Making it up as they go along
More revelations from the Webberley hearing
The Helen Webberley tribunal is in its 9th week and continues to throw curveballs to those observing. For any not aware of the background to this case, Dr Helen Webberley is a Welsh GP who has set up various online consultation and prescribing websites, including Gender GP. This specialises in gender medicine and has been prescribing puberty blockers and cross-sex hormones for children, adolescents and adults despite her having no specialist training.
The General Medical Council’s charge sheet against her is long and focuses primarily on what they describe as failure to provide good clinical care to 3 young people with gender dysphoria. Other charges include inappropriate prescribing and follow up of more typical GP patients, poor safeguarding and dishonest behaviour. She has already been found guilty and fined for running a separate online medical practice without being properly registered. She remains at Gender GP, owned by Hong Kong-based shell company Harland International, as a non-medical advisor on trans rights but retains a Welsh address.
We shouldn’t forget the damning character report from her appeal against her initial suspension in 2018, which makes for a sobering read. The Tribunal found she had lied to investigators saying “She has deeply ingrained attitudinal flaws which make it impossible for her to reflect in any real sense..." and "She does not show any recognition of proper governance. She is unsuitable.” The full decision can be read here:
Proceedings have been fractious at times, typically because the case preparation wasn’t completed beforehand and because a lot of the defence’s reports have been entered extremely late; including Webberley not submitting her Skeleton Argument until 10th September. The GMCs case management has also been shambolic, for example, they amended their charges after the tribunal had started.
Things came to a head the week beginning 13th September when the prosecuting QC requested the GMC could submit extra evidence after the defence had started its own case. This lack of supporting evidence led to Webberley’s QC applying to have 15 of the original 29 charges dismissed. After nearly a week's deliberation, the tribunal panel announced on Monday 20th September that 10 of those 15 charges were to be wholly or partly dropped. The dropped charges include Gender GP being set up in a manner to avoid UK regulatory frameworks such as the GMC and CQC, and some dishonesty charges. Other charges covering online prescribing through a pharmacy website, ensuring adequate patient follow up, dishonesty around her suspension and operating and controlling Gender GP alongside her husband Michael remain in place.
Most importantly, the charges regarding Webberley’s failure to provide good clinical care to the 3 children with gender dysphoria, Patients A, B and C, remain in their entirety. These span multiple areas of care including a failure to take adequate medical histories, arrange adequate physical and psychological examinations, communicate with other practitioners, errors in prescribing, consent and record keeping. Also a failure to adhere to professional guidelines and working outside the limits of her competence. The list is very long and comprehensive and if found guilty, she will be struck off the medical register.
Over the weeks, Webberley’s QC’s style of cross examination has, we think, deliberately tried to bamboozle the panel by flitting around all over the case in a seemingly random order hoping that something will stick. Or he was looking for an opening that he can prise wide open in order to build his case, such as positioning Webberley as a saviour alleviating the distress of children on long GIDS waiting lists. Thankfully the lack of supporting evidence has only scuppered discrete sections of the case and the central arguments put forward by the GMC remain intact. Much of the prosecution’s argument centres on Webberley working either alone or in what is called a hub and spoke arrangement with a patient's GP/counsellor. One expert witness stated her method had failed to address significant patient comorbidities. This is a very different way of working than the UK and Europe's GIDS standard of a multidisciplinary team (MDT) which provides rigorous assessment and debate about each patient's needs and progress, especially input from specialist paediatric endocrinologists. MDTs are also the typical way of providing Child and Adolescent Mental Health Services (CAMHS) in the UK.
Expert witnesses for the prosecution are clear that being a GP confident in prescribing hormones is insufficient experience for blocking puberty and administering and monitoring cross sex hormones in adolescents, judging that Webberley’s practice fell well below the expected standards of care. They have been adamant regarding the role of medication in distress, with one expert saying: “Of course distress needs to be alleviated, but that alleviation is separate from overall treatment e.g for dysphoria. Distress is something to address in its own right. You would not prescribe cross-sex hormones or puberty blockers "for distress". The GMC has also argued that she hadn’t undertaken the necessary work to acquire competence and lacked supervision.
As expected, Webberley’s QC’s cross examination of witnesses aimed to show that ‘time is of essence for this treatment’ and how, in comparison to the long waiting lists at GIDS, Webberley could provide immediate ‘harm reduction’. Obviously no shortcoming of an NHS service can be an excuse for a private practitioner to evade standards and best practice. This is exactly what she herself has said on 22nd September, her first day of examination by Simon Jackson QC for the GMC. Some of her testimony has been truly eye watering. Here are some highlights:
Q: did you rely on Dr O-K's data in making your judgement for patient A? DRW: no, it was my feeling and general impression that patients were much younger when hormones were prescribed
Q: When did you first prescribe hormones or blockers? DRW: I don't recall when I first prescribed them. SJ: what was the age of that person? DRW: I don't have any records and cannot recall.
Q: in terms of your assessment of competence, you assessed yourself? DRW: Yes, I determined that I was competent to provide that care. SJ: Not an assessment from a third party professional? DRW: an independent self-appraisal. I discussed with lay colleagues and charities… I spoke with colleagues and developed networks, including Susie Green. Did not include experienced clinicians because there is a paucity of experienced clinicians. There was no network of such clinicians.
DRW: I disagree that gender dyshporia is a rare and complex condition these days, it's common.
DRW: I see myself as a gender specialist.
Q: It is not appropriate to draw a parallel between a paediatric endocrinologist working in an MDT in a major centre for gender medicine and your own self-learning and practice? DRW: I disagree that the only way to learn is from people who were all in the same building. My position is that my learning was extensive and from a variety of sources
DRW: Endocrinologists use mental health professionals to do what I can do as GP.
DRW: we were connected by Susie Green, CEO of Mermaids, so that Dr Spak could offer me support as necessary and he sent me many paper copies of articles.
DRW: We involve the people that are most important in that person's immediate circle. It might be mum or dad, an aunt, it could be a friend or a teacher.
DRW: No, I don't agree with training. Does not require the skills of a paediatric endocrinology, as the treatment of transgender is not in the competence of that curriculum.
DRW: I don't agree that those specialists are the only acceptable way to manage transgender patients. GP approach is better
DRW: Gender incongruence is similar to a request for birth control…. It's not my job to diagnose their gender identity.
DRW: No I don't agree with training. Does not require the skills of a paediatric endocrinology, as the treatment of transgender is not in the competence of that curriculum.
DRW: There is no training so I focus on knowledge and skills.
DRW: I took the view that I was able to provide the best care and perhaps better care than NHS/GIDS
I did prescribe blockers for children at Tanner Stage 2 younger than Patient A, identical twin sister of A, was going through puberty as a girl, and A's identity was very fixed as the opposite gender so I made the decision for A that gender-affirming hormones were appropriate. But other patients have different needs.
most doctors are not well informed or not as well informed as their patients. Patients are 'informing' doctors about what best practice and good treatments are.
from discussion with colleagues I knew that the consensus view outside the UK was different and the UK and Amsterdam were considered to be rigid
hormones should match the gender identity of that patient and the appearance of their genitals is not the most relevant factor
But if distress is from lack of access to treatment then we shouldn't withhold those treatments.
I disagree that GD is a rare and complex condition these days, it's common.
The best person to 'diagnose' someone's gender identity is the adolescent or they and their family. The role of the medical doctor is to help the individual achieve their goals. (Webberley disagreeing with the need for a mental health diagnosis).
I started using my own model of care developed during my time as a GP and a sexual health professional. My model of care comes from my experience as a GP. With my model of care, the patient and I decide what happens next. Transgender people shouldn't be treated any differently from other patients
Q: as comparators, you have accepted that the standard of care includes the role of the psychological assessor and the medical provider. DRW: Agreed. But the expertise to do both is within the competence of many doctors
DRW: the future of transgender healthcare is to minimise the stigma that arises from unwanted puberty...through earlier medical intervention. So that young transwomen don't develop large feet, big shoulders and masculine features.
SJ: “Rather than it being triage, you are coming to a conclusion prematurely and being led in that process by the patient saying, ‘What I want is hormone treatment’ the family saying, ‘hormone treatment’. Your acceptance of the patient as being the person who knows best is obscuring your judgment, rather than going through the hoops?” DW: “I don’t agree. I don’t think I came to a conclusion prematurely.
(Thanks to @tribunaltweets, who are covering the hearing)