How children can order life-altering transgender drugs from their bedroom The Telegraph 26.02.21
The original article is here.
Foreign doctors are prescribing powerful sex change hormones to 15-year-olds in England without their parents’ involvement, a Telegraph investigation has found.
GenderGP, an online transgender healthcare services clinic, uses a legal loophole to flout NHS rules to issue valid prescriptions which can then be used to obtain the medication from pharmacies in Britain.
The sex change, or “cross-sex” hormones irreversibly change users’ bodies over the course of treatment and can also leave users infertile.
An undercover Telegraph reporter posing as a 15-year old girl was prescribed testosterone – the male hormone, which is a controlled drug – after just two Skype appointments with counsellors and one Skype appointment with a doctor at the online clinic.
Staff never asked to speak to her parents nor demand proof that any adult knew of her plans to transition, beyond a single email from a 20-year-old half-brother confirming that he would pay for treatment.
Staff accepted at face value the reporter’s stated belief that she was really male, telling her “we’re not worried about your truth because there’s no debate about that”.
The reporter, posing as a 15-year-old, received a prescription for a four-month supply of ‘Testogel’. GenderGP defended its practices on Thursday, claiming that “not all parents are supportive” and that when a young patient is able to consent to their treatment “in their own right, then that treatment can be appropriate and necessary”.
It also confirmed that it has prescribed cross-sex hormones to children as young as 12, and puberty blockers to children as young as 10.
The findings will raise fresh questions over the duty of care shown to patients by the online clinic.
Whilst research suggests that the majority of transgender patients who take cross-sex hormones benefit from the treatment, a minority have regretted doing so and believe they were misdiagnosed or not properly counselled and advised.
The rules around prescribing these drugs to children in England and Wales were significantly tightened last December to guard against children being given unsuitable medications.
Doctors in England and Wales are no longer allowed to prescribe cross-sex hormones or puberty blockers to any child under 16, unless the decision, taken jointly by at least two specialist doctors including a senior hormone specialist and a senior psychosocial clinician, is endorsed by a court order.
Signed off by doctor in Romania
The reporter, posing as a 15-year-old, received a prescription for a four-month supply of ‘Testogel’, during which time her voice could irreversibly deepen and facial hair start to grow.
It was signed by a doctor in Romania, who the Telegraph has identified as a geriatrician also trained in administering Botox. GenderGP does not offer patients the chance of an appointment with her, even though she authorises the medication. Instead they are directed to a doctor in Egypt, who told the reporter that it was “excellent” that, aged 15, she knew she never wanted to have children.
On Thursday night, Debbie Hayton, a teacher and transgender rights campaigner, called for the loophole to be closed. “For a doctor in Eastern Europe to prescribe a class three controlled drug to a child they have never spoken to is an egregious breach of protocol and safeguarding…the adults need to be called to account.”
GenderGP said it is a global organisation and its specialists are regulated in their respective countries. It added that there are “no formal qualifications in this field” but that its practitioners are “very experienced and fully educated in transgender healthcare”.
The Egyptian doctor, Yasmeen El Rakhawy, also told the reporter over Skype that the online clinic she worked for did not need to go into the same level of detail on certain issues “as other practices will do, or will demand”.
Neither would they insist on regular appointments with medical staff once the 15-year-old started taking the testosterone. “At no point will counselling sessions be enforced. At no point will the medical consultations be, you know, required regularly. It’s only if there’s ever a concern.”
“I have no concern that this is absolutely the right path for you… Getting to that first prescription is on the horizon now. You can anticipate that and I appreciate the excitement.”
Sure enough, the undercover reporter received a valid prescription and secured the life-altering medication without any parental involvement. The process had been relatively simple. All it had taken was three Skype appointments and some emails, which she had been able to do from her bedroom. The clinic had not required proof that her parents knew of her plans.
We started to look at GenderGP after finding comments online that suggested that children were able to obtain drugs under the age of 16, and that some patients were given prescriptions without even talking to a doctor.
We were also made aware of messages posted on a moderated chat forum hosted by Mermaids, a support group for trans minors which has ties with schools, where children had described how they had been able to obtain prescriptions from GenderGP.
Mermaids said on Thursday night that it has no affiliation with GenderGP, but that it is aware that some young transgender people seek private treatment because of the “considerable barriers” if they go via the NHS. It “closely and carefully” monitors any discussions about medical journeys that take place on its platform, it added.
Founder’s controversial past
GenderGP is no stranger to controversy. Its founder, GP Dr Helen Webberley, has been suspended by the Medical Practitioners Tribunal Service since 2018 after she prescribed hormones to a child aged 12 – although no finding of fact has been made against her practice.
She was later fined for running an unlicensed trans clinic from her home in Monmouthshire and is due to face a “substantive” General Medical Council hearing in July.
Eventually, she relocated to Spain and the company was reinvented as a complex international structure which navigates around the rules in England and Wales, and exploits a loophole which makes prescriptions signed by doctors registered anywhere in the EU valid for use at British pharmacies.
It has won a lot of devotees. Last year, GenderGP started more than 1,800 patients on cross-sex hormones, according to an annual report published on its website. It does not state how many it started on puberty-blockers, but it has separately admitted that it has prescribed them to a child aged 10. Nearly one in six of its patients are under the age of 16.
Patients seeking medical appointments are directed to Dr El Rakhawy in Cairo, whose specialism, if she has one, remains unclear: there is a block of Latin dummy text next to her name on the GenderGP website and her LinkedIn profile reveals that she only finished the university portion of her medical training in 2017.
Prescriptions are signed by the geriatrician in Romania, whose identity GenderGP does not readily disclose – a move that a GenderGP staff member admitted was “cloak and dagger”.
This set up allows children under the age of 16 to order life-altering drugs from their own bedrooms, without any oversight or involvement by a parent or guardian.
When the reporter first contacted the organisation, she told the clinic that her mother and father did not support her decision to transition – believing that her desire to become a boy was something she would simply grow out of.
She said that her support network was so limited that she depended on her half-brother, a university student, to fund the process for her. The medicine cost £112 from a pharmacy, but between the £195 GenderGP set up fee, its £30 monthly subscription and three consultations, the process had so far cost £682.
No one asked to speak to a parent
Over virtual appointments, two GenderGP counsellors and one of its doctors asked the reporter some questions to satisfy themselves that this would not cause problems. They checked that her brother would keep on making the payments, and that the 15-year-old’s parents would not eject her from the family home when the effects of the testosterone became evident.
“What we don’t want to do is be involved in a family row,” explained its lead counsellor Marianne Oakes, in another Skype session.
The 15-year-old did her best to allay any concerns. At GenderGP’s request, her “half-brother” sent a single email confirming that payments would continue uninterrupted. She also told staff via the internet that her parents would eventually come around, and that even if they did not fully endorse her decision, they would not force her to leave home.
No one at GenderGP asked to speak to the brother in person. Nor did they seek any form of contact with Charlie’s parents, or ask for any evidence that they even knew she was seeking treatment.
GenderGP also appeared to fall short of its own stated precautions for patients. Despite requesting in an email that patients under the age of 18 who have support should have an adult with them for part of their Skype calls, the reporter posing as Charlie conducted all of her appointments alone. GenderGP said on Thursday that it was not “an absolute requirement”.
Those checks are there for good reason. Alongside the life-changing physical effects, puberty blockers and cross-sex hormones come with risks – some well-chronicled on the NHS website – and some whose severity of which is still unknown because there is little data about their use in children
Even the makers of Testogel caution against using it on under 18s, because there is “no clinical information” available for such children.
With the hormones, some of the effects – such as facial hair and a deeper voice – are permanent even if users stop taking the medication.
They undoubtedly have a huge positive impact on the lives of many people who take them, but there is also a well-documented minority who feel that they were put on to them too readily and have come to deeply regret the decision.
‘I made a brash decision’
The best-known example is Keira Bell, a former patient of the Tavistock clinic who was prescribed puberty blockers at the age of 16, testosterone the following year and subsequently took the clinic to the High Court for failing to “challenge” her sufficiently.
“I made a brash decision as a teenager, (as a lot of teenagers do) trying to find confidence and happiness, except now the rest of my life will be negatively affected,” she told the court, describing her regret.
The NHS has strict protocols in place to guard against this sort of situation, even if they failed in her case. Children in England and Wales should not be prescribed cross-sex hormones until “around 16”, and after a year on puberty blockers and an extended period of assessment by a multi-disciplinary team.
Any decision to prescribe puberty blockers or hormones before their 16th birthday must be overseen by at least two specialist doctors directly involved in their care, including a consultant endocrinologist and a senior psychosocial clinician.
Following the Keira Bell ruling, it must also be endorsed by a court order. The judges presiding over that case ruled that it was “doubtful” that 14- and 15-year-olds could “weigh the long-term risks and consequences”.
However, as the Telegraph’s investigation found, GenderGP provides a short-cut.
While GenderGP confirmed the evidence that the Telegraph uncovered, it defended its practice on Thursday. It said that it treats children according to “stage not age”, and that there may “occasionally be compelling reasons” to prescribe cross-sex hormones to a 12-year-old who is “completely aligned with their gender identity”.
It added that it assesses patients’ capacity to consent in a number of ways, including email messaging, questionnaires and consultations, but that “not all parents are supportive, and when a young patient is able to consent to their treatment in their own right, then that treatment can be appropriate and necessary.”
“GenderGP operates according to a gender-affirming model of care. Transgender patients of all ages who come to our service can be assured of receiving belief, support and compassionate access to medical care,” it said.
The clinic also subscribes to an “informed consent” model, in which the patient makes their own decision about what treatment they should pursue, “using a combination of their own understanding of their situation and needs, and the medical advice supplied to best inform them.”
The clinic believes that children are capable of giving their “informed consent” – even, it would seem, under the age of 16, operating alone from their childhood bedroom, and without an adult present.
The loophole that allows GenderGP to offer its services to children in the UK
Due to a legal loophole, pharmacies in the UK will accept prescriptions for drugs such as testosterone even when they have been given out over the internet by doctors based in the further reaches of the European Union.
The Government directs pharmacists to accept prescriptions from EU doctors for testosterone and other powerful drugs, such as anabolic steroids, just as they would from a UK doctor.
In fact, only EU prescriptions for drugs that are highly controlled due to their addictiveness and potential for misuse, such as morphine or temazepam, are invalid at pharmacies here.
Even following Brexit, the instruction to honour prescriptions for many drugs from European doctors has remained unchanged, and the loophole remains.
In contrast, other countries who are still in the EU, such as France and Italy, do not allow their pharmacists to accept prescriptions at all from doctors outside their borders.
Concerns are that the prescribed drugs may be inappropriate for the person ordering them, as often the doctors don’t have access to the patients’ NHS medical records.
The foreign-based doctors who issue the prescriptions are also outside the remit of the UK regulators, and the equivalent bodies in countries such as Romania may not be as rigorous as they are here.
For Gender GP, the loophole allows it to continue to offer its services to children in the UK as its prescriptions for testosterone are easily exchanged at high street pharmacies, despite having been issued by a doctor in Romania who has never even spoken to the patient for whom they are prescribing.