Queer Endurance In Defiance’s Statement On The Proposed Restriction Of Puberty Blockers

On 21 November 2024, the Ministry of Health released a paper outlining plans to restrict access to puberty blockers, with public submissions on the plan closing on 20 January next year. These restrictions are described as follows:

“The new precautionary approach signals the need for clinicians to exercise caution in prescribing, including that prescribing should only be initiated by clinicians who are experienced in providing gender-affirming care, and are part of an interprofessional team offering a full range of supports to young people presenting with gender identity issues (note 1).”

Despite the claims of their press release that these restrictions are motivated by “a lack of good quality evidence to back the effectiveness and safety of puberty blockers”, the plans have nothing to do with medical safety; the restrictions are intended to cause harm to young transgender people in order to curry favour with conservative voters and donors.

Gonadotrophin-releasing hormone analogues (GnRHa; AKA puberty blockers) are a medicine prescribed to young transgender people at their request to stop the onset of natal puberty. GnRHa are widely used for other means besides blocking puberty for trans people - as the Ministry of Health’s own evidence brief acknowledges, they are used to treat prostate cancer, breast cancer, endometriosis, and tumours of the uterus, as well as early-onset puberty in cisgender young people.

Although the proposed puberty blocker restrictions are being promoted as motivated by safety concerns, the Ministry of Health is not considering restricting their use for other purposes: if they really had concerns that GnRHa drugs were unsafe when used to block puberty, or if there was a lack of evidence to support the effective of GnRHa drugs in suppressing puberty, would the Ministry not also propose restricting their use to stop early-onset puberty? The fact is that GnRHa are a safe and effective medicine for suppressing puberty, and the restrictions are not about safety. Gender Minorities Aotearoa have written in more detail about the blatant discrimination displayed by these moves to ban treatments for trans people that are permitted for other purposes (note 2).

Puberty blockers should be available to all patients who feel a need for them and consent to take them, whether they are transgender, intersex, or experiencing early-onset puberty. Blockers are already dangerously difficult to access for young transgender people across the country, and effectively impossible to access in some regions; the Ministry of Health should be moving to widen rather than restrict their access.

The evidence brief released by the Ministry to support their campaign follows the UK’s Cass Review from earlier this year which similarly rejected established standards for evaluating medical research, and refused to weigh up the benefits of providing treatment to trans youth against the negative outcomes caused by refusing treatment. Both the Cass Review and the Ministry of Health’s brief treat non-treatment as a “neutral” outcome, when in fact refusing treatment means forcing trans youth to submit to natal puberty, which has serious psychological and physical impacts on our wellbeing. This must be taken into account when considering the efficacy of puberty blockers.

The Cass Review and the Ministry of Health brief both make a big deal out of only considering “high quality” research when judging studies of the efficacy of puberty blockers. The Cass Review claims to use the GRADE framework for appraising medical research, while the Ministry brief claims to follow the ROBINS-I standard. Both standards differentiate between “high quality” research carried out under controlled conditions - i.e. studies that include non-treated control groups and eliminate other variables - and lower quality research. Here is the problem: neither GRADE nor ROBINS-I are intended to reject the use of lower quality research. There are very important ethical reasons why medical research does not always include the kind of controls you would find in laboratory research: medical research is carried out on living human beings operating in a world where variables cannot always be controlled. Forcing studies to refuse treatment to some of their patients is ethically dubious; this is particularly the case for paediatric medical practitioners, who frequently have to make use of new treatments outside of controlled trials in order to save lives. The Cass Review’s failure to follow established standards for evaluating medical research has been thoroughly critiqued in a paper released by Yale Law School’s Integrity Project (note 3).

What makes the Cass and Ministry’s reviews misuse of evidence standards worse is that both reviews claim that in order to only consider “high quality” evidence, studies in which transgender youth had positive family and school support and counselling available to them while undergoing treatment had to be rejected, because this positive environment was an uncontrolled variable. Since the Ministry’s proposal is to restrict access to blockers to only those youths who have “an interprofessional team offering a full range of supports”, the Ministry has effectively refused to consider studies regarding the effectiveness of treatment within the very conditions they are proposing.

Despite the Ministry’s failure to consider much of the research demonstrating the safety and efficacy of puberty blockers, the evidence brief does ultimately acknowledge that there are no serious, proven safety risks; and the one study that the Ministry did consider to be of a sufficiently high quality showed that treatment with puberty blockers led to a “statistically significant improvement” in the wellbeing of transgender youth (see page 21 of the evidence brief).

Even after misusing medical research frameworks to reject valid evidence for the safety and efficacy of puberty blockers, the Ministry still found no evidence that blockers are seriously dangerous, while they did find significant evidence that blockers have a positive impact on transgender people’s lives. And yet, the government is still proposing to restrict access to them.

Blockers are not dangerous. Blockers are a compromise: most transgender youths who request access to puberty blockers would prefer to have access to full hormone replacement therapy, in order to experience the puberty that accurately matches their gender at the same point in life as their peers. But the level of anti-trans prejudice among the medical establishment and legislators is such that we have had to live with a compromise of only blocking puberty until patients reach the age of majority. And now even this compromise is being restricted.

It is important that we take some time to consider what the Ministry means by “restriction”. The Ministry of Health has not, so far, proposed outright banning puberty blockers for transgender health care, but rather restricting their prescription to “clinicians who are experienced in providing gender-affirming care, and are part of an interprofessional team offering a full range of supports to young people presenting with gender identity issues.” And in an ideal world, this is how treatment would take place! But at present, our under-funded health system simply does not include sufficient experienced clinicians or interprofessional teams able to provide the support outlined in the restrictions.

Unless the government immediately announces a substantial boost to funding for transgender health care, these supposed restrictions are a ban in all but name. Yes, it would be ideal for prescribing doctors to have the experience and support outlined, but at present they generally do not, and in the meantime, there are hundreds of young people desperately trying to improve their quality of life by accessing the medicine they need, and who are now going to be denied this treatment. This is unacceptable.

The Ministry has opened a process for the public to make submissions regarding the proposed restrictions. But the Ministry has made it clear that they are not interested in hearing from anyone who opposed the restrictions; they are only interested in hearing whether further restrictions should be created beyond those already proposed. The blogger PostingDad has published an excellent summary of how the submission form uses leading wording in order to guide submitters into opposing the use of puberty blockers, and how you can respond in such a way that you can submit in opposition to the proposed restrictions (note 4).

We recommend everyone who is appalled by the proposed restrictions make a submission. Healthcare is a right, not a privilege. Decisions regarding whether to treat a patient using a medicine that is known to be safe and effective should be left to medical professionals, not made by politicians trying to curry favour with prejudiced voters and donors.

1: https://www.health.govt.nz/news/additional-safeguards-for-puberty-blockers

2: https://genderminorities.com/2024/11/21/trans-only-restrictions/

3: https://law.yale.edu/sites/default/files/documents/integrity-project_cass-response.pdf

4: https://postingdad.medium.com/how-to-submit-in-favour-of-gender-affirming-care-d3be265a1349

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