to parents and that creates problems.

RQ: You have to be careful what you assume needs explaining
SJ: Fies consenting still involve engaging the children and they understand?

RQ: most certainly. It's really good practice for child to give their own asset. It stores up less problems for the future and the more prepared they are. The more a child understand the condition better adherence to treatment.

SJ: What skills does MW have to undertake this?
RQ: none whatsoever
SJ: What history?
RQ: No useful exposure at all or doing practice...its simply not part of a physician. Unless a radical change in career and a period of significant retraining.

RS: what basis do you make the statement?
RQ: first thing, 16-18 is an area where may or may not be an overlap between child/adult ward.
The way gender services were set up in NHS were only for over 18.

RQ: a different cut off point was set for then and even now if you were to talk to responsible gender doctors doing private practice none of them would see a patient who was under 18 for their first App.

SJ: you say about training for MW and he's worked with a colleague with a special interest, what from your knowledge of GID is the period of training undertaken before prescribing to children and adolescence TG medicine ?

RQ: in terms of prescribing in children and adolescence there is no possible mechanism for a physician to retrain unless they came through an entirely new system. If he had retrained as a GP, who see all ages, he could then gain expertise in TG medicine

RQ: But that's the only way he could have done this in a legitimate manner to prescribe to children.

(Missed)

RQ: WPATH assumes every gender specialist is a mh professional. The UK is different that our GPs have good MH training and some come from reproductive health. Others can gain skills to do MH assessment eg...

RQ: In order to deal with children and adolescence the skill set is different and that's why we have specialist child psychiatrists, child psychologists. Here's an eg. of a child and an adult gender specialist who wouldn't feel competent to treat and...

RQ: ...yet an adult gastrologist MW believes themselves competent to treat.

SJ and Chair discuss timings for the afternoon as we break for lunch. On returning, SJ hopes to finish with RQ by 3pm, we'll then have a break and Trib will question RQ.

@threadreaderapp please unroll