This week's developments in the Webberley Tribunal

The Medical Practitioners Tribunal is hearing witnesses and experts on the fitness of Dr Helen Webberley to practise medicine. The GMC present evidence on Webberley’s treatment of patients and calls expert witnesses. Webberley is defended by her own legal team and will call her own experts. Three weeks into the Tribunal, she has not yet presented her own witness statement. 

Here is the Tribunal Tweets collective’s report from the week of 16 August. 

The tribunal heard evidence from Dr Daniel Klink, a paediatric endocrinologist and transgender healthcare expert at the University of Amsterdam. 

The GMC’s barrister Simon Jackson questioned him about what he considers to be the “gold standard” for treating children and adolescents with gender dysphoria. Dr Klink said that in his clinic each individual patient is cared for by a multidisciplinary team (MDT) consisting of mental health professionals, paediatricians, endocrinologists, and sometimes other specialists including physical and speech therapists where necessary. 

Young patients are normally within their care for three to four years before hormones are considered, and that these are only prescribed after many sessions of counselling to ensure that the patient fully understands the consequences of receiving puberty blockers and/or cross sex hormones. 

Dr Klink talked about the importance of informed consent and follow-up of the patients to ensure that they were being monitored for changes to their physical and mental health after receiving treatment. He said the average age in his clinic for starting hormone treatment was 16.

Helen Webberley’s QC Ian Stern followed with his cross-examination. He questioned Dr Klink’s credentials as an expert legal witness and intimated that he, Klink, was not familiar with the state of transgender healthcare in the UK. Stern spent much time quoting from an 2008 NHS document called Guidance for GPs, other clinicians and health professionals on the care of gender variant people” which was co-authored by transgender GP Dr Richard Curtis. (This doctor has been investigated by the GMC on three separate occasions after being accused of prescribing sex-change hormones to several patients that were not appropriate, and ignoring restrictions placed on his practice.) This guidance concerns the treatment of transexual adults, not children or adolescents, as Dr Klink pointed out several times. 

Ian Stern then tried to elicit agreement from Dr Klink that it is acceptable for a GP to prescribe hormones to children, focussing on the necessity of “bridging prescriptions” when a specialist is not available. He also attempted to persuade Dr Klink to agree that if an adolescent said they had suicidal thoughts, it was acceptable for a GP to prescribe hormones to prevent self-harm. Dr Klink refused to be drawn on this and said that a child presenting with suicidal thoughts should always be referred to a psychiatrist. 

The next day, cross-examination by Ian Stern QC continued. Stern delivered a rapid barrage of questions and references to many guidance documents and articles. Many of the issues were brought up repeatedly (including from yesterday). Dr Klink appeared to find these questions at times frustrating - not least when the guidance referred to by Stern related to adults, rather than adolescents or children.

Dr Klink pointed out that treating children is much more complicated and requires expert input for diagnosis and medication/monitoring. He was adamant that for adolescents, multidisciplinary teams or their equivalent are required at all stages, along with input from multiple experts involving robust debate.

He pointed out that as there’s not yet any data on outcomes for under-16s started on cross-sex hormones and these are a vulnerable cohort, careful consideration of any and all treatments is needed. Although he appreciates the drivers for earlier treatment and that this is an area of robust debate, he feels that primary care doctors are unable to prescribe blockers or cross-sex hormones without specialist support, even as bridging care.

Other noteworthy points from the cross-examination:

• Dr Klink stated that the experience of treatment isn’t fully reversible; even if some changes can be reversed, it’s hard to stop and has fertility implications

• Flexibility of care is needed for geographical reasons but this requires protocols and guidelines by experienced practitioners. You need good arguments and reasoning to proceed differently from your expert peers.

• Dr Klink stressed the importance of an MDT before prescribing hormones in adolescents

• There is not yet any outcome data on those starting cross-sex hormones under the age of 16, so we should be careful how we treat these vulnerable adolescents and children. This should also be balanced against length of time on puberty blockers.

• In the absence of an MDT, Paediatric Endocrinology should liaise with mental health professionals for thorough exploration of GD and ways forward.

• GMC Bridging guidance is only for adults. In his view, the only appropriate bridging medication that should be given prior to full assessment by specialists is oral progesterone to stop menses 

• There is only data on a small number of patients who began CSH before age 16, and as this isn’t age-banded it’s hard to assess safety in this group

The charge sheet was updated and can be found here. Webberley has admitted charges 28 & 29 concerning her 2018 criminal conviction and £12,000 fine for running an unregistered medical agency. Her GMC license to practice medicine has been suspended by an interim order tribunal during the investigation and tribunal. 

This report has been written by a loosely organised collective of volunteers, attending in their own time at their own cost, to report from the Medical Practitioner Tribunal Service in  Manchester. Follow them on twitter at @tribunaltweets or you can catch up using this thread reader.