Helen Webberley - hearing continues

Determination on sanction is expected imminently according to TT.

The committee's determination on misconduct and impairment can be found here...

www.dropbox.com/s/vn772ae59r9ubmv/Dr%20Helen%20WEBBERLEY%20%283657058%29%20DETERMINATION%20ON%20IMPAIRMENT%20–%2028_06_2022%20Impairment%20-%20FINAL%20%281%29.pdf?dl=0

That’s pretty bad, surely?

Sounds pretty bad doesn’t it? Especially since she’s had around 5 years to think about it.

I just get the impression that this committee are really quite sympathetic to HW.

Thanks for the link.

It also says the tribunal did not consider she had developed sufficient understanding as to i ) the significance of how she had failed 11 year old patient C by not discussing the risks to fertility before prescribing puberty blockers and as to ii) how she can be sure this will not be repeated.

That’s pretty bad, surely?

I get the feeling that this committee will find a way to allow HW to return to practise.

“The tribunal said it was satisfied that Dr Webberley would implement changes if she returned to practice.”

www.bbc.co.uk/news/uk-wales-61970235.amp

There’s an item about the misconduct findings on the Wales news page on bbc co uk

There is a vanguard alright, Helen. But, it’s coming towards you.

Decision on sanction expected on 30th June.

HW's defence are submitting that public interest would be damaged by a sanction of suspension because then HW wouldn't be able to treat patients with her "vanguard approach [...] saving the lives of many patients."

The GMC have asked for a suspension (presumably with a review)...

@ tribunaltweets...
SJ: GMC submission is that minimum sanction is suspension. That avoidance of regulation (the conviction) is a risk of future risks to patient safety and public confidence. GMC is submitting that tribunal should impose a suspension.

Whatever happens she’ll lose her licence in the end, because she doesn’t accept that she has to practise in line with medical and legal norms.

Helen Webberley hearing has been continuing today. The committee have found misconduct and current impairment and are now hearing submissions on sanction.

twitter.com/tribunaltweets/status/1541700082717925377

Tribunal are considering sanctions and will return by last week of June.

'The panel will now withdraw to consider whether HW fitness to practice is impaired. Which will take some time. If we have reached a decision at the end of next week we will let you have it; otherwise it will be the last week of June'

threadreaderapp.com/thread/1534809749828603904.html

MW, I think.

HW - This pt cohort have a very high rate of self harm and suicide. I thought I could help and can’t. Real risk of harm. I’ve seen and experience suicide on this pt group - I have to give big consideration to.

There has been at least one suicide of a patient of the Webberleys. A female patient who had been prescribed testosterone (not sure if HW or MW was the prescribing doctor).

thanks for updates.

Also the risk that she poses is not easy to remediate because it is attitudinal. There isn't a course she can go on to learn about the importance of being registered as a health care prescriber. At this point in time she still isn't certain how she would act if put in the same situation. She says that "Hypothetically, if I was - I’d be faced with exactly the same situation. It’s horrible. Do I save myself or risk the care to pts. I’d like to hope. I’d never put myself in that situation."

She also says in relation to her criminal conviction...

"I don’t think I’ve said he didn’t take it into account. He said in terms did I break the law yes - definitely. But reasons why I did it, this wasn't a charlatan, I was helping pts. Pts would have come to harm because of lack of service elsewhere."

She doesn't perceive that what she did put patients at risk. In fact she thinks the opposite, that she would have put patients at risk from stopping. She just doesn't get it. I'm not sure how the committee could look at this and consider that she is safe to be working with patients.

I'm confused about what the threshold is for criminal charges for this pair. If a medic is found to be lacking in adhering to informed consent, keeping robust notes or doing a thorough assessment then they are inevitably doing harm to children (in these cases).

I'd like to see them pursued in the civil courts and am hoping there is enough in the judgement today to see this woman be held to account.

I can dream, I guess.

I've been watching. The questions that the committee asked HW were quite revealing I thought. Especially in relation to the criminal conviction and working without being regulated and how would she do things differently now if faced with the same situation. They show a worrying lack of insight (which isn't a huge surprise). I can't see how the committee could possibly conclude that there was no risk of repetition....

C - took a bit longer. We have one or two questions.

P (panel member) - one area - requirement to liaise on shared care or multiple professionals.
If I understood your evidence if there’s a risk of drug interaction, that’s when sharing is important and also consent.

Q1 - is it your position that Professor Butler didn't need to know you were prescribing testosterone to pt A.

Q2 if faced with a situation in the future where pt was withholding consent, [does] the dr pt imperative override the liaison [with colleagues] imperative?

HW - is it that Prof B did not need to know abt testosterone for Pt A?

Obviously, not a yes or no answer. So all should be aware - best care all come together and collaborate - best for Pt A.

HW - In UK, we lack protocol, clinical guidelines, the only guideline is the NHS working to GIDS. UCLH and GPs - clearly said Pt A wasn’t allowed the treatment.
Prof B was already against that treatment for Pt A.
Protocol also says highly unusually, NHS care would be withdrawn.

HW - Quite unusual. I was faced I was operating different clinical guidelines,
UCSG, Endocrine Society and WPATH and I was faced a Pt who was desperate. To have that care, I feared for his mental health.

HW - It wasn’t that Prof B didn’t need to know. It was that his care would have been withdrawn. The family couldn’t afford the blocker privately. So he’d have gone through a female puberty. He knew what was the case. They [pt and his mother] didn’t want him [Prof B] to know.

HW - The reason I gave the roaccutane example. If Pt continues with PB, no interaction with [my prescription]. Might have come to light[if pt developed] facial hair & dropped voice.

But not a risk of harm if other prescriber not aware.

HW - In beginning, people are very scared. Then we discuss more collaboratively, the acute distress - when that’s the [goal]. Then it’s the time to have that discussion and Dr Deane's persuasive words - not time zero or never.

HW - In terms of future - the first priority safety of Pt - that Pt ends up with best care, whatever that best care is. It’s important to work on patient doctor relationship, know you’ve got their [confidence] will reach the best outcomes.

HW - The only time you’d break that is if at risk of harm.

My relationship with pt is utmost importance and outcome is most important. To risk breaking that in favour of a doctor doctor relationship.

HW - There have been times in my sexual health practice, where I have to break it, and I can tell you about times when I have.

P - you’ve clarified that very well. If [you have the] dilemma [of a pt] withholding consent, will you take advice from a colleague or a supervisor?

HW - I haven’t had experience of immediate danger in my transgender work. Best made with [lists types of colleagues, primary care etc] and medical defence union] even then ask is that what you would do.

HW - Have I got that right? Increased doctor communications - not just next door or on phone. Many ways [for advice online].

Grateful you clarified.

C - in 2016/17 - you spoke of large clientele - you mentioned GPs having 6k pts,. How many gender pts?

HW - You’ve picked on something which is definitely not my forte. I would be guessing 500 or maybe 1,000. Asked in
PACE interview. I don’t recall. Quite difficult.

HW - Not everybody is on medication - some accessing support or questions, accessing [counselling] Marianne Oakes and Avril Collet. Every GP has around 6k. It wasn’t that many but it was a significant number.

P - where did you get 6,000 pt number from?

HW - I think that’s what the average list is in the valleys in wales.

P Are you aware Wales have less pts than in England?

HW - No

P - you told them you’d not see new Pt. If similar situation occurs, how would you [handle it]?

I’ve learnt so much - not just dr needs to be regulated but also service. I will always make sure any service I have has the required regulation. I don't think I'd start up a new service. I‘d make sure any service would have the regulation.

P - how will you deal if it happens again. What about existing pts?

HW - I would like to think I’d never be in that situation that iId be needing to stop care. I don’t think the situation would arise again. Without making sure.

Hypothetically, if I was - I’d be faced with exactly the same situation. It’s horrible. Do I save myself or risk the care to pts. I’d like to hope. I’d never put myself in that situation.

P - were you able to get any help from any colleagues?

HW - I was heavily involved in the community.

That’s when [name] GIRES and [name] Unique write to HIW to express there were concerns - hurry up and get service registered - would be a safer outcome.

Discussing widely with colleagues and charities.

HW - I can't remember if I discussed it with my indemnity provider. They’d have had to have their treatment stopped, and I was scared of the harm that would [happen]. Even disappointment is a harm.

HW - This pt cohort have a very high rate of self harm and suicide. I thought I could help and can’t. Real risk of harm. I’ve seen and experience suicide on this pt group - I have to give big consideration to.

C - I realise the conviction is about managing the medical agency without being registered. Timing questions - HIW interview - some confusion about what company needed to be registered, and in matrix reference as to which provision to register under.

Q1 - to what extent if at all do you say problems over confusion one which company or relevant provision played a part in not applying earlier.

HW - No. Explain timeframe. Aug 2016 - crikey let me sort it out. I made inquiries. Who is service provider. Well I am. It needs to be a company. Yr websites need to be registered. What are the companies?

HW - There was confusion - I had company names mywebdoctor and Gender GP - but not trading. So we started 2 applications and then some time into it they said not trading.

HW - And I said I have Online GP Services ltd , which I used for tax - so new application went in. Confusion around the clinic and agency - 2 sets of legislation and HIW guidelines. I was seeing pts in Abergavenny. Newport and London. So I applied as a clinic.

HW - It wasn’t until April 2107 that I had notice of proposal to
refuse registration as 1) not fit and proper person and 2) does not fit scope of registration - not a clinic.

HW - I sought advice, discussion between my representatives and HIW - does this mean it’s an agency - eg offering flu jabs. Not fixed premises. As time went on - miscommunication - formal notice in August 2017 didn’t arrive. Went to my representative.

HW - Can I come and speak to you re agency or clinic? Kate Chamberlain HIW said no need for a meeting. If situation has changed, put in new application.

HW - for me I still didn’t know. I realised I wouldn’t get registration and I needed to secure safety of my pts. I think if application had gone forward in August - it would have been accepted as the other difficulty would not have come to light.

C - para 28 allegations March 16 to Feb 18 - you are saying you might have been registered?

HW - yes. 10 March is first letter. First letters said we are working out so you can continue while we work towards registration. So I believed we were working towards registration.

C - in term of sentencing remarks, I think subject of observations you made in a podcast. Yr complaint is your case wasn’t taken into account, the judge understanding why you were continuing to provide treatment, why you continued to look after yr cohort?

HW - I don’t think I’ve said he didn’t take it into account. He said in terms did I break the law yes - definitely. But reasons why I did it, this wasn't a charlatan, I was helping pts. Pts would have come to harm because of lack of service elsewhere.

HW - But reasons why I did it, this wasn't a charlatan, I was helping pts. Pts would have come to harm because of lack of service elsewhere. But his job - a service that require registration.

C - thank you. Any question arising from trib?

SJ - interesting issue on status of sentencing remarks. Judgment doesn’t bind a trib in context, but here these charges were pleaded to and admitted before the trib. Weight and consideration LJ Mostyn in a case - now in course of trib questions, touches on those.

Reconcile approach adopted by court proceedings and evidence from HW during the trib.

I’d want to check various matters.

C - So we need to adjourn for just under an hour to 2.30pm.

(from tribunaltweets twitter account)

The Helen Webberley tribunal has started again. They are hearing evidence to decide whether & what the sanction or remedy should be.

Tribunal tweets have been live tweeting but I have not followed as yet so don't know what's been said.

mobile.twitter.com/tribunaltweets/status/1534218628454928384

This is an interesting analysis of the determination...

voidifremoved.substack.com/p/no-competence-needed?s=r&utm_campaign=post&utm_medium=web&utm_source=direct

I think those of us who were following tribunal tweets on Twitter thought the evidence against Webberley to be damning.

This - along with the "assigned at birth" judge in the Allison Bailey case - makes me think we've been getting overconfident

I would also like to know if the chair is a medical or a lawyer. How does it normally work? Lawyer I think.

I think there is a mismatch between how we see things & how they can be perceived by others including judges, which is worth remembering. Alot of ppl on the other side followed live tweeting, and they thought it went really well, saying she was 'schooling' the court on how to provide care. Ibtelligent ppl (!) not just anime avatars who say 'lmao' alot. She was able (rightly) to defend herself and explain everything from her own perspective. She has obviously persuaded the chair by how she came across and what she said. He came to agree with her view of the treatment they do.

But still, 36 counts proved.

A bit if a tangent but as an example, Allison Bailey said she didn't want to be referred to as cis. The case is about beliefs & it's a bit like not wishing to be called an infidel, heretic, gentile or whatever. But she also said she would refer to individual tw as men because that's her belief (yes I know we think it's a fact but the other lot think it's an erroneous belief, and that's the realm that the case is in). So I don't know how that will go down with the judge. Are witnesses not allowed to use the language & framing of their own belief to call Allison cis, but they have to accept the language & framing of her belief to call them a man even if they don't believe it. Surely the witness has to be able to use their own language in giving evidence even if it's about Allison? So I didn't cheer about that when I read it in the tweets.

Pretty upsetting that the WHO are ideologically captured along with (a large chunk of) the judiciary and frontline nhs services

Thanks fir the explainer. I had wondered why the differences between dsm5 and icd 11 proposals and now i know.

Re HW, anyone have a feel for the likely sanction? I also hate the mpts verdicts and find the process arbitrary. (if HW were to be of a different skin colour I wonder if the result would be different)

I. Think one reason she's not been as severely criticised is because the families /parents are on her side. This doesn't mean she's right though!

Anyone know if the result can be appealed?l

Comparison with DSM-5

The most important difference between the proposals for ICD-11 and the DSM-5 is that the latter has retained the categories related to gender identity as a part of its classification of mental disorders. Both childhood and adult forms of Gender identity disorder in DSM-IV have been renamed in DSM-5 as Gender dysphoria, defined by “marked incongruence between one's experienced/expressed gender and assigned gender of at least 6 months’ duration” and “clinically significant distress or impairment in social, school, or other important areas of functioning”3. Both the name of the DSM-5 condition − dysphoria − and the diagnostic criteria, therefore, emphasize distress and dysfunction as integral aspects of the condition. They are also the central rationale for classifying these conditions as mental disorders; without distress or dysfunction, gender dysphoria would not fulfill the requirements of DSM-5's own definition of a mental disorder.

In contrast, the proposal for ICD-11 is to include child and adult Gender incongruence categories in another chapter that explicitly integrates medical and psychological perspectives, Conditions Related to Sexual Health. The proposed ICD-11 diagnostic guidelines indicate that distress and dysfunction, although not necessary for a diagnosis of Gender incongruence, may occur in disapproving social environments and that individuals with gender incongruence are at increased risk for psychological distress, psychiatric symptoms, social isolation, school drop-out, loss of employment, homelessness, disrupted interpersonal relationships, physical injuries, social rejection, stigmatization, victimization, and violence. At the same time, particularly in countries with progressive laws and policies, young transgender people living in supportive environments still seek health services, even in the absence of distress or impairment. The ICD-11 approach provides for this.

A challenge to DSM-5 conceptualization of Gender dysphoria is, therefore, the question of whether distress and dysfunction related to the social consequences of gender variance (e.g., stigmatization, violence) can be distinguished from distress related to transgender identity itself83, 84. A recent study of 250 transgender adults receiving services at the only publicly funded clinic in Mexico City providing comprehensive services for transgender people71 found that distress and dysfunction associated with emerging transgender identity were very common, but not universal. However, more than three-quarters of participants reported having experienced social rejection and nearly two-thirds had experienced violence related to their gender identity during childhood or adolescence. Distress and dysfunction were more strongly predicted by experiences of social rejection and violence than by features related to gender incongruence. These data provide further support for ICD-11's conceptualization and the removal of gender incongruence from the classification of mental disorders.

Finally, there are several technical differences between the proposals for ICD-11 and DSM-5 in relation to these categories. The most substantive is that the DSM-5 diagnosis of Gender dysphoria of childhood requires a duration of only six months, in contrast to two years in the ICD-11 proposal, and does not specify a lower age limit at which the diagnosis can be applied.

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Links to Full Text (Open access) here: pubmed.ncbi.nlm.nih.gov/27717275/

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The area of transgender health is characterized by calls for change in health system responses 58, 74, 75, by rapid change in social attitudes in some countries, and by controversy. As a part of this work, the Working Group on Sexual Disorders and Sexual Health received proposals and opinions from a wide range of civil societies, professional organizations, and other interested parties 72, 73. The most controversial issue has been the question of whether the childhood diagnostic category should be retained 73. The main argument advanced against retaining the category is that stigmatization associated with being diagnosed with any health condition − not just a mental disorder diagnosis − is potentially harmful to children who will in any case not be receiving medical interventions before puberty 76. A more substantive critique is that, if it is the case that the problems of extremely gender-variant children arise primarily from hostile social reactions and victimization, assigning a diagnosis to the child amounts to blaming the victim 77. This latter concern suggests a need for further research as well as a broader social conversation. The Working Group has recommended retaining the category based on the rationale that it will preserve access to treatment for this vulnerable and already stigmatized group. Treatment most often consists of specialized supportive mental health services as well as family and social (e.g., school) interventions73, while treatments aimed at suppressing gender-variant behaviours in children are increasingly viewed as unethical.

The diagnosis also serves to alert health professionals that a transgender identity in childhood often does not develop seamlessly into an adult transgender identity. Available research instead indicates that the majority of children diagnosed with DSM-IV Gender identity disorder of childhood, which was not as strict in its requirements as those proposed for ICD-11, grow up to be cisgender (non-transgender) adults with a homosexual orientation 78-80. In spite of the claims of some clinicians to be able to distinguish between children whose transgender identity is likely to persist into adolescence and adulthood and those likely to be gay or lesbian, there is considerable overlap between these groups in all predictors examined 80, and no valid method of making a prediction at an individual level has been published in the scientific literature. Therefore, while medical interventions are not currently recommended for prepubertal gender incongruent children, psychosocial interventions need to be undertaken with caution and based on considerable expertise so as not to limit later choices 59, 81, 82. The inclusion of the category in the ICD-11 is intended to provide better opportunities for much-needed education of health professionals, the development of standards and pathways of care to help guide clinicians and family members, including adequate informed consent procedures, and future research efforts.

Finally, the ICD-10 category F64.1 Dual-role transvestism − occasionally dressing in clothing typical of another gender in order to “enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change” 4 or accompanying sexual arousal − has been recommended for deletion from the ICD-11, due to its lack of public health or clinical relevance.

("Fetishistic transvestism" was also deleted from ICD-11, as part of the revision of F65 DISORDERS OF SEXUAL PREFERENCE. This is a separate section in this document dealing with paraphilias. "The Group proposed that the paraphilic disorders included in ICD-11 consist primarily of patterns of atypical sexual arousal that focus on non-consenting others, as these conditions could be considered to have public health implications".)

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