Transgender children deserve access to healthcare

This is my submission to Manatū Hauora's consultation on the rights of transgender children in Aotearoa to access the healthcare they need. You can make your own submission any time before the 20th, and I think you should - you should also contact Minister of Health Shane Reti, who has requested this work, and Associate Minister of Health with the Mental Health and Rainbow portfolios, Matt Doocey.

Here are some useful guides for making your own submission:

• Gender Minorities Aotearoa: Analysis of puberty blockers review
• InsideOUT: Submission guide for puberty blockers
• Te Ngākau Kahukura: No need for further restrictions on puberty blockers
• Emily Writes: How you can stand up for trans kids being targeted by this government
• How to: Submit in favour of gender-affirming care

Your submission certainly doesn't have to be as long as mine, but I thought people might find it useful to see what I'm saying. I'm also really, really furious about this. It is categorically discriminatory and the Ministry have no justification for this other than that they're following the orders of the Minister. This is politics masquerading as concern for transgender children, when we know full well the impacts this work is having already here in Aotearoa, and the impact restrictions have had overseas.

This is my personal submission - while I draw on my experience and expertise across my professional roles, in this one I needed to speak with my full chest. It's long, but I've broken it into sections and included a summary.

Please - if you do nothing else, send pbconsultation@health.govt.nz a quick email today saying "I do not support any further restrictions on the use of puberty blockers for transgender children". That's all it has to be - anything else is a useful extra.

Here's my submission:

Executive summary

Transgender people face poorer health and wellbeing outcomes in Aotearoa as a result of systemic and structural intolerance and gender minority stress, and face inequitable access to healthcare in Aotearoa - in many places, puberty blockers are already near-impossible to access.

The Ministry of Health’s evidence brief had methodological flaws that meant that it did not accurately assess the full benefits of puberty blockers to transgender children, nor the full risk of not providing this care.

There must be no further restrictions on the prescription of puberty blockers to transgender children. There is no evidence of any need for further restrictions. Introducing additional restrictions would be an act of political interference, not motivated by clinical experience, evidence, or the needs of transgender children.

If the Minister intends to continue the process of investigating potential restrictions to the prescription of puberty blockers, the Ministry must engage meaningfully, ethically, and safely with those most affected by these regulations in line with the United Nations Convention on the Rights of the Child - transgender children themselves. In that case, the Minister must extend the deadline given to the Ministry of Health to provide advice to Cabinet in order to allow for this to occur.

About the author

I have been working in the field of transgender health and wellbeing for the last ten years. I am currently the President of the Professional Association for Transgender Health Aotearoa, and Healthcare Lead at Qtopia. I lead a national training programme for primary care around gender diversity and gender affirming care. Every day I am at the coalface of the provision of gender affirming care around Aotearoa, and am intimately aware of the inequities our communities face when accessing all healthcare.

This submission draws on my professional and personal experience over the last ten years. While I draw on the experience gained in my roles, this submission is my own. It sits alongside further submissions from PATHA, Qtopia, and many other professional and community organisations.

Introduction

It is well-established now that transgender people, including transgender children, face poorer health and wellbeing outcomes in Aotearoa as a result of systemic and structural intolerance and gender minority stress (Counting Ourselves, 2018). Our communities face inequitable access to healthcare in Aotearoa - both general healthcare and gender-affirming care. Access to care remains a postcode lottery throughout Aotearoa, with many services unavailable or so inaccessible they are functionally unavailable in many parts of the country.

Pathways to gender-affirming care in Aotearoa have historically been and in some cases are still pathologising, believing transness was at best, a less-than-ideal outcome and at worst, something caused by underlying issues that could be resolved. This approach has done immense harm, with those forced to endure treatment that, whether explicit or implicit, attempts to “fix” their transness experiencing lifelong impacts, being “taught to feel ashamed, developing low self-worth, accompanied by poor mental health and high levels of self-harm and suicidal ideation” (Horton, 2023).

Evidence is resolutely clear now that the poor health and wellbeing outcomes many trans and non-binary people face are the result of gender minority stress, rather than an underlying pathology. Research shows that transgender children supported in their identities, with appropriate access to care and support do not experience higher levels of psychopathology than the general population (Olson, 2016).

This is because transness is not a pathology - not something to be fixed by finding the causes of and preventing. A transgender child growing up into a transgender adult is not a failure of the system. A transgender child growing up at all is a resounding success. That has been the work of depathologising transgender health and identities - a matter of suicide prevention.

This work is now recognised internationally, with clinicians working to best practice models now utilising the World Health Organisation’s ICD-11 classification of “gender incongruence” rather than the DSM IV or V classifications of “gender identity disorder” or “gender dysphoria”. 

In Aotearoa, too, we are moving to a self-determination based model. Te Whatu Ora supports an informed consent approach to prescribing gender-affirming hormone therapy to adults in primary care, based on the understanding that gender diversity is a natural and positive aspect of human diversity, and that everyone is assumed to have the capacity to consent until proven otherwise. This affirmative approach recognises transgender people’s bodily autonomy and right to self-determination, and stands in clear contrast to previous pathologising models in which transgender people had to ‘prove’ their transness through extensive, onerous, harmful, and shameful barriers to care.

Through this approach, health bodies and transgender health advocates, myself included, around Aotearoa have undertaken work to improve relationships between healthcare systems and providers and transgender communities, beginning the long process of acknowledging the harms pathologising systems have done to our communities, acknowledging the lack of trust our communities hold in our health systems, and (in some areas) committing to improving access to care and thus health and wellbeing outcomes for our communities.

The work Manatū Hauora is now engaging in burns that trust, and instead of looking forward to a future in which the rights of our tamariki are upheld, is looking back to systems and processes that did immense and enduring damage to transgender people in Aotearoa. It is a betrayal of the generosity and understanding of the transgender health advocates and clinical champions around Aotearoa.

Article 3 of te Tiriti o Waitangi binds the Crown in an obligation to protect the health and wellbeing of Māori, as it is required to do for all New Zealanders. Gender diversity existed in Aotearoa prior to colonisation. By engaging in a process that seeks to re-establish and enshrine the pathologisation of gender diversity in Aotearoa, the Ministry of Health is in breach of te Tiriti o Waitangi.

Currently, Aotearoa prescribes puberty blockers at rates higher than other countries. This is a sign of a successful system, not a failure. While access to this care is inequitable around our country, it is a sign that transgender young people are being seen by our healthcare system, instead of being forced to wait an average of 100 weeks before even being seen in a UK gender service. The countries Aotearoa is frequently compared to by members of internationally recognised anti-LGBTQIA+ hate groups are characterised by pathology and healthcare systems that do not prioritise the rights of the transgender people accessing their services. They should not be used as positive models for comparison.

Similarly, the oft-quoted rates of young people accessing puberty blockers who then access gender-affirming hormone therapy (GAHT) is a success, not a failure. Reports from the UK showcase the success of a system that prioritises the avoidance of the absolutely slim possibility of regret over the current health and wellbeing of people accessing gender services, putting patients through rigorous, time-consuming, and damaging assessment processes (Horton, 2023).

Both internationally and here in Aotearoa, rates of anti-transgender violence, extremism, and disinformation are on the rise, with some researchers raising the alarm that this rhetoric is reaching “genocidal” levels. It is impossible to disengage this consultation and these decisions from this context. It is highly unusual for the Ministry of Health to be engaging in public consultation about a medical matter for a vulnerable minority in this manner. That the Government has requested them do so is shameful. We categorically would not be having this conversation without the broader context of hate and disinformation that is weighing heavily on our communities, that the Ministry of Health is now actively contributing to.

There must be no restrictions on transgender young people’s right to access healthcare. There must be no restriction or regulation on puberty blockers beyond the regulation they are already subject to under New Zealand law. This consultation process is actively contributing to the suicidality, distress, and harm for young people, and must be immediately halted. The Government and the Ministry must work to undo this harm, adequately resource transgender young people’s access to appropriate healthcare, and work to restore the trust they have destroyed by opening these proceedings.

Rights of the child

The UN Convention on the Rights of the Child, which Aotearoa ratified in 1993, emphasises children’s right to participate in the development of health policy and services, noting that children’s views should be sought on all aspects of healthcare provision.

The Medicines Act 1981, section 105 enshrines a requirement to consult with those substantially affected by any potential regulations. Read in conjunction, it is clear that those most substantially affected by any proposed regulation or restriction on transgender children’s right to access healthcare is transgender children themselves.

The Ministry of Health’s consultation plan does not meaningfully engage with transgender children on these restrictions. Initially, a 30 minute consultation session was planned with a large number of rainbow community organisations, one of which was the Parents of Transgender Children NZ group, representing a couple of thousand parents of transgender children throughout Aotearoa. While this meeting was extended to one hour, one hour with 25 representatives of a number of community organisations does not constitute meaningful consultation nor children participating in the development of health policy in line with the UNCRC, not least because no transgender children themselves were in the meeting.

As child-rights focussed transgender health researcher Cal Horton along with New Zealand researcher Jaimie Veale note in a 2024 editorial of the International Journal of Transgender Health:

“Trans children are disadvantaged compared to trans adults in their ability to mobilize and collectively demand healthcare rights at an institutional, sectoral and national level, especially when already overwhelmed with a fight for rights, dignity and survival at family, school and community level” (Horton et al, 2024)

While transgender children often rely on their parents, whānau, and transgender adults to advocate for them, that does not mean they do not have a voice, and it does not negate Aotearoa’s obligations under the UNCRC to enable their meaningful participation in the development of health policy and services. This is a systematic erasure of their voices by the Crown and the Ministry of Health via a rushed consultation period that did not plan to directly include the voices and experiences of transgender children.

“A prejudice-driven rhetoric of child protection or safeguarding can ironically be weaponised to undermine child rights in a sector like trans healthcare” (Horton et al, 2024)

The Ministry initially planned to follow up with two online ‘town hall style’ consultations with the broader rainbow community, which again do not meaningfully include transgender children themselves. It is my understanding that the Ministry intend to re-examine their consultation plan. Rainbow community organisations and representatives of the whānau of transgender children in Aotearoa have strongly recommended an extension to the consultation to allow the development of an engagement process in partnership with community organisations that would enable the safe, meaningful, and ethical involvement of transgender children in this consultation, in line with the UNCRC.

I am aware that the deadline for the Ministry of Health to provide their advice to Cabinet has been set by Minister of Health Shane Reti, and does not give enough time for this process to take place.

I call on Minister Reti to immediately halt the consultation process in order to develop a safe and fair consultation programme that enables the adequate and safe consultation with, and participation of transgender children in this health policy in line with the United Nations Convention on the Rights of the Child.

Safely and meaningfully consulting with transgender children is not possible in a rushed two-month period over the summer break, not least when this work has caused significant damage to the relationship between the Ministry of Health and transgender communities, including transgender children and their parents. As raised in a meeting with the Ministry of Health, it is impossible to safely and meaningfully ask transgender children how they feel about their right to healthcare being restricted - certainly not without adequate relationship-building, a tangible commitment from the Ministry of Health to their wellbeing, and appropriate and adequate safeguarding plans.

At a minimum, the Minister must extend the deadline he has given to the Ministry of Health to provide their advice to Cabinet in order to engage meaningfully, safely, and ethically with transgender children in partnership with rainbow community organisations.

Harms of public consultation

The Medicines Act 1981 requires the consultation with persons substantially affected by regulations being considered by the Crown. It does not require public consultation. This is an additional request made by Minister Reti to the Ministry of Health. It is a request that is already doing significant harm to our communities, and to transgender children in particular. It risks inviting prejudice and disinformation into a matter that should be made purely on clinical expertise, not political agendas.

PATHA’s Briefing to the Incoming Minister of Health Shane Reti (2023) outlines the significant detrimental impacts that anti-transgender discrimination has on the social determinants of health for transgender people in Aotearoa. Forthcoming Counting Ourselves 2022 data provided in this briefing shows that 60% of transgender people in Aotearoa were seeing negative messaging about transgender people on social media on a weekly basis. Research is clear that anti-transgender discrimination and hateful rhetoric is on the rise online and on the ground here in Aotearoa.

By opening this matter to public consultation, Minister Reti and the Ministry of Health are knowingly exposing transgender children to significant risks of harms to their health and wellbeing.

Harmful online consultation

The online consultation form is poorly designed, with no way to verify the identities and experiences of those providing feedback. Anyone could self-identify as a transgender young person, or as a paediatrician with 15 years of experience, with no means for the Ministry to confirm this feedback.

Experiences from other transgender community health research projects have shown a high rate of inauthentic data, requiring a significant amount of data cleaning to ensure accurate results. Internationally, flooding forms with inauthentic data as a means to sway political decision-making is a common tactic amongst anti-transgender extremists. A quick search on X/Twitter makes it clear that there is an intentional campaign to generate inauthentic submissions from international audiences, part of a rapidly-growing international anti-transgender extremist network fuelling disinformation campaigns about gender diversity and transgender healthcare. Internationally recognised pro-conversion practices and  anti-transgender hate group Genspect have published a call for their international audience to submit via the online form.

The form itself preempts restrictions, with questions framed in ways that would not pass any ethics board approval. Question 7 in particular, which asks “Which young people should be able to receive treatment with puberty blockers for gender dysphoria?” gives “Those who are already receiving treatment,” “Participants in an approved clinical trial,” and “Any other groups” as options. The current status quo and best practice - any transgender child with gender incongruence causing distress who meets the WPATH SoC-8 criteria - is not given as an option and lumped into the “any other groups” option. Good quality survey design requires giving the current status quo as an option. This survey design will be biased towards restrictive outcomes.

Harms to transgender children of proposing restrictions

International evidence is now clear of the negative impacts of the very proposal of restrictions such as the Ministry has proposed on the parents of transgender children. In an extensive 2019 paper in Psychology of Sexual Orientation and Gender Diversity, Roberto L. Abreu outlines the impacts of bans on gender affirming care of parents of transgender children, finding that these parents already experienced heightened rates of anxiety, hypervigilance, stress, and depression. Parents are preemptively concerned for their tamariki and rangatahi. 

Cal Horton’s 2022 research on transgender children, adolescents, and parents experiences of puberty and puberty blockers shows that a majority of transgender children were aware of the existence of blockers, and that this knowledge of puberty blockers were vital for reducing their child’s anxiety and improving their wellbeing. One parent shared their experience of their child knowing that there would be an option in their future to prevent unwanted and irreversible permanent changes to their body:

“...she’s comfortable to be happy in her childhood now. It’s almost like, essential, to lower her anxiety, and let her thrive in the here and now - that’s why, it’s like a promise I’ve made her, over my dead body, you will have the treatment you need, and deserve, whatever.” (Horton, 2022)

The proposal of taking away care that their children rely on does damage not just to the child but to the whole whānau. It is doing harm, here and now, to children in Aotearoa for whom the very possibility of puberty blockers has been a lifeline.

Harms to Aotearoa healthcare workers

The Ministry should now be well aware of the context of risk that transgender people and clinicians working with transgender communities are now operating in. Earlier this year, the Ministry of Health released the name of two clinicians who had reviewed their evidence brief. One of them, Dr Sue Bagshaw, is a provider of gender-affirming care to transgender young people in Ōtautahi Christchurch. It took a matter of days between this information entering the public sphere and te Tahi Youth, Dr Bagshaw’s practice, dealing with anti-transgender extremists protesting on their doorstep, requiring the cancellation of appointments and paying for additional security for the practice.

A number of clinicians working in the area have had to file Special Situation Alerts with the NZ Police. Even more PATHA members have had to take action to protect their personal safety in an ever-worsening context of online hate and disinformation about transgender people and gender affirming care.

By opening this consultation to the public, the Ministry of Health are feeding these flames. They are putting Aotearoa healthcare workers - in some cases, their own employees - at further risk. They do so in full awareness of the risk and damage this process will cause. 

They do so at Minister Reti’s direction, in the name of the safeguarding of our children, aware of the additional harms they cause to transgender children and those that care for them.

Harms of restrictions

Introducing additional unnecessary and discriminatory restrictions on trans children’s access to healthcare would do significant harm, not just now but long into the future. Evidence from both the UK and the UK show that the harm is not a singular event, and instead persists over time.

A recent paper examining the impacts of anti-transgender legislation introduced in the United States (Lee, 2024) has shown increases in year-on-year suicide attempts amongst trans and non-binary young people of up to 72%. These increases are not restricted to the year in which legislation was introduced - Lee found significant increases two and three years after the introduction of anti-transgender legislation, including bans or restrictions on access to gender-affirming care.

In the UK, Natacha Kennedy (2024) carried out qualitative research amongst parents of transgender children - those who have never had access to puberty blockers; children that have maintained access under the ban; and those previously had access and no longer do. Kennedy’s findings show significant impacts among all these groups, with children with no access experiencing heightened distress, anxiety, and reduced ability to participate in public life. Those who have retained access describe “an overwhelming sense of relief that they are still able to receive them”.

Parents in Kennedy’s research unilaterally describe ‘puberty dominating every conversation’, “reflecting the ever-present and constant worry, expressed by many others, amongst trans children and young trans people, that they might be forced to experience a harmful puberty”. Kennedy continues:

“The puberty blocker ban needs to be understood as something that causes persistent and unending stress, trauma and anxiety amongst its victims, it is not a ‘one-off’ event that can be ‘cured’ with any kind of psychiatric support, it is ongoing and its effects cumulative.”

Evidence

The Ministry of Health’s evidence brief was delayed in order to take into account the findings of the Cass Review. The Cass Review into the UK’s gender services has been widely criticised by health professional organisations, leading experts, and transgender community organisations worldwide. Yale’s Integrity Project published extensive analysis of the Review’s methodological and ideological flaws, and the British Medical Association, who represent every doctor in the United Kingdom, has called for an immediate pause to its implementation. It’s worth noting that the Review itself did not call for puberty blockers to be banned - this additional step taken by successive UK Governments goes beyond the scope of the Review.

During the timeframe of the brief, a review into Queensland’s gender services was also published, finding that those services were safe and evidence-based:

“An independent panel of representatives from across the country has found that the care provided by the statewide Queensland Children’s Gender Service (QCGS) is safe, evidence-based and consistent with national and international guidelines for treatment and care of children and adolescents with diverse gender experiences."

Despite the Queensland review’s relevance to provision of gender-affirming care in Aotearoa - being provided in a state closer to home, under a model more similar to Aotearoa’s model of providing healthcare than to the United Kingdom’s approach of centralised clinics - the evidence brief did not take this review into account, and did not give it the same attention and weight as it did the flawed Cass Review.

Discussion with the Ministry of Health post-publication of the evidence brief and statement reveals an alignment with the ideological flaws of the Cass Review. Notably, the expert advisory group convened by the Ministry to oversee this work does not include any transgender lived experience despite the wealth of transgender clinicians with both personal and professional expertise in this area. The Ministry found that EAG to not be a safe space for transgender members, and instead of taking this as a warning sign, continued this work without transgender input.

The EAG also “intentionally did not include anyone affiliated with an advocacy group” including the Professional Association for Transgender Health Aotearoa, according to the Chief Medical Officer Joe Bourne. PATHA contains the bulk of professional clinical expertise in the provision of gender-affirming care to adolescents in Aotearoa. Excluding this professional expertise has done significant harm to the quality of the evidence brief, and to transgender communities in Aotearoa. Taking this approach is akin to reviewing cancer care in Aotearoa while intentionally excluding the New Zealand Society of Oncology.

Neither the evidence brief nor the position statement, in their assessment of the limited quality of evidence for the risks and benefits of providing puberty blockers, make clear the other areas of health where evidence is lacking. As Professor Simon Denny, Director of the Mater Young Adult Health Centre in Brisbane, noted in his comments about the evidence brief:

“It’s important to recognize that in many medical fields, high-quality evidence is often limited. A review of Cochrane systematic reviews across various medical disciplines found that only about 13.5% reported high-quality evidence for primary outcomes, with the majority relying on moderate, low, or very low-quality evidence. This pattern is observed in areas such as anesthesia, breast cancer, cystic fibrosis, and multiple sclerosis. Therefore, while acknowledging the current limitations in evidence regarding puberty blockers, it’s consistent with broader medical practice to proceed with treatments based on the best available evidence, especially when guided by experienced professionals and established guidelines.”

The Ministry of Health is holding healthcare for transgender children to a double standard that many other areas of health do not meet. “Evidence-based care” as a framework does not only include academic research - that is one of three pillars of good practice. The other two are clinical experience and patient values. The Ministry of Health intentionally excluded both clinical experience and patient values from this work, and is continuing to exclude the values of the patients accessing this care through this consultation process. The evidence brief and public consultation cannot be called “evidence-based medicine” as a result.

Puberty blockers are successful at what they are intended to do - suppress puberty. This has significant benefit to the young people who use them for this purpose - but many of these benefits do not manifest during the period in which they are utilising this intervention. For transgender young people, experiencing unwanted changes to their bodies - or changes they are simply uncertain about - can trigger significant mental distress. Puberty blockers do not reverse any changes that have already occurred - nor do they trigger any changes that might be desired. They simply halt those changes.

The mental health benefit that would be appropriate to assess in this case, then, is not improvement in mental health outcomes, but stability. Mental distress not worsening over the period that puberty blockers are being used is a sign of success - unwanted changes are being prevented, so distress is not worsening, but dysphoria is not necessarily being resolved.

Longer-term benefits have not been considered by the evidence brief. These include long-term benefits to mental health and safety, particularly that result from the ability to ‘pass’ as one’s affirmed gender. They also include economic benefits for Aotearoa’s healthcare system - transgender adults who have accessed puberty blockers may not need expensive surgical interventions later in life as a result.

The evidence brief did also not engage with the harms of not providing puberty blockers to those who need it. Nor did it assess the evidence for risks and benefits of any alternative treatment options.

The evidence brief examined puberty blockers’ impact on the cognitive development of young people using them, finding no evidence for harm in this area. It would have been appropriate for the brief to also consider the impacts on cognitive development of withholding puberty blockers, in order to give a full understanding of the benefits of this care. McNamara (2024) in the Yale analysis of the Cass Review makes this clear:

“Chronic stress, particularly during adolescence, does indeed impact cognitive development. Gender diverse youth with gender dysphoria who are denied the option of medically affirming interventions are thus forced to undergo unwanted physical development. This can cause significant distress that then limits learning, building friendships, future orientation, and other developmental milestones in adolescence. The harms this poses to healthy cognitive development cannot be ignored. Clinicians, parents, and youth themselves are rightly concerned with the cognitive impact of untreated gender dysphoria, but the Review clearly is not. (p26)”

Similarly, the brief has not considered the wealth of research on the impacts of dysphoria and minority stress that transgender young people and their whānau experience, which is often mitigated by access to puberty blockers at an appropriate age. The brief cannot be considered a full assessment of the risks and benefits of the use of puberty blockers in transgender children when it has not considered the harms of no treatment.

Finally, the brief did not assess any alternative treatment options to puberty blockers in transgender young people. This is likely appropriate, as the only ‘alternatives’ being proposed are ‘watchful waiting’ (doing nothing) and ‘gender exploratory therapy’. Gender exploratory therapy is widely regarded as a euphemism for conversion practices (Ashley, 2022) and is rightfully considered illegal in Aotearoa. Regardless, ‘watchful waiting’ or not providing puberty blockers when they would otherwise be appropriate is not a neutral act, and is in fact an act in itself. By not examining the harms of this medical intervention being withheld, the evidence brief has not considered all the evidence for the risks and benefits of puberty blockers in transgender children.

Research Ethics

Amongst the options the Government seems to be considering is restricting access to puberty blockers to a clinical trial - the approach the United Kingdom has taken. This approach has been thoroughly critiqued by the Council of Europe, pointing out that restricting care to a trial breaches “the fundamental ethical principles governing research”.

The World Medical Association’s Declaration of Helsinki on medical research, which should be upheld by anyone engaging in medical research, makes it clear that “free and informed consent is an essential component of respect for individual autonomy”, and that “participation by individuals capable of giving informed consent in medical research must be voluntary”. A patient cannot meaningfully consent to a trial when that trial is the only way for them to access the care they need.

The Declaration also states that “researchers may not engage in research involving human participants unless they are confident that the risks and burdens have been adequately assessed and can be satisfactorily managed.” It has become clear through this process that these risks have not been assessed, and that there is no plan to manage these risks. This consultation process alone is currently doing harm to our communities. It is having a tangible mental health impact on transgender young people, their families, and transgender communities more broadly. The Ministry of Health has not outlined any plan or resourcing for support for the individuals they are inviting to participate in consultation meetings. There is no management of these risks.

Similarly, the New Zealand Health Research Council’s Ethics state: “the participants’ consent must be voluntary and not unduly influenced… by duress in any manner.” The National Ethical Standards for Health & Disability Research and Quality Improvement state that researchers should “engage with communities about which research questions are important, and reflect on the ethical issues associated with their study,” and that “non-maleficence requires researchers to avoid causing harm to individuals and communities”. It also states that “participants’ consent in research must be voluntary”, and that “the consent process must protect participants from coercion, deception, manipulation or other undue influence”. Finally, it makes clear that “researchers are responsible for ensuring that participants know that they are free to accept or decline an offer to participate in a study, and that they will not experience any disadvantage by making either decision.”

All of these ethical codes and standards are in total opposition to restricting access to puberty blockers for transgender children to a clinical trial. In our consultation meetings, the Ministry of Health have been clear that they do not feel a clinical trial would be appropriate or feasible. Yet, a clinical trial is presented in the online consultation form at the request of the Government. The Government must consider these ethical standards when making their decision.

Recommendations

There is no evidence for the need for any further restrictions, regulations, or safeguarding on the prescription of puberty blockers to transgender children. This is clear in the Ministry’s evidence brief and their position statement. There must be no further restrictions, regulations, or safeguarding on transgender children’s right to access healthcare, or to puberty blockers.

Introducing any further restrictions would be an act of discrimination towards a minority group, based on an unethical double standard, motivated by political ideology and not clinical expertise, medical evidence, or the needs of transgender children themselves.

The Minister must immediately halt the Ministry of Health’s consultation in order to develop a consultation process, in line with the United Nations Convention on the Rights of the Child, that engages meaningfully, safely, and ethically with transgender children. At a bare minimum, the current deadline for the Ministry of Health to provide advice to Cabinet should be extended to allow for this process to occur safely. Not doing so would mean the advice given to Cabinet would be flawed, and any decision made would contravene the UN Convention on the Rights of the Child.

If the Government is truly concerned about the wellbeing of transgender children then the answer is clear - instead of restricting access, the Ministry should act to increase the resourcing and support of the varied clinicians around the country working in line with best practice to provide this care. Puberty blockers are already near-impossible to access for many around the country. Clinicians are interested in learning more to be able to provide this care safely to those in their local communities. They need access to education and supervision and to clear pathways. Transgender children and their families need access to safe and culturally appropriate social and mental health support from teams and organisations with experience working with transgender children, not mainstream providers.

If the Government is concerned about the wellbeing of transgender children, they must depower the harmful rhetoric putting them, their families, and the clinicians that care for them by setting clear standards of communication. They must stop engaging with disinformation about gender diversity, and stop using transgender people as political footballs. They should reaffirm trans children’s right to access healthcare. Reaffirm the importance of gender affirming care. Disavow rhetoric that denies their humanity, denies their human rights, subjects them to double standards. Disavow anyone threatening trans people or providers of trans care. Show your support of the people working for Aotearoa’s healthcare system by resourcing their work appropriately and enabling them to access further education in the field.

References

Ashley, 2022. Interrogating gender exploratory therapy. https://journals.sagepub.com/doi/10.1177/17456916221102325

Counting Ourselves, 2018. http://countingourselves.nz/ 

Horton, 2022. Experiences of Puberty and Puberty Blockers: Insights from Trans Children, Trans Adolescents, and their Parents

Horton, 2023. “It felt like they were trying to destablise us”: Parent assessment in UK children’s gender services

Horton et al, 2024. Child rights in trans healthcare - a call to action

https://www.tandfonline.com/doi/full/10.1080/26895269.2024.2360359

Kennedy, 2024. Children of Omelas: Effects of the UK Puberty Blocker Ban. https://www.academia.edu/124722434/Children_of_Omelas_Effects_of_the_UK_Puberty_Blocker_Ban

Lee, 2024. State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA. https://pubmed.ncbi.nlm.nih.gov/39327480/

McNamara, 2024. An evidence-based critique of “The Cass Review” on gender-affirming care for adolescent gender dysphoria. https://law.yale.edu/sites/default/files/documents/integrity-project_cass-response.pdf

Olson, 2016. Mental health of transgender children who are supported in their identities. https://pubmed.ncbi.nlm.nih.gov/26921285/ 

Queensland Government, 2024. Independent evaluation finds Queensland paediatric gender services safe and evidence-based. https://statements.qld.gov.au/statements/100859