What’s the best way to care for children and young people experiencing gender questioning? It’s a contested subject, so much so that it’s a common reason for conscience issues. So when the Ministry of Health finally released its review of the evidence on puberty blockers late last year, there was a lot of interest in what it had to say.
The Ministry summarised their headline conclusion like this: “there is insufficient basis to say that puberty blockers are safe and reversible (or not) for use as an intervention for gender dysphoria in adolescents.” They went on to say that, “clinicians should exercise caution in prescribing” puberty blockers and should only do so as part of “an interprofessional team” offering a broad range of support to young people who are questioning their gender.
Doctors practising “gender care” featured in media articles responding to the review, in some cases emphasising that their practice didn’t need to change in response to the review, and that the evidence “indicated use of puberty blockers was ‘safe’”—despite the Ministry’s conclusion.
Over the summer, Professor Charlotte Paul provided her analysis. Paul, an emeritus professor at Otago, is a medical epidemiologist with a research background in sexual and reproductive health, the safety of medicines, and in the methods and ethics of research. She began by saying that, “[g]ender clinicians in NZ ... are severely minimising the problems” involved in the use of puberty blockers, before turning to two key issues with the Ministry’s evidence brief.
First, she said, the brief is “too narrow”. While she didn’t elaborate on this point, the brief itself notes that it excludes consideration of “[u]se of cross-sex hormones, gender-affirming hormone treatment such as estrogen or testosterone, gender-affirming surgical treatment and progress from puberty blockers to any of these”. This is a significant omission; Paul says that most children and young people who receive puberty blockers “go on to cross-sex hormones. Thus, puberty suppression may alter the trajectory of development of gender identity.” In other words, the review doesn’t tell the full story about the potential impact of starting on puberty blockers.
Second, Paul said, there are “[i]nsufficient high-quality studies” to warrant Medsafe approval of puberty blockers. “There has been inappropriate reassurance about this ‘off-label’ use.” By contrast, the Cass Review carried out in England:
examined a wider range of evidence and the team interviewed more than 1000 individuals. Not only was the evidence of benefit remarkably weak, but Cass identified potential serious harms:puberty suppression may alter the trajectory of development of sexuality and gender identity and may temporarily or permanently disrupt brain development.
As Professor Paul concluded, children experiencing gender questioning need and deserve our care and support. But most of these children will grow out of their gender dysphoria, and other countries are moving towards a more holistic, developmentally informed approach that seeks, for example, to understand co-existing mental health conditions and to provide psychological support rather than uncritically affirming gender transition. It’s the kind of approach we recommended in Students and Social Transition, our policy guide for New Zealand schools, which Professor Paul commented favourably on.
The Ministry is currently considering whether there should be restrictions on the use of puberty blockers, and there will be plenty of attention focused on their conclusions. Commenting on the Ministry’s review, the president of the Professional Association for Transgender Health Aotearoa said, “So much has changed in just 10 years – we will not let that progress go lightly.” But as Professor Paul said,“[i]ncreasing numbers of young people are de-transitioning and expressing regret. Many blame the medical profession that unquestionably affirmed them.” It’s clear that we can expect the use of puberty blockers, and “gender-affirming care” for young people more generally, to be a subject of debate and a catalyst for conscience issues for some time to come.