Welcome Puberty Blockers Report But Beware Derailing Transphobia

Tuesday, 7 January 2025, 5:16 pm
Opinion: Ian Powell

On 21 November the Ministry of Health released its long awaited position statement, accompanied by an evidence brief, on the safety and long-term impacts of puberty blockers (a non-medical intervention) when used in the context of gender-affirming care:

Puberty blockers evidence brief.

The document is not official government policy. Nor does it claim to be either a clinical analysis of (or a guideline about) the use of puberty blockers. Further, the information it is based on is confined to up to September 2023.

After considering and citing much material it concludes that the evidence about the impact of puberty blockers on clinical and mental health and wellbeing outcomes is scarce; that evidence which is available is “largely of poor quality.”

In no small part this is because studies “…generally rely on small, localised cohorts, making it difficult to extrapolate to other, larger cohorts.” Further:

Given the dearth and poor quality of evidence, and New Zealand-specific evidence, there is an urgent need for high-quality, longitudinal data and research to help us understand the specific needs of gender-dysphoric adolescents in New Zealand.

Hippocratic Oath

The Health Ministry’s position statement provides a starting point for the development of robust guidelines over the prescribing of puberty blockers. In this context it is a welcome document.

It also resonates with my earlier Otaihanga Second Opinion post on puberty blockers (26 September):

Puberty blockers and the Hippocratic Oath – Otaihanga Second Opinion

I argued that the approach to what is known as the Cass Review of puberty blockers in the United Kingdom should be seen through the lens of the Hippocratic Oath (first do no harm).

Hippocrates’ oath still relevant today

This is not an anti-trans rights lens. I have previously posted twice in my politics blog Political Bytes my support for trans rights and opposition to anti-trans bigotry (links to both are in my above-mentioned puberty blockers post).

It is also the right of all people to have the treatments they might receive for whatever condition to be consistent with the Hippocratic Oath.

This includes the right of young trans people to evidence and experience based guidelines on puberty blockers that includes being seen through a medical lens (I use the term medical to include all branches of medicine including psychiatry and general practice).

Cautionary article

Epidemiologist Emeritus Professor Charlotte Paul (Otago University) along with two colleagues (Simon Tegg and Sarah Donovan) have written a ‘must read’ cautionary article on the use of puberty blockers for children and young people with gender dysphoria published in the New Zealand Medical Journal (27 September):

Use of puberty-blocking hormones for gender dysphoria in New Zealand: descriptive analysis and international comparisons – The New Zealand Medical Journal

Emeritus Professor Charlotte Paul and colleagues issue timely caution over puberty blockers

They note that the prevalence of prescribing puberty-blocking hormones generally (not just gender dysphoria) in Aotearoa New Zealand increased from 2011 (when the first national guidelines were published) to 2016 and then more steeply from 2016 to 2022, before declining.

The rapidity of this prescribing increase from 2016 was most marked among those aged 12–17 years (a more than threefold increase) which the authors very largely attribute to use for gender dysphoria.

Prevalence

The difference in prevalence was even more marked compared to England and Wales up to 2020, such that New Zealand had 6.9 times the cumulative incidence of prescribing.

By 2021 government imposed restrictions were introduced following the High Court judgement on the Tavistock controversy in the United Kingdom.

Paul and her colleagues identify several difficulties in making comparisons between Aotearoa and other countries because of differences in methodologies.

Further, data on prescribing puberty blockers for gender dysphoria is not always disaggregated from prescribing for other non-controversial purposes.

Nevertheless they are confident that the finding of much higher prescribing in New Zealand is robust notwithstanding not having the exact figure.

Prescribed puberty blockers now 11 times higher than England and Wales

Current prevalence of the use of puberty blockers in New Zealand is now 11 times higher than in England and Wales compared with 6.9 in 2020. The authors attribute this to a sharp decline in use following the judicial review of treatment practices in 2020.

Why is prescribing so high in New Zealand

Their article also asks an obvious question; why is prescribing so high in New Zealand and why has it increased so rapidly?

One possibility might be a steeper rise in the prevalence of adolescent gender dysphoria or transgender identity in New Zealand. But there is no evidence for a rise in transgender identity from 2012 to 2019.

On the other hand, the authors highlight “a strikingly high proportion of girls” aged 12 years in 2021-22 who reported a non-binary or transgender identity (8.2% of natal girls and 1.5% of natal boys) suggesting “a very recent increase among children.”

The main reasons given for higher prescribing of puberty blockers are considered to be found in New Zealand’s health system. The authors suggest these reasons might be:

• easier access to assessment;
• a lower threshold for diagnosis of gender dysphoria; or
• greater likelihood of recommending treatment through puberty blockers for those with gender dysphoria.

The article also reports decline in prescribing from 2021. If it is not a “chance occurrence” it could be, the authors tentatively suggests that health professionals and parents may be becoming aware of more cautious approaches overseas to prescribing puberty blockers for gender dysphoria.

However; beware of transphobic influences

This article by Professor Paul and her colleagues is broadly consistent with the Ministry of Health’s above-discussed evidence-based position paper. It also resonates with my own above-mentioned concerns.

Dr Rona Carol: A ‘must read’ timely caution about the influence of transphobia

Dr Rona Carroll, Senior Lecturer in Primary Health Care and General Practice at Otago University has, however, written a timely caution published The Conversation (5 December):

NZ is consulting the public on regulations for puberty blockers – this should be a medical decision not a political one

Dr Carol is experienced in the prescribing of puberty blockers for gender dysphoria. She is concerned that public rather than medical consultation risks opening up to decisions being influenced by bigoted misinformation from vociferous transphobes.

Brian Tamaki at forefront of vociferous transphobia

Transphobia comes predominantly from the far right such as Brian Tamaki’s Destiny Church. But it also includes some who consider themselves part of the political left (but not representative of it).

Within the National-ACT-NZ First coalition government, transphobia is more visibly discernible within NZ First.

Consequently Dr Carol is right to be concerned. Further, she also raises another valid but related concern. While the Health Ministry’s focus is on the risks of puberty blockers, it does not consider the benefits. She is well placed to understand these benefits.

What we need and don’t need

Dr Carol supports medically based regulations but warns about the detrimental health effects of bans or non-medically based restrictions.

Both the Health Ministry position paper and Professor Paul’s published article are compelling. While not intended as such, I consider them to be complementary.

Aotearoa needs robust medically based guidelines consistent with the Hippocratic Oath for the prescription of puberty blockers to help young people suffering gender dysphoria.

What we don’t need is this process being derailed by transphobia. Ministry and Minister of Health; please take note!

© Scoop Media

Ian Powell

Otaihanga Second Opinion is a regular health systems blog in New Zealand.

Ian Powell is the editor of the health systems blog 'Otaihanga Second Opinion.' He is also a columnist for New Zealand Doctor, occasional columnist for the Sunday Star Times, and contributor to the Victoria University hosted Democracy Project. For over 30 years , until December 2019, he was the Executive Director of Association of Salaried Medical Specialists, the union representing senior doctors and dentists in New Zealand.

Contact Ian Powell

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