en English

On day 36, counsel for the GMC Mr Jackson QC, cross examined Dr Pasterski, witness for the defence. Dr Vickie Pasterski is a psychologist, psychotherapist, and gender specialist. She has over two decades of experience in the field of gender identity services, having initially studied psychology at Loyola Marymount University, LA, before pursuing a doctorate in behavioural neuroendocrinology at the University of London and a post doctorate in the diagnosis and management of gender dysphoria at Columbia University, New York. As part of her doctoral training she worked with specialists in paediatric endocrinology at Great Ormond Street, and from 2008 to 2016 she was a clinical research psychologist in paediatric endocrinology at Addenbrooke’s Hospital.

Mr Jackson QC suggested to Dr Pasterski that there is an important distinction between prescribing for adults and adolescents, to which Dr Pasterski replied that she did not agree. “Once puberty has started and that individual has demonstrated whether they are 15,16,18,22 or 40 that they are living in preferred gender role and that all indications suggest they should go forward with treatment, I would say there’s no difference in age.”



Then Mr Jackson QC asked Dr Pasterski if she agreed that there is a greater need for support for peri-pubertal children during early treatment. Dr Pasterski reminded Mr Jackson QC that there are no medical treatments available to peri-pubertal children. It’s hard to know where Mr Jackson was going with this question, it doesn’t seem possible that he could have reached this stage of the hearing and not be aware of the fact that Tanner Stage 2 is the earliest time any interventions are required for trans children.



Questioning the training required to prescribe to trans adolescents, Mr Jackson QC asked Dr Pasterski if she felt it was very important that prior to prescribing a clinician should look for assistance or peer review. Dr Pasterski simply responded that if someone is qualified to prescribe, they should prescribe. Dr Webberley has repeatedly stated her expertise in managing hormone treatments in both cis and trans patients, she also told the hearing that there had never been any medical adverse reactions as a result of the hormones she prescribed for trans patients.



Mr Jackson QC asked Dr Pasterski about the importance of MDTs in providing care for trans patients. Dr Pasterski clarified that MDTs do not mean that every member of the team must see or assess a patient, but that it is a way for patients to have faster access to any care they may need.



Asking about the importance of addressing psycho-sexual and social issues with trans youth, Mr Jackson QC implied these should be addressed before treatment is offered. Dr Pasterski disagreed, adding that there are clinical guidelines that say Doctors should provide care. ”That’s where you start, if the aim is harm reduction then delays to treatment cause an incredible amount of distress.”

Mr Jackson QC pushed his line of questioning further, “I’m suggesting one has to consider with care what are the options to reduce harm and how that can be achieved, one shouldn’t simply consider that medical intervention is the only route to reduce risk of harm.”

Dr Pasterski addressed this attempt at legitimising the withholding of life-saving treatment with a measured response,”I’m not really sure how to answer that, the clinical guidance is that medical intervention is the appropriate treatment for gender dysphoria. Are you suggesting there’s another method of treatment that doesn’t involve Hormone therapy?”



Mr Jackson said he was addressing the timing of prescribing with his question. Dr Pasterski replied that the timing was “ very clearly laid out” in clinical guidance and that, “knowing when to prescribe is actually quite simple and explicit.” Dr Pasterski added that it would be counterproductive to insist on lengthy discussions before prescribing.



Raising the issue of capacity to consent Mr Jackson asked Dr Pasterski if she believed all cases require evaluation as to if the child understands “the implications of embarking on something that may proceed to be lifelong treatment?” Dr Pasterski responded, “We have to establish understanding according to their level of development, it’s not contra-indicative that someone start hormones or blockers only because they don’t have the cognitive development of a 25 year old. If for their age they can understand implications, if they have age appropriate understanding, then yes you can prescribe. Their comprehension is not based on the understanding of someone who is much older.”



Mr Jackson asked Dr Pasterski about the treatment plan for Patient A. Dr Pasterski said that under the NHS Patient A was facing being on blockers until they were 16, which she described as being “far too long”. Dr Pasterski shared that blocker use is only recommended for six months with cis adolescents but the guidelines allow for 24 month use in trans adolescents and if Patient a had continued to receive care solely from the NHS he would have been on blockers for four years.



Dr Pasterski finished her testimony with some revelations about the Tavistock and UCLH that Mr Jackson appeared to find shocking (but that won’t shock many of the trans patients of these clinics). Dr Pasterski said that she was aware from her other patients that they felt they received insufficient support from Tavistock and that “Patient A got very little support from Tavi and no reply from Professor Butler”.



After lunch Dr Shumer returned to give evidence. Dr Shumer stated that his position on the time to prescribe gender affirming hormones is a stage not age approach, “It has a lot more to do with developmental stage, sources of distress. Putting a hard & fast age cutoff on a developmental issue can be a harmful criteria for making these types of decisions.”

Mr Jackson QC appeared surprised when he heard that social workers triage the incoming patients to Dr Shumer’s clinic. He asked what level of training the social workers had and Dr Shumer said they were Masters level social workers considered Mental health workers in the US.



Dr Shumer said that there were times when physical examinations of pubertal youth were not needed, especially in cases where it would be traumatising for the child. This contrasts with the practise of Professor Gary Butler, who said that Dr Webberley should have carried out a physical exam on Patient A.



Contrary to the testimony of KOI’s Dr Kierans, Dr Shumer said that it is not necessary to have all mental health issues treated before embarking on hormone therapy. He also stated that puberty blockers have no effect on fertility and therefore fertility is not a discussion that needs to be had with puberty blocker candidates.



Mr Jackson appeared to push back on this, citing arguments used in the now-overruled Bell V Tavistock case that because a large percentage of youth on puberty blockers go on to choose hormone therapy that means discussions about fertility should be happening when puberty blockers are prescribed. Dr Shumer replied that, “conversations about fertility and Puberty Blockers are more geared toward parents, as the role of Puberty Blockers is to allow maturation to occur without the impact of puberty so more mature conversations about puberty can occur later on.”



Speaking about being a provider of healthcare to trans youth, Dr Shumer said, “ for some people the premise of providing interventions for young people with gender dysphoria is met with astonishment, whereas other people, myself included, know this care to be life saving. Our politics…we are a deeply divided country along politics, many places are trying to make the work I do illegal, and other states have no protections for trans individuals and they’re discriminated against. Providers in this field have to have some courage in that they know what they’re doing is controversial in some places.”



Finally, Dr Shumer finished with a resounding endorsement of Dr Webberley’s actions and care provided. He said he believed she had the necessary expertise to prescribe and monitor this cohort, that he could understand why patients went to her for care and that the care she provided was beneficial to her patients.