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Day 13 of Dr Helen Webberley’s MPTS hearing began, once again, with an unexpected bundle of evidence being dropped in the defence’s lap. The bundle – some 150 pages of expert testimony with comments – was delivered after close of business on Friday. After a chaotic few moments it was agreed the hearing could continue, with the Chair saying that they were ‘boxed in’ despite Mr Stern saying that it would affect how he could cross-examine.

Dr Daniel Klink, a paediatric endocrinologist working with Genderteam Zuid-Nederlands, was sworn in as an expert witness for the GMC. Dr Klink repeatedly reiterated one of his criticisms of Dr Webberley’s care, namely the need for a Multi DIsciplinary Team (MDT) in the provision of gender-affirming care. This lead to some hilarious takes from the trans community, but more importantly when cross examined by Mr Stern QC, Dr Klink acknowledged that there are many clinics and practitioners who provide transgender healthcare without using MDTs, even NHS clinics in the UK. Dr Klink stated that being able to access an MDT was a position of “privilege”.

 

 

Mr Stern QC outright asked Dr Klink if there was any research or evidence to show that the use of an MDT was the best thing for trans patients. Dr Klink admitted that there was no clear cut evidence to show that an MDT was the best way to provide trans healthcare. Despite this, he went on to say that an MDT was important to ensure that trans people make well-informed decisions and have a ‘successful transition’. Responses from the community were indignant – thousands of people who cannot get access to this ‘gold standard’ of care have still transitioned successfully, despite Dr Klink’s somewhat patronising statement.

 

 

Another criticism levelled at Dr Webberley by the GMC is that as a GP she should not have been prescribing medications for trans youth as she wasn’t sufficiently qualified to do so. Mr Stern QC read from 2008 NHS guidance: ‘Sometimes a GP will develop a specialist interest and be able to provide healthcare and prescribe to transgender patients’. He asked Dr Klink if what he was saying was that provision of hormones was so complex that only a paediatric endocrinologist could do it?

Dr Klink responded that he thought that was the case when treating a developing child.

When pressed, however, he conceded that he wouldn’t say that there was no other way. Mr Stern QC read more from the guidance: “The assessment may be carried out by the GP if the GP feels competent to complete it. If the GP has reason to believe there are co-existing conditions they may require a referral to mental health professionals, but treatment for GD must not be delayed.” He then asked Dr Klink if it followed that a GP can carry out this assessment if they feel competent. Dr Klink agreed.

Later Mr Stern QC read from the WPATH7 Guidelines, which stated that “On competency of hormone prescribers: Psychotherapy is not required but regular interaction with a mental health provider is advised. With appropriate training hormone therapy can be provided by a number of HCPs including nurses and primary care providers.” Dr Klink said “I don’t fully disagree”.

 

 

With Dr Klink having agreed that GPs can, in fact, make this assessment, Mr Stern QC pointed out that the WPATH Standards of Care do not demand that a mental health professional evaluate a trans child or adolescent patient, rather, they list the skills that the evaluating professional should have. Dr Klink did not dispute this, and he also agreed that GPs are used to evaluating not just physical health but mental health as well.

 

 

A consistent theme in the GMC’s Mr Jackson QC’s questioning was around the appropriate age to start gender-affirming treatment. This line of questioning relates to Dr Webberley’s treatment of Patient A, a 12 year old trans boy who was prescribed GnRHa and Testosterone. On multiple occasions Mr Jackson QC pressed Dr Klink about the appropriate age to start gender-affirming hormones, and appeared to be trying to pin down an exact figure. Dr Klink responded by saying that while in 2015 the conventional minimum age for these treatments was 16, clinicians at that time knew 16 was too late and had already moved to 15. Other centres of excellence, he said, start at 14. This evidence appears to directly contradict the evidence of Professor Butler who previously told the Tribunal that gender-affirming treatments aren’t given until 16 and that is the case in the main European states as well: ‘It’s just not done’ he was quoted as saying. Professor Butler and Dr Klink are presumably known to each other as both are members of the ESPE (European Society for Paediatric Endocrinology).

Mr Jackson QC asked Dr Klink to detail the various ways that endocrinologists can measure the development of and changes in transgender youth. Dr Klink was forthcoming, although it was unclear why any of the checks he mentioned – weight, blood pressure, voice deepening – couldn’t be monitored by a GP. When asked about hormone dosage for trans adolescents Dr Klink said that it was relatively straightforward, beginning with a lower dose after blockers and gradually increasing to simulate natural puberty. He said that testosterone injections can cause mood swings and psychological effects (much like endogenous puberty!) but that the body adapts to it in around six months.

Dr Klink explained that each centre relies on it’s own evidence, experience, and practice, because there simply isn’t a great deal of research around on starting age for hormones. He mentioned early onset gender dysphoria, which requires earlier intervention, and added that the idea of the ‘right’ age for interventions was hard to objectify.

 

 

Mr Jackson QC asked Dr Klink what the basis would be for prescribing blockers in the case of Patient B. Dr Klink responded that, in trans healthcare, you tailor the treatment trajectory towards the patient’s wants or needs. When Mr Jackson asked if there was a right way or a wrong way, Dr Klink responded that the most adequate way is to explore the patient’s needs, expectations, and wishes.

Mr Stern QC, referred to the recommendations set out by the Endocrine Society in 2009. These guidelines read, ‘we recommend that the suppression of hormones happens no earlier than Tanner stages 2-3’, but uses softer language to describe gender-affirming hormones: ‘we suggest that pubertal development of the desired opposite sex be initiated at the age of about 16 years’. Dr Klink agreed that, while healthcare practitioners have to meet the criteria set by their local clinical practices, around the world clinicians were providing gender-affirming hormones to people under the age of 16, and the subject continues as an ongoing debate to this day. Ian Stern QC noted that in the Netherlands children can access transgender hormone therapy from the age of 12 with parental consent, something Dr Klink seemed to be unaware of.

 

 

Mr Stern QC read from various research papers showing the positive effects of blockers and hormone therapy on youths. Dr Klink told the Tribunal that his clinic has treated youths as young as nine with puberty blockers. Dr Klink admitted that blockers are a neutral act and agreed that early intervention with blockers could prevent invasive surgery at a later date caused by an unwanted puberty.

 

 

Mr Stern QC read from a U.S study by Joanna Olson Kennedy that found that hormone therapy in youths as young as 12 was safe and effective. Dr Klink said he agreed and had recently published a similar paper of his own.

 

 

Mr Stern asked Dr Klink about the current situation for trans people in Belgium, where Dr Klink practices, and where until 2014 people who wanted to change their gender identity were required to have sterilising surgery. The current legal situation is that a person must have a mental health practitioner state that they have a ‘permanent conviction’ that they belong to a different gender to the one assigned at birth. Dr Klink said that they are currently rethinking this law.

 

 

Mr Stern QC asked Dr Klink about WPATH guidelines, asking was it the case that the guidelines were created more as a consensus document rather than as evidence backed? Dr Klink agreed. Mr Stern QC suggested that it takes so long to get guidelines in place with respect to transgender healthcare that by the time they are signed off they are out of date; Dr Klink said he agreed to a certain extent.

Mr Stern QC pointed out that although patients are theoretically able to pursue private care without compromising their rights to NHS care, in practice transgender patients – including one of the patients with whom this trial is concerned – are disallowed from accessing NHS care if they choose private options. When asked if patients who sought a second opinion at his own clinic would still be able to be seen there, Dr Klink answered that they would not unless they returned to the beginning of the assessment process.

 

 

 

It is alleged that Dr Webberley did not provide an adequate physical examination of her patients. Physical examination can be traumatic for all patients, and is especially difficult for young trans people. Mr Stern asked why doctors can’t just ask the patients what physical changes they’ve had, particularly in the case of genital examinations. Dr Klink replied that it was harder to rely on self-reporting in younger patients as they are less reliable. Mr Stern QC asked Dr Klink what benefit there is to looking at a child’s genitals if you already have information about their tanner stage. Dr Klink replied that in younger age groups it’s because the patient experience “may be biased, for example the patient may say their breasts haven’t regressed as much as they wanted to”.

Ian Stern QC read from American Guidelines that stated their aim as “to aid clinicians to treat trans and gender non-conforming patients. These guidelines compliment existing WPATH and endocrine guidelines. This document states that unnecessary genital exams can be distressing for gender dysphoric patients. “An examination should only be performed on the area only when required to view this particular area” – states only an exam can be performed when it’s really relevant. Otherwise it should not take place.”

 

 

A key argument for the defence is that Dr Webberley was prescribing for harm reduction reasons. Dr Klink said he agreed there is an allowance to provide bridging prescriptions where there is risk of self-harm or suicide. However, when Mr Stern QC asked him what he would do if a suicidal adolescent with gender dysphoria presented to him, he said he would refuse them hormone medication and refer them to a psychiatrist. Being suicidal, he said, is not a reason to start hormones. Those following the hearing online responded with shock and sadness. Not only did it seem unconscionably cold to respond in this way, but it was particularly distressing in light of the patient stories of pain and suffering that Dr Webberley’s team had presented to the tribunal.

 

 

The questions moved on to bone density – a contentious subject, and one that is often thrown around in anti-trans media as grounds for opposing puberty blockers. Dr Klink said that, while bone density should be monitored, if access was not immediately available it was fine to wait as much as two to three years for an X-ray.

Dr Klink is yet to give his specific evidence relating to Dr Webberley’s patients, however his general testimony has confirmed that the age not stage method of dealing with trans children is better than setting a specific age for interventions. He agreed that care – including prescribing – could be given by GPs, (with the caveat that they have some expert guidance or supervision) He agreed that physically, blockers are fully reversible and safe as long as they are not used for too long, in which case they can affect bone density. Dr Klink realised this was an argument for starting hormone therapy earlier, something which he also seems to endorse, where appropriate for that specific patient.

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