GMC v Dr. Webberley – GP provision of adolescent gender-affirming care
The care of three GenderGP patients under the care of Dr. Helen Webberley was carefully evaluated by the Medical Practitioner’s Tribunal (MPST) Panel and the High Court between 2021 and 2023.
The hearing consisted of:
- Careful evaluation of the medical records
- Expert opinion from various specialists in the field
- Cross-examination of witnesses and experts to seek their opinions and advice
- Evaluation of National and International research and guidance
- The assessment and diagnostic process
- Prescribing of puberty blockers and gender-affirming hormones
Outcome
The outcome of this case will be very useful in empowering other doctors to find the confidence and gain the skills and knowledge to provide this care.
Dr. Webberley’s model of care that is provided via GenderGP was fully evaluated by the Medical Practitioner’s Tribunal Service (MPTS) in 2021. The panel examined three young transgender patients who were prescribed either puberty blockers or testosterone.
It was determined that Dr. Webberley is indeed to be regarded as a gender specialist and that the GenderGP model of care is in line with international standards of best practice. This is a new and emerging field of medicine. Although that can lead to fear and reluctance to help, patient safety and wellbeing must and always will be at the heart of everything that we do.
Gender-affirming care improves outcomes in many areas of health.
“it is, in the view of the Tribunal, hardly surprising that some GIDS service users, such as Patients A, B and C, sought out Dr. Webberley as an alternative to GIDS. It is also the Tribunal’s finding that for Dr Webberley to have replicated the GIDS care pathway in her own practice would have been absurd, given the resource intensive nature of GIDS and the dissatisfaction expressed by some patients with the care offered to them by GIDS. The logical and proper approach in those circumstances was, in the view of the Tribunal, for Dr Webberley to seek out safe and effective alternatives to the GIDS care pathway and in doing so to embrace the new thinking that transgenderism [sic] is not a mental illness.”
Meet the Patients
Patient A
Patient A was a 12 year old transmasculine adolescent who had been started on puberty blockers at the age of 11 by Professor Butler, the Clinical Lead for the UK Gender Identity Development Service (GIDS). For various reasons, Patient A was very keen to start male puberty at the age of 12 and not wait until the age of 16 which is the current NHS protocol. He was aware that other centres across the world were exploring the earlier use of gender-affirming hormones and he wanted to have the same access.
He had gone through the assessment and diagnostic work up with GIDS and then was assessed by Dr Webberley via GenderGP for eligibility for hormones. Her evaluation was that although young, his gender identity was well established, and the benefits far outweighed any risks of starting hormones at a young age.
The prescribed dose of testosterone was a quarter of a sachet per day and this was found to be appropriate. Importantly, the GenderGP model of care where care is led by a doctor, calling on other specialists such as endocrinologists or psychologists to support a treatment package as and when required, was found to be in keeping with Good Medical Practice.
It was evident that Patient A had thrived on the treatment and that his mental health was at risk from withholding this medication until the age of 16.
Patient B
Patient B was 16 at the time of presentation to GenderGP. He was on a long waiting list for UK NHS care and his mental health was suffering as a result. His natal oestrogen puberty was complete, but he was very keen to start testosterone hormones to allow his body to masculinise and match his gender identity.
Dr Webberley carried out the sole assessment for this patient and the tribunal determined that she was competent to do so and that the assessment was sufficient, without the need for a supplementary report from a psychologist or counsellor.
The testosterone prescribed was approved by the panel as indicated for this use and prescribing was supported in this case by Patient B’s psychiatrist..
Patient C
Patient C was 10 at presentation and was assessed by Dr Webberley and by a psychologist on the same day in her clinic, and the assessment was that puberty blockers would alleviate the distress that was being caused by pubertal development in someone questioning their gender.
Mum was taught how to administer the blocker to Patient C as the GP at the time was reluctant to assist. At the last known time, Patient C had ceased the blocker to resume female puberty. It is not known whether that has since changed.
It was noted in this case the importance of discussing fertility issues at the early stages, even though the effects of puberty blockers themselves are reversible.
Important findings:
- In the mid-2010s the GMC, the NHS and professional associations around the world were promoting the involvement of GPs in transgender healthcare services. WPATHSOC7 and Endocrine Society Guidelines 2009 did not preclude GPs from being hormone prescribers.
- General Practitioners (GPs) are able to assess and create a management plan for the care of transgender people of all ages, including those at the start of puberty and those wishing to start a new puberty.
- GPs are able to gain the skills and knowledge to prescribe and monitor puberty blockers.
- GPs are able to gain the skills and knowledge to manage the induction and progression of puberty with sex hormones. There seems to be no reason to believe that using sex hormones to induce puberty in a transgender adolescent is any less safe than using them to induce puberty in a cisgender adolescent.
- Doctors practising in transgender healthcare in the UK can be described as being ‘self-validated’ in that there are no independently validated qualifications in this ‘new field of medicine’.
- GPs are very well placed to evaluate and manage the mental, psychological and physical health of patients, even young patients, who are gender incongruent. They are perhaps in an even better position than endocrinologists due to their holistic approach to the patient.
- Stage of development, both physical and psychological, is more important than age, when considering treatment plans, and there shouldn’t be a ‘one size fits all’ approach to care.
- With regards to the concerns about desistance, the distinction between gender dysphoria in children and in adolescents is crucial. Gender dysphoria manifesting before puberty (i.e. in children) may be self-remitting, whereas gender dysphoria persisting into puberty or manifesting itself during puberty is far more likely to go on to require gender-affirming therapy.
- The role of puberty blockers in adolescents is not ‘time to think about their gender identity’, they are already settled in their mind and the majority will go on to seek hormone therapy. The role of puberty blockers is to prevent the changes of natal puberty, and gender-affirming hormones should be intrduced when the adolescent is ready, without unnecessarily enforced periods of time on blockers.
- Although being able to refer for specialist input from therapists and mental health practitioners and other healthcare professionals is of course useful, a formal ‘in-house’ multi-disciplinary team is not a prerequisite for being able to provide such care.
- Once a diagnosis is established and treatment criteria are met, there is no need for unnecessary lengthy assessments that may delay treatment.
- Gender incongruence can no longer be classified as a mental illness, although it is acknowledged that there may be reasons why mental health suffers, including rigid protocols and long waits for care.
- In the absence of National or local peer-reviewed, published clinical guidelines, the following guidelines are recognised as an evidence-base for best practice:
- World Professional Association of Transgender Health, Standards of Care version 7 (since updated to version 8)
- The Endocrine Society Guidelines for the care of gender incongruent people
- The University of California and San Fransisco Guidelines for Primary Care