Puberty Blocker Consultation Submission, January 2025

An essay I didn’t want to write

Not for the first time, I’m posting here a submission I’ve made to an NZ government agency about something I feel passionately about. A little too passionately, perhaps: I procrastinated on this one right up until the day before it’s due, and then as I was doing research to confirm details I half-remembered got even more angry about it than I expected and ended up staying up into the AM writing. But like for most groups in similar situations being emotional here only serves as an excuse to be dismissed, and so I’ve tried to be as level-headed as possible under the circumstances.

For my international readers (and those in the future, for as they say the past is another country) the New Zealand Ministry of Health belatedly published an evidence brief and position paper on puberty blockers for transgender adolescents in November 2024, and somewhat inexplicably asked for public submissions about future regulation on the matter. This has been viewed with understandable alarm in the transgender community, given that this is explicitly related to the current political climate, and many of us have participated if only to counterbalance the voices of those that would do us harm. You can read a much better submission from Jennifer Shields, among many others who know what they’re talking about, but on balance I’ve chosen to make my own public on this blog because it focuses on the specific aspects of this matter that really get to me personally.

Submissions close at 5pm on Monday the 20th of January; at time of writing this paragraph it is 2:30pm so it’s lucky today is a public holiday in the part of the country where I live—the settlers did something useful. Even if you’re reading this after that deadline you should still keep this in mind as an active issue; there will be other opportunities to make your opinions known should the government choose to go down the same route as their frankly embarrassing British counterparts.

Submission

I am responding to the Ministry of Health public consultation about puberty blockers, and wish to express my not-inconsiderable concern about the prospect of additional restrictions on the use of these medications by transgender youth.

I am a transgender woman who transitioned in my early 20s, too old for adolescent gender care. However, I feel obliged to respond to this consultation for two key reasons: because I wish to preserve the access to needed medication for future generations more fortunate than myself; but also for self-interested reasons, as the distinction between gender affirming treatment for adolescents and adults is much less than has been implied and so changes here will have ramifications for my own treatment.

You will have received numerous submissions from other more qualified writers arguing that access to blockers should be preserved and even expanded - I encourage you to follow their recommendations. Less laudably there will also have been submissions from those presenting policy changes that will, however cloaked in the language of concern, have a negative impact on the health and wellbeing of the young people of New Zealand. In lieu of a comprehensive discussion of all the arguments likely to appear in the latter set I would like to briefly touch on one particular datapoint that is often abused in these discussions, and which stands in as an example of the deliberate failures of reasoning commonly used to deny dignity in healthcare.

In Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK, Carmichael et al. (2020) (cited as reference 42 in the MoH evidence brief), using data from the Tavistock clinic, noted that of the 44 patients involved, at the end of the study “one ceased GnRHa [puberty blockers] and 43 (98%) elected to start cross-sex hormones”. This has been cited, for example by anti-trans organisation Genspect, as a negative, implying that gender affirming care of this kind causes adolescents to be more likely to transition as adults. Setting aside that if the study had shown any lower rates of continuance it would be used to argue that these young people are being given inappropriate medical treatment because they were not really transgender, the 98% figure shows that we can accurately identify cohorts of young people with gender dysphoria but are being much too conservative in the treatment we are offering them.

Puberty blockers, when used without corresponding hormone treatment, are an attempt to pause irreversible body changes until the patient is older and we feel it is appropriate to prescribe hormone care in addition. But if 98% go on to take these hormones it is clear that the correct treatment would have been to give these adolescents hormones from the beginning in order that they may go through the correct puberty at the same time as their peers. Meanwhile, it also strongly suggests that there were other patients excluded from the study that would have benefited from a pause in their biological maturation while they considered transition in later life.

A later study, van der Loos et al. (2022) Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands (not cited in the MoH evidence brief, although other van der Loos papers about the Dutch cohort were) also comes up with a 98% figure. In this case 720 patients were given puberty blockers for a minimum of three months and were then given the option to take hormones, all of which did; at the time of followup more than half a decade later 98% were still taking them. This is a much better protocol than at Tavistock with the same exceedingly low level of desistence, but if future prescriptions are limited to those included in clinical trials we are likely to see the more conservative English approach being applied unnecessarily.

The prospect of further clinical trials is raised because, as the evidence brief says, the use of GnRH agonists as gender affirming care for adolescents is off-label. However this is an example of a case where, in our topsy-turvy world, the medical care of vulnerable children and adolescents is being used as the thin end of the wedge against a wider community: as is not mentioned in the primary MoH materials the same medications are often used as part of hormone treatment for transgender adults because suppression of endogenous hormones is still useful after puberty has taken effect. (Note that since funding changes in 2016 adults tend to be on goserelin (brand name Zoladex) while adolescents take leuprorelin (Lucrin); this is because while goserelin implants are a more invasive procedure they are also cheaper, and Pharmac considers the drugs interchangeable.) This means that adults like me are also in danger of losing access to critical medication if their use with children is threatened. We should not need to enrol in an eternal series of academic studies to retain access to medication that is clearly working for us.

It is telling that the headline negative finding from the evidence brief, as highlighted in the position statement, is lowered bone density in patients taking blockers compared to their peers. This is another aspect that should be taken in the context of the adult transgender population: studies like those summarised in Rothman and Iwamoto (2019), Bone Health in the Transgender Population, show that even adult transgender women who have not taken blockers or in fact begun any pharmaceutical treatment at all also have lowered bone density (this was also true of me personally). The most parsimonious explanation given the evidence we have available is that it is the stress of existing as a trans person in cis-gendered society that is impacting the musculoskeletal system of the trans population, and restricting access to medication will only make matters worse.

Ultimately the most troubling part of this evidence brief to me is the nature of evidence that is and is not able to be considered. Much is made of minor potential risks to organ function and of clinical trials that could never hope to be run both ethically and in a properly double-blinded fashion, but ultimately the production of happy and healthy adults that happen to be transgender cannot be considered against it. This harkens back to a paradigm where transition can only be accepted where all else has failed, rather than a beautiful thing in its own right.

I hope that you will heed the advice you have been given by those more qualified than myself to not restrict access to this important medication. Many of us feel betrayed that this has been opened to public consultation in a politically charged environment. Lets work together to fix that.

Questions

This response is delivered free-form via email, however for completeness I will include explicit responses to the questions given in the online form:

What is your main interest in the consultation topic?

  • I am a young person with gender-related health needs
  • I have a young family/whānau member with gender-related health needs
  • I am a health practitioner who works with young people with gender-related health needs
  • I have a role in an organisation that works with young people with gender-related health needs
  • Other (please describe)

Other: I am an adult transgender woman who takes the same class of drugs for the same basic purpose under the same legal framework.

Do you live in New Zealand?

Yes.

Publishing submissions

You may publish this submission.

Official Information Act responses

Remove my personal details from responses to Official Information requests.

In your view, how should puberty blockers be prescribed for gender-affirming care in New Zealand?

  • Continued as it is now (up to the prescriber’s clinical judgement, guided by the Position Statement)
  • Continued as it is now but with more safety checks and monitoring
  • Restricted by regulations
  • Other or unsure

Continued as it is now or expanded. No additional restrictions, safety checks, monitoring, or regulations are required.

Who do you think should be able to start patients on treatment with puberty blockers?

  • Only medical practitioners who are experienced and working in a team that provides gender-affirming care?
  • Paediatricians?
  • Psychiatrists?
  • General practitioners?
  • Other hospital specialist (eg. gynaecologist, endocrinologist)?
  • Other prescribers?

All of the above, and especially those of the above that are able to prescribe the same medications to cis-gendered children for treatment of precocious puberty or who prescribe for adult transgender people.

Which young people should be able to receive treatment with puberty blockers for gender dysphoria?

  • Those who are already receiving treatment?
  • Participants in an approved clinical trial?
  • Any other groups?

All of the above. Any young child who is able to consent to medical care and who needs puberty blockers for gender dysphoria should have access. Further clinical trials are not needed to allow the fundamental access to care, and should not be erected as a barrier to it.

If prescribing of puberty blockers is restricted by regulation, how might this affect you and/or the people that you represent?

Restriction of puberty blockers by regulation affects future children going through the same life trajectory as I did. Medical care should become more accessible, not less, and I have the right to hope for better things for future generations. Additionally, because the medical care I receive myself is so similar to that which is under discussion I cannot assume that further regulation in this direction won’t affect me personally.

Do you have any further views on how any regulation should be designed?

There is no need for regulation here.

  • Rothman and Iwamoto 2019 Bone Health in the Transgender Population
  • Carmichael et al., 2020 Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK
  • van der Loos et al., 2022 Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands