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Professor Gary Butler, witness for the GMC, admitted during cross-examination on day 4, that there is no qualification pathway and no formal qualifications for treating patients with gender dysphoria. One of the allegations against Dr Webberley is that she claimed to be a gender specialist but did not have the relevant qualifications, but Butler’s testimony here seems to suggest that there was no pathway available that she could achieve this within the NHS (she instead pursued specialist training through, for instance, WPATH).

Prof Butler insisted that to treat GD you must be a paediatric endocrinologist but when Ian Stern QC, counsel for Dr Webberley, asked whether gender dysphoria was available on the medical curriculum in 2016 Professor Butler avoided this question. When pressed he said it likely wasn’t, “probably not formally.” (And it still isn’t today). On Day 5 Psychiatrist Dr Roger Walters admitted that he was not a specialist in treating patients with gender dysphoria either, though he said that since Patient A’s case he had undertaken specialist training. When questioned as to what the training was, Dr Walters said it was a one day course for CAMHS practitioners.

 

 

A key point in favour of gender-affirming care came when Professor Butler confirmed that numerous studies confirm that puberty blockers do not irreversibly damage bone density, (despite this being a key talking point in anti-trans discourses).

Ian Stern asked Professor Butler what adolescents who begin puberty blockers aged 12 should do if they cannot progress from blockers to hormone therapy until the age of 16? Professor Butler said that that is “the reason in the past why puberty blockers only started at 15-16” but did not offer a solution for what could be done in this situation. (In fact, later intervention with puberty blockers, as suggested here, are significantly less effective. Evidence has shown that puberty blocking treatment is most effective when begun around Tanner stage 2, as recommended in e.g. the WPATH Standards of Care.)

One of the tribunal members asked Professor Butler about the NHS Service specifications that relate to the prescribing of cross sex hormones to children under the age of 16. The Chair asked where is the evidence for the age of 16 coming from and what is it that led the NHS to say it is not advisable? Profesor Butler replied that there was not enough evidence. “There have been no studies, no one has experience of treating someone that age” said Professor Butler, a statement which is demonstrably untrue and which excludes a considerable quantity of international research and practice.

 

 

The tribunal member asked would it be fair to say that, “The Review of the evidence is there is no evidence?” Professor Butler agreed. (Despite the fact that there is evidence available that presumably Prof Butler is unaware of?). The tribunal member then said “So it’s only not advisable because there is no evidence, not that there is evidence to suggest a negative outcome?” and Prof Butler again agreed. In fact, not only is there no evidence for a ‘negative outcome’ from treating children under 16 with gender-affirming hormones, but the most recent evidence suggests that early interventions are linked to improvements in wellbeing and mental health outcomes.

Dr Webberley’s counsel Ian Stern QC produced evidence in the form of a letter from UCLH (Professor Butler’s employer) to Patient A’s Mum stating that young people may be given hormones from 14 “in exceptional circumstances”. In response to this Professor Butler said he didn’t know of any exceptional circumstances where someone under 16 could be prescribed Cross Sex Hormones.

 

 

Ian Stern identified discrepancies between letters from Professor Butler regarding the amount of testosterone prescribed to Patient A (having referred variously to half a sachet and a quarter of a sachet of testogel). This is significant because the safe prescription of testosterone is a key factor in the allegations against Dr Webberley.

During the questioning around Patient A, Professor Butler was cross-examined on his concerns that Dr Webberley’s prescription of testosterone might stunt the patient’s growth. The tribunal heard that Professor Butler’s fears were unfounded and that Patient A is now taller than his twin sister. When Professor Butler was told of Patient A’s current height he deemed the information “irrelevant”. Professor Butler said his concerns were based on predictions of expected height for a feminine, rather than masculine hormone profile. This seems to completely ignore Patient A’s transmasculine pathway, and disregards the desired outcome of early gender-affirming treatment.

It also emerged that Patient A’s mother had made a complaint about Professor Butler to his employer UCHL, and to the GMC. Patient A’s mother said that Professor Butler implied that Patient A could start testosterone earlier than 16 but when she next met him Professor Butler “casually shrugged off” the suggestion and said that it would only be available for 15 year olds. The hearing heard that Patient A’s mother said she begged Professor Butler to give Patient A Cross Sex Hormones as it would be life-saving for him. In response Professor Butler said it’s not possible under the NHS for under 16’s to receive Cross Sex Hormones, so therefore he couldn’t offer it to Patient A.

 

 

Simon Jackson QC, counsel for the GMC, asked Professor Butler what guidance clinicians should follow. Professor Butler responded by saying that BAGIS (The British Association for Gender Identity Specialists) are a recently formed association he is connected with whose aim is to set professional guidelines and standards of care for the treatment of transgender patients.

Professor Butler claimed that it is a recent association, (BAGIS was formed in 2014), and he said they were working on guidelines. Our investigations found that they have not produced any clinical guidelines or standards of care despite being founded 7 years ago and hosting six symposia for their members.

 

 

Simon Jackson then asked Professor Butler what qualifications are necessary to make a diagnosis of gender dysphoria, and Professor Butler responded that the person would need to be a fully qualified psychologist/psychiatrist etc. and would need an additional period of training. It is unclear why Professor Butler insists that this diagnostic capacity should be restricted to mental health professionals, when the ICD-11 no longer classifies gender dysphoria as a mental disorder but as part of a group of conditions relating to sexual health (especially considering the aforementioned lack of pathways for medical professionals to become specialists in transgender medicine).

He went on to ask Professor Butler to explain the NHS Service Specifications for diagnosis of gender dysphoria. Professor Butler responded that a minimum of four assessments are required over six months, and that “The young person must cooperate with GIDS and ourselves if they wish to receive treatment”. This (understandably) provoked backlash from the trans and non-binary community with its implication that trans people’s compliance must be extorted. It seems particularly insensitive given how inaccessible current specialist services are, and how invasive the NHS assessment process can be.

 

 

Dr Roger Walters, a Consultant Child and Adolescent Psychiatrist for CAMHS saw Dr Webberley’s prior patient, 17 year old Patient B, for low mood and suicidal ideation. Dr Walters said that he was aware that Dr Webberley had requested a shared care agreement with Patient B’s GP, but that he could find no such shared care agreement when he attended the GP’s surgery to look through Patient B’s notes.

Dr Walters explained that Patient B had been referred to him regarding a possible need for anti-depressants, and conceded that gender dysphoria is outside his experience – he is not an expert. Despite this, he provided a bridging prescription of testosterone in the interests of harm reduction. The amount he prescribed was half a sachet of testogel. Ian Stern asked whether this was a normal dosage. Dr Walters said considering Patient B’s medical history it was not an abnormal dose. Dr Walters said he had discussed Patient B with Professor Butler but admitted under cross-examination that he could not say whether he had consulted him specifically about the dosage before making the bridging prescription. This is important to Dr Webberley’s case as she is accused of prescribing the same dosage without consulting with or being supervised by an endocrinologist.

Dr Walters’ testimony here seems to vindicate Dr Webberley. The allegations against her include A) Prescribing testosterone without sufficient expertise or specialist knowledge; B) Prescribing testogel in a half sachet measure, which is difficult to administer accurately; and C) Prescribing without consulting an endocrinologist. If Dr Walters concedes to doing all of these things for harm reduction, it seems extremely unreasonable that Dr Webberley should be put on trial for doing the same.

Dr Walters reiterated that Patient B was not referred to him because of concerns about his testosterone prescription, he was referred because of his mental health issues. The hearing heard from Dr Walters that patient B’s triggers included feeling like he wasn’t being listened to, worry about the delay in receiving gender affirming healthcare, and his experience of poor responses from other professionals (including CAMHS). Dr Walters said that Patient B’s poor mental health was connected to his gender dysphoria, but that his depression and suicidal ideation were not entirely motivated by gender dysphoria. Dr Walters emphasised that the bridging prescription was important for harm reduction in the context of Patient B’s mental health, and he acknowledged that the response from both CAMHS and the GIC had aggravated Patient B’s mental health.

 

 

Photo by George Becker from Pexels