What's actually happening with puberty blockers in Aotearoa

This is a slightly longer version of an article published in the Spinoff today.

At the end of last month, after many delays and all of a sudden, the Ministry of Health finally released their evidence brief and position statement into the use of puberty blockers.

The brief and statement were pretty much what we've come to expect - limited quality evidence for both the risks and benefits of puberty blockers for trans children. None of the Ministry's documents clarified that this is not unique to trans health - as Professor Simon Denny, Director of the Mater Youth Health Centre in Brisbane says:

“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.” [emphasis mine]

Like with other international reviews into transgender healthcare, the Ministry's evidence brief has some concerning methodological flaws, including the classic fatal flaw of failing to consider the primary outcome of puberty blockers: whether they prevent further changes to a young person's body.

Gender Minorities Aotearoa have some excellent analysis on these flaws:

[The evidence brief] also said that evidence about gender dysphoria being reduced by puberty blockers was bad evidence if the researchers didn’t also check if psychological support, family support and school support could fix “gender dysphoria.”

These have never been considered treatments for gender dysphoria, except in conversion practices, which have been proven to not work, and to cause harm.

Family support, psychological support, and support at school are human rights that everyone should have by default. They are not targeted health interventions that can resolve a transgender person’s gender incongruence.

The brief was delayed a number of times to take the findings of the Cass Review into account, even publishing a separate addendum to the brief that specifically examines the results of the Cass Review and subsequent restrictions on care in the UK. It's good they gave Cass so much attention and diligence, considering how widely-reported the ideological and methodological flaws found in the Cass Review since publication, right?

Wrong. Not once are any critiques of the Cass Review are mentioned. No reference to the excellent Yale report on its methodological flaws, nor any to the British Medical Association, representing all doctors in the UK, calling for an immediate pause to the implementation of the review's findings.

What also goes without mention, despite being infinitely more applicable and relevant to a New Zealand context, is the publication of the review into Queensland's gender services, which found they delivered safe and evidence-based care.

How did this happen? How, when we were given reassurance after reassurance that they were taking the time to get this right, did we get such a clearly ideologically-driven publication that seems to use the Cass Review's flaws as an instructional manual?

Could it be that the Expert Advisory Group set up to oversee this work - and now provision of gender-affirming care more broadly - has no transgender people on it? The Ministry decided to exclude trans lived experience because they could not make that group safe for transgender people. This should have been an immediate red flag, a sign that they'd got something wrong, and that they needed to immediately reassess.

It could also be that the Expert Advisory Group specifically excluded anyone affiliated with an "advocacy group", including the Professional Association of Transgender Health Aotearoa, which includes the vast bulk of professional clinical expertise on transgender health in Aotearoa.

The Ministry of Health and their EAG systematically excluded the best expertise we have in this country from contributing to this vital work. They systematically excluded transgender lived experience. And what do we have now?

Well - what was new in the Ministry's publications was a call for public consultation on further restrictions to accessing puberty blockers. This consultation and the consideration of restrictions has come from the Government - not the Ministry, not from the clinicians most experienced in delivering this care, and not from community concerns. It is entirely politically-driven, and the Government is using public consultation as a way to manufacture consent for restricting trans young people's access to care.

And it sure does seem like they have a predetermined outcome in mind. Despite initial reassurances from the Chief Medical Officer that the Ministry felt that clinical trials were inappropriate, restricting access to only those in a clinical trial is one of the suggested options in the online consultation form. When I asked the CMO about this, I was told they were asked to include it.

It is Minister Reti that has set the timeline for this consultation - opening late in November, running over the summer break, and closing 20th January. The Ministry initially organised a 30-minute consultation meeting with 25 members of rainbow community organisations, because the timeline is beyond their control. This is not adequate or meaningful consultation, and it certainly isn't with those most affected by these decisions - trans children themselves.

Because how could you possibly safely ask children how they feel about their right to access healthcare being restricted? Certainly, you can't do that in a 2-month period when the Ministry, on direction from the Government, has burned any trust our communities have had with them. The Ministry must take the time to get this right, and the Minister must allow them to extend the consultation timeframe to allow this.

After the consultation period closes, the Ministry will give advice to Ministers Reti and Doocey. These Ministers will then work with the Ministry to send a paper to Cabinet, who will make the final decision. It will not need to go through Select Committee, and our communities and the experts will not have any further input into the decision.

How many decisions on healthcare have Cabinet made this year that totally contravene the evidence the Ministry have provided? There is no reason to believe they will follow the evidence here. It now seems all but a given that they will move - quickly - to introduce burdensome, unnecessary, and harmful restrictions on trans children's right to access healthcare early next year.

We now have clear evidence that restrictions like this have disastrous effects on the mental health of our young people. A recent study from the US shows a 72% year-on-year increase in suicide attempts amongst trans young people after the introduction of anti-transgender legislation. A heartbreaking paper from the UK asked parents of trans children about their experiences under the puberty blocker ban, and increased anxiety, distress, and poor mental health is near-universal. Trans people in Aotearoa already experience psychological distress at 9 times the rate of the general population (Counting Ourselves, 2018). This Government will have blood on their hands.

This is a discriminatory act, plain and simple. When asked why they were undertaking this work specifically for trans children and not cisgender children using blockers for precocious puberty, the Chief Medical Officer told us:

"...precocious puberty is a condition where there is an oversupply of sex hormones at an inappropriately young age, which has a consequence for long term health"

I'm sure it's as clear to you as it was to us in that hui that this is not a meaningfully different use to their use in trans children - who experience an oversupply of sex hormones at an inappropriately young age that causes them distress and has a consequence for their long term health unless we intervene.

The Government is directing the Ministry to engage in sex-based discrimination, working to implement restrictions on one population's right to access healthcare without good cause. They are rushing this process, hoping we don't notice over the summer break. They have specifically and intentionally excluded the best expertise available to them. And they will make whatever decision they choose to make with no oversight, no requirement to be guided by evidence, and seemingly with no care for the wellbeing of Aotearoa's transgender children.

Please - it's vital that you not only submit through the Ministry's consultation process, but that you make sure that Ministers Reti and Doocey hear from you, too. Meet with your local MP - they are required to represent their constituents in parliament. Make sure they know that this process is discriminatory, already doing harm, and has the potential to do massive and irreversible damage to a generation of trans children.

Gender Minorities Aotearoa have an excellent submission guide, as does InsideOUT (coming tomorrow). I've written one for Emily Writes for parents and whānau, too (also coming soon).

Trans kids did not come into existence through access to healthcare, and removing their access to healthcare will not make them disappear. Especially not this generation, which has grown up with unprecedented levels of visibility and acceptance - it hasn't been perfect (or at times, good) by far, but this generation have had a glimpse of what a truly trans-inclusive society could be like, and they will not let it go.

It's only ten years ago that Aotearoa included a "real life experience" requirement to access gender affirming care - a year of living as your gender with no medical support. Many people stayed in the closet, and many more accessed hormones outside of the medical system. So much has changed in just ten years - we will not let that progress go lightly.

To our whānau and parents: this is going to be difficult, but your children will be okay. Your support of them is the number one protective factor for their wellbeing. Stand by them, stick by them. Do everything you can for them, as I know you already are.

To our rangatahi and tamariki: we will not let this happen without a fight. We will stand with you and for you and we will fight tooth and nail to ensure you continue to have the right to access the healthcare you need.

We love you, and we're proud of you. We're sorry the government are taking these actions, and we'll do everything we can to stop them. Stay strong, and stay safe.