Health professional organisations have come together in a public statement against the government’s proposal of further restrictions for access to puberty blockers. 

Puberty blockers are a well-established component of gender-affirming healthcare, supported by the World Professional Association for Transgender Health (WPATH) Standards of Care version 8 and the Aotearoa New Zealand Guidelines for Gender Affirming Healthcare. Released today, the statement highlights that restricting access to puberty blockers would disregard established clinical guidance and international best practices, placing political interests above the wellbeing of young people.

The measures being considered, including limiting access to clinical trial participants, would impose unethical and discriminatory barriers to care. The professional bodies warn that requiring adolescents to enrol in research studies as a condition for receiving care endorsed by national and international professional bodies would be coercive and inconsistent with ethical healthcare practices. Evidence from the Ministry of Health’s Evidence Brief reveals that while claims of harm associated with puberty blockers are inconclusive, withholding this care risks exacerbating gender dysphoria and harming young people’s mental health.

“Decisions about puberty blockers must remain in the hands of young people, their whānau, and their healthcare providers,” says Dr Rona Carroll, Vice-President of the Professional Association for Transgender Health Aotearoa (PATHA). “These decisions are guided by professional training, clinical experience, clinical guidelines and the best available evidence—not by political agendas.”

The coalition of signatories, which includes PATHA alongside the Aotearoa New Zealand Association of Social Workers, Ara Taiohi, Auckland Sexual Health Service, AusPATH, the College of Child and Youth Nurses,

the New Zealand College of Clinical Psychologists, the New Zealand Medical Students' Association, the New Zealand Paediatrics Society, the New Zealand Psychological Society, the New Zealand Sexual Health Society, the New Zealand Society of Endocrinology and the Society of Youth Health Professionals Aotearoa, calls on the government to uphold equitable and evidence-based access to this care.

The statement reads:

Statement on safety measures for the use of puberty blockers in young people with gender-related health needs

We support the continued use of puberty blockers in gender affirming care in Aotearoa New Zealand, in line with the WPATH Standards of Care version 8 and the Aotearoa New Zealand Guidelines for Gender Affirming Healthcare. This is consistent with the Ministry of Health’s position statement, which specifies that clinicians who initiate puberty blockers should be experienced in providing gender-affirming care and have input from relevant multidisciplinary fields. As with any other specialty service, this care should be provided by professionals with appropriate expertise.

We do not support banning the use of puberty blockers for gender affirming care, or severely restricting access to this care, for example by limiting access to those enrolled in a clinical trial. Requiring adolescents to participate in a research project as a prerequisite for accessing care that is supported by major national and international professional bodies and has an evidence base comparable to other similar forms of paediatric care would be coercive and ethically inappropriate. The Ministry of Health Evidence Brief identified that any evidence of harm associated with providing puberty-blocking medication is limited and inconclusive, and withholding this care may exacerbate gender dysphoria and negatively impact mental health. Equitable and non-discriminatory access to this care should be provided and maintained throughout the country. 

Decisions about prescribing puberty blockers should continue to be made collaboratively between young people, their families or support people, and the health professionals involved in their care. These decisions are individualised, based on informed consent, and guided by professional training, clinical experience, and the best available evidence. Any move to restrict access to puberty blockers would be a political decision and not one based on clinical guidance from health experts in New Zealand and international best practice. Medical decisions should remain free from political interference.

Signatories:

Aotearoa New Zealand Association of Social Workers

Ara Taiohi (Peak Body for Youth Development)

Auckland Sexual Health Service

Australian Professional Association for Transgender Health

College of Child and Youth Nurses

New Zealand College of Clinical Psychologists

New Zealand Medical Students’ Association

New Zealand Paediatrics Society

New Zealand Psychological Society

New Zealand Sexual Health Society

New Zealand Society of Endocrinology

Professional Association for Transgender Health Aotearoa

Society of Youth Health Professionals Aotearoa

This is PATHA's submission to Manatū Hauora the Ministry of Health's consultation on possible further restrictions to access puberty blockers. This submission has been developed amongst PATHA's Policy & Advocacy and Executive Committees, and draws on the professional expertise of both clinicians and community members amongst PATHA's membership.

Summary of PATHA Recommendations

• Puberty blockers should be prescribed as per international and Aotearoa New Zealand guidelines.

• The process of prescribing or initiating puberty blockers do not require restrictions, given that they are currently prescribed in line with best practice.

• Support, continuing professional development and funding should be provided to enable clinicians to provide accessible care throughout Aotearoa. 

• Restrictions around which clinicians initiate puberty blockers are not required, given that they are currently prescribed in line with best practice.

• Puberty blocker initiation should not be restricted to certain specialties. In Aotearoa, a range of prescribing clinicians should be able to provide this care.

• Clinicians initiating puberty blockers should have an understanding of up to date international best practice and guidelines. Experience working in this area, or support by other experienced clinicians, is important.

• Primary care prescribers with appropriate expertise and support should be able to continue prescribing and initiating puberty blockers in the context of a multidisciplinary team.

• All clinicians initiating puberty blockers should be working as part of an MDT. How this may be configured, and operate, will depend upon which resources and health professionals are available. MDTs may be virtual and may involve correspondence. 

• Access to multidisciplinary team members, including psychologists, counsellors, social workers and peer support workers, should be supported and resourced.

• Any young person with gender incongruence who is seeking puberty blockers and who meets the WPATH Standards of Care 8 criteria should be able to access puberty blockers by having access to an informed consent approach supported by an MDT. Access to puberty blockers should not be further restricted in any way.

• There is currently regional variation in access to puberty blockers. Funding is required to ensure equitable access to puberty blockers around the country.

Read the full submission here:

Puberty_Blockers_Submission-WebVersion.pdf

PATHA President, Jennifer Shields, and Vice-president Dr Rona Carroll, have published op-ed pieces about the current public consultation on regulations for puberty blocking medication.

In her piece in The Spinoff, Gender-affirming care affects a small minority – so why the public consultation? Jennifer Shields argues that the process is flawed and appears to prioritise political objectives over evidence-based care.

"The government is directing the ministry 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... This process is discriminatory, already doing harm, and has the potential to do massive and irreversible damage to a generation of trans children."

In her piece in The Conversation, NZ is consulting the public on regulations for puberty blockers – this should be a medical decision not a political one, Dr Rona Carroll highlights the inappropriateness of involving the public in a medical decision for a vulnerable minority group.

"Medical decisions should be guided by scientific or clinical concerns and remain free from political interference. Banning or restricting access to puberty blockers would go against best-practice recommendations from major medical bodies – including the Endocrine Society, the Royal Australasian College of Physicians, the American Psychiatric Association and the American Psychological Association – and likely cause harm to young people."

You can make a submission to the public consultation here. See this guide by InsideOUT for suggestions about how to make a submission.

Manatū Hauora / the Ministry of Health recently published an Evidence Brief and Position Statement on the use of puberty blockers in gender-affirming care

Following PATHA's statement about the Evidence Brief, PATHA leaders have been giving comments to the media. 

Dr Rona Carroll, PATHA Vice-President, General Practitioner, and Senior Lecturer at the University of Otago gave the following comment to the Science Media Centre:

“I welcome the Ministry of Health’s evidence brief and position statement around the use of puberty blockers as part of gender affirming care. All young people deserve access to quality care in which clinicians take a holistic approach which includes their family and whānau, and which offers wider support services when needed. Just as with any other specialty service, this care should be provided by people with expertise, as is already the case in Aotearoa New Zealand.

“Whilst the review did not find high quality evidence of benefits for puberty blockers, it also did not find evidence of harm. However, the evidence accumulated for this position statement focussed entirely on the mental health effects and some specific negative clinical outcomes and doesn’t consider the physical benefits which are the main indication for prescribing puberty blockers in this context.

“Puberty blockers work to prevent potentially unwanted physical changes of puberty, which may result in distress to transgender people. Puberty blockers do not by themselves result in any physical changes; they simply delay the physical effects of puberty that would otherwise occur. The review focussed on identifying evidence to support puberty blockers improving mental wellbeing, but this is not necessarily an expected outcome of the treatment; mental health may not change because the potentially distressing pubertal changes are not happening. It is more important to note the adverse effects on mental wellbeing by not using puberty blockade and therefore experiencing pubertal change, and the position statement does not acknowledge this.

“Furthermore, the review does not take into account the improved outcomes for people beyond adolescence who go on to take gender affirming hormone therapy. In my experience, individuals who have used puberty blockers are more likely to see the physical changes they would like to see in adulthood from sex hormone therapy, as irreversible physical changes that occur during puberty are not present. It is at these later stages where we see the clinical benefits. Every week in my GP clinic I hear from young people and adults with gender incongruence who did not have puberty blockers, and who now suffer and struggle in ways which have a huge impact on their day-to-day life, due to the physical changes which occurred during puberty. There is little published data on this as an outcome, but it remains a primary indication for the use of puberty blockade.

“Another consideration of the narrow focus of this review is that it only reviewed evidence in relation to these medications in the context of gender affirming care. The same medications used to achieve puberty blockade in this context are widely used in other areas of healthcare such as precocious puberty and menstrual disorders. There is no evidence for sustained adverse effects from this in these areas, but this is not considered in the statement.

“When considering the balance of the potential benefits and low level of identified risks, limiting or restricting access to puberty blockers would not be an ethical approach to take. I fully support the need for high quality longitudinal data in this area, alongside continued access to holistic and interprofessional care for young people seeking gender affirming healthcare.”

Dr Carroll also gave the following comment to The Post:

"The ministry’s advice just cemented the need for a best practice approach ‒ which should have already been happening.

“Clinicians already exercise caution. They understand it's a complex area. They work in teams. They really provide that time and support to make sure it's the right thing for people.

“They're actually quite difficult to access. There’s a really long waiting list to get into these services, and they're being prescribed by people who have expertise in the area.

"Any moves to restrict or block access to puberty blockers would almost definitely cause harm”

 Jennifer Shields, PATHA President, gave the following comment to RNZ:

"The evidence brief has only been out 24 hours and I've already had a number of families message me quite distressed, concerned for the wellbeing of their young people, concerned about their ability to access healthcare in the future.

"Any further restrictions are unnecessary and would only do harm to those who need that care the most

"PATHA is concerned about the appropriateness of opening this consultation on a medical matter to the wider public particularly when the matter of gender affirming care has become highly politicised and subject to disinformation.

"I would really caution the Ministry of Health to take that into consideration when they are assessing the findings of that consultation and really would caution government in particular about the impacts that a public consultation process is likely to have on the health and wellbeing of trans people of all ages but particularly for trans young people."

"It is important to take the politics out of a healthcare matter and bring it back to the wellbeing of the young people.  At the centre of this there are children and young people who are experiencing mental distress, who are navigating a journey of gender recognition, who really do need access to this care and I would encourage people to think about what that experience is like.

"To even have questions about your identity and whether the body you have is the right one for you and to be experiencing potential permanent changes to your body that you have no control over, knowing that there is an intervention out there that can give you the time to make a decision without those permanent changes looming over you and then to have that option taken away is really traumatic for a lot of people.

"A lack of high quality evidence is not unique to puberty blockers. When we're thinking about high quality evidence, quite often we're talking about randomised control trials and those are really difficult and challenging to undergo for gender affirming care particularly. Partly because of the ethical considerations around withholding necessary care but also because if you're giving one group a placebo and another group puberty blockers or hormone therapy it becomes pretty obvious pretty quickly who's on what.

"I think it's really important that we're not holding this kind of healthcare to a standard that healthcare for the general public doesn't meet.

"Best practice often looks like paediatricians working alongside mental health professionals, peer support and social workers to help a young person and their family make the choices that are best and right for them, with the support they need. If the government is concerned about the safety of gender diverse young people, it is important to make sure clinicians nationally are adequately resourced and have access to this multidisciplinary support. PATHA would like to see standardised access to care and investment from the ministry for this.

"There may be limitations to comparing a New Zealand context to that of other countries. Particularly around the model and approach we take here in Aotearoa, some of the biggest comparisons that are often drawn are with healthcare provision in England, in the UK, and their approach to gender care, for a very long time, has been a centralised clinic model, which has meant long wait times and lower rates of access. Care in New Zealand is provided locally with every region having a distinct pathway, something which has a tangible impact of those accessing care.

"The Ministry's position statement makes it clear that puberty blockers can continue to be used as part of a comprehensive care plan for trans and gender diverse young people where needed.  The statement is not a new set of rules, but guidance that acknowledged the approach experts already use.

"PATHA will continue to work to ensure access to this important care is maintained."

The Professional Association for Transgender Health Aotearoa (PATHA) welcomes Manatū Hauora’s (the Ministry of Health’s) evidence brief and position statement into the use of puberty blockers in gender affirming care, released today. Today’s position statement makes it clear that puberty blockers can continue to be used as part of a comprehensive care plan for trans and gender diverse young people where needed. PATHA will continue to work to ensure access to this important care is maintained.

PATHA is an interdisciplinary professional organisation working to promote the health, wellbeing and rights of transgender people. Our members work professionally for transgender health in clinical, academic, community, legal, and other settings. Our vision is that all transgender people have equitable access to the healthcare they need, and that all healthcare providers have access to information and resources which enable them to provide safe and informed healthcare.

“It’s reassuring to see Manatū Hauora recognise the best-practice approach Aotearoa is already taking, making it clear that trans and gender diverse children and young people will still be able to access puberty blockers, and that there is a need for more long-term, Aotearoa-based research into the clinical, mental health, and wellbeing impacts of this care,” PATHA President Jennifer Shields said. “The Ministry has been clear - puberty blockers can continue to be used as part of a comprehensive care plan. The statement is not a new set of rules, but instead guidance that acknowledges the approach experts already use.”

Manatū Hauora’s evidence brief has found limitations in the quality of evidence for the benefits and risks of using puberty blockers, reflecting the methodological and ethical limitations of running randomised-controlled trials for gender affirming care. While the brief found some evidence that puberty blockers can slow the rate of bone density increase, it found no impact on renal or liver function, the onset of diabetes, or fertility, while finding benefits for mental health outcomes such as depression, anxiety, and suicidal ideation.

Manatū Hauora’s position statement is in line with current practice in Aotearoa, where healthcare professionals providing puberty blockers are experienced in providing gender affirming healthcare and are doing so with the support of interprofessional teams, and the young people accessing this care have access to social and mental health support.

“Manatū Hauora recognises the importance of access to high quality health care which meets people's needs” said Dr Rona Carroll, a GP working in gender affirming care and Vice President of PATHA. “As a clinician, an important aspect of providing equitable and holistic care is to give trans and gender diverse youth the time and space to explore their identity, free from prejudice. Puberty is a critical time of change and development and for some trans and gender diverse youth, puberty blockers provide much needed breathing space. We have decades of experience in using these medications in other medical contexts.”

Manatū Hauora has opened consultation on the possibility of further restrictions or regulations on prescribing puberty blockers for gender affirming care. PATHA is concerned about the appropriateness of opening this consultation on a medical matter to the wider public, particularly when the matter of gender affirming care has become highly politicised and subject to disinformation. The approach to providing this care outlined by Manatū Hauora’s position statement is in line with best practice. PATHA cautions against further restrictions, and would encourage Manatū Hauora to approach this care the same way they would any other health intervention.

“It’s important that Manatū Hauora continue to centre the young people seeking gender affirming care as they move forward,” Shields said. “Our rangatahi deserve the same access to healthcare as any other young person. Exploring any additional criteria or conditions should prioritise improving support for prescribing clinicians and ensuring equitable access to this vital care. There are likely to be human rights implications if any additional standards or barriers were introduced for trans and gender diverse young people, when none exist for cisgender young people accessing the same medication.”

PATHA welcomes the proposal for more Aotearoa-based research into the benefits of puberty blockers and the wellbeing of trans and gender diverse young people. During this process, the involvement of transgender community experts is critical. Research into the effects and impacts of blockers will need to include qualitative analysis with young people and their families to understand the experiences of those undergoing this care.

PATHA looks forward to reviewing the evidence brief in further detail, and to the opportunity for its members - and other clinicians and transgender community experts around the country - to provide expert advice as Manatū Hauora explores its next steps. These next steps will require input from clinicians, whānau, and trans and gender diverse people to ensure the best possible outcomes for the health and wellbeing of trans and gender diverse young people throughout Aotearoa.

PATHA responds to a recent NZMJ article regarding prescribing rates for puberty blockers in Aotearoa New Zealand

The NZMJ article compared New Zealand's prescribing rates with those England, Wales, and the Netherlands.

GP Dr Rona Carroll from PATHA's Executive Committee states:

Puberty blockers can have a positive effect on the mental health and wellbeing of transgender and gender diverse young people. In New Zealand, children and young people access puberty blockers through a careful assessment and support process that includes a team of healthcare professionals and psychological input.

New Zealand is a progressive country which recognises the importance of accessibility to healthcare and support for gender diverse young people. Our model of care is different from the centralised gender clinic model used in the comparison countries in this paper. These centralised clinics overseas have often led to excessively long wait times for care.

For these reasons, it is not surprising that New Zealand has higher rates of prescribing puberty blockers. As the authors point out, the number of transgender young people does not appear to be increasing. Instead, the higher prescribing rates may be because young people feel safe expressing their gender and healthcare needs, have access to appropriate health services and live in a country where inclusion and respect for transgender individuals is growing. It is a good sign that young people are feeling comfortable to discuss their gender with their whānau and express their needs.

Using data from UK gender clinics might not accurately reflect the true need for puberty blockers in the UK, where accessing this care can be extremely difficult. Our goal should not be to match UK prescribing rates, but rather to ensure that gender diverse children and young people receive accessible, individualised, and holistic care. The PHARMAC data presented in the paper suggests that New Zealand is responding to this need.

- 27 September 2024

Further responses are available here.

PATHA will be holding its 2024 Annual General Meeting via Zoom at 2pm on Saturday 24 August 2024. This is expected to run for approximately one hour.

Agenda

1. Welcome
2. Note any apologies and appoint minute taker
3. Receiving the minutes of the previous Society Meeting
4. President’s Report
5. Financial statements
6. Election of Executive Committee Members
7. General business - Welcome to new Policy and Advocacy Committee members, and thank you to outgoing Policy and Advocacy Committee members.
8. Close meeting

PATHA members can log in to find the Zoom link for the online AGM, copies of the reports, and information about nominees received for the Executive Committee. Some of this information is already available to members upon logging in, other information will be uploaded to the same page closer to the date of the AGM.

The Professional Association for Transgender Health Aotearoa (PATHA) is disappointed to see the number of harmful recommendations made by the NHS-commissioned Cass Review, released yesterday in England. This review ignores the consensus of major medical bodies around the world and lacks relevance in an Aotearoa context.

The Cass Review is a report into England’s approach to providing gender affirming care through a centralised gender clinic model. The 2022 interim report found this model was not fit for purpose, with wait times for the service extending into years. As a result, the clinic was closed while the NHS determined a better approach to providing this service.

The final Cass Review did not include trans or non-binary experts or clinicians experienced in providing gender affirming care in its decision-making, conclusions, or findings. Instead, a number of people involved in the review and the advisory group previously advocated for bans on gender affirming care in the United States, and have promoted non-affirming ‘gender exploratory therapy’, which is considered a conversion practice.

It’s shocking to see such a significant inquiry into transgender health completely disregard the voices of transgender experts. It would be like reviewing women’s health with no women, or Māori health with no Māori involved.

PATHA has shown the benefit of collaborations between transgender community members and clinicians providing gender affirming care. The lived experience and knowledge of our community members and clinicians does not make them biased - it means they’re the experts in this care.

The Review commissioned a number of systematic reviews into gender affirming care by the University of York, but seems to have disregarded a significant number of studies that show the benefits of gender affirming care.

PATHA welcomes further research about the health interventions that support the wellbeing and lives of trans and non-binary people, and of trans communities locally and globally. While we certainly look forward to more longitudinal research, the evidence in support of gender affirming care is clear, and we’re disappointed to see this review discard so much robust work from researchers around the world. When multiple observational studies produce similar findings, the cumulative evidence becomes compelling.

The Review’s recommendations include restricting access to both social transition and gender affirming hormone therapy, and would require the approval of a national multi-disciplinary team for any gender affirming care to be provided to anyone under 18. Restricting access to social transition is restricting gender expression, a natural part of human diversity. Requiring clinical approval for haircuts and wardrobe changes is intrusive, inappropriate, and a waste of money and time.

We’ve seen the benefits that increased access to gender affirming care have had on trans communities around Aotearoa. Barriers to care have detrimental impacts on wellbeing, and create additional work for healthcare systems already under stress. Our holistic approach, utilising multi-disciplinary teams, works well for Aotearoa.

In Aotearoa, gender affirming care is available no matter where you live, and has evolved over the last 15 years based on clinical experience, emerging evidence, and updated guidelines. Clinicians around the country, supported by specialists and multidisciplinary teams where needed, work alongside whānau to ensure best practice that is holistic, individualised, and whānau centred, with the best possible outcomes for our rangatahi.

Clinicians working in gender-affirming care welcome the increasing body of evidence about puberty blockers. This is important to help young people and their families make the best decisions about their individualised care.

PATHA is proud to support clinicians and community members working to promote the health and wellbeing of trans and non-binary people around Aotearoa. Our members have contributed to the evidence base in support of gender affirming care, and of trans wellbeing more generally, and will continue to work to improve access and the quality of care around the country.

We’ve collaborated with AusPATH and other rainbow organisations on this statement released by Equality Australia, and encourage that everyone take good care of themselves, and take time to unplug and check in with those around you. Aroha nui and kia kaha.

AusPATH/PATHA Joint Hybrid Conference

Advocating for Change, Advancing Best Practice

2 - 4 November 2023, Melbourne, Australia

Virtual Registration Still Available!

The PATHA Executive Committee are delighted to report that the joint AusPATH/PATHA conference has sold out in-person attendance! It is amazing to know so many people are interested in this event and transgender and non-binary health and wellbeing. As the conference is hybrid, virtual registration is still available. This gives you 6 months access to content.

The AusPATH/PATHA Joint Conference will offer opportunities for professional development and networking for a multidisciplinary audience, bringing together researchers, primary healthcare providers, community, specialist clinicians, general practitioners, policy experts, academics, and mental health practitioners. This conference would be of interest to anyone who works with patients, works with transgender, non-binary, or takatāpui individuals or communities, or who is interested in learning more about this incredible area of research.

There is a concession rate for those where finances may be a barrier. If there are any students, early career researchers, or community members, for whom cost is still a barrier, we urge them to contact Cassie, the hybrid co-ordinator, at cassie.withey-rila@outlook.com.

Register your place now

If you have any questions regarding the conference, please contact Cassie or the conference secretariat at conference@ashm.org.au

The Annual General Meeting for the Professional Association for Transgender Health Aotearoa (PATHA) will be held via online video call from 2-3pm on Saturday the 22nd of July, 2023.

Agenda

1. Welcome
2. Note any apologies and appoint minute taker
3. Receiving the minutes of the previous Society Meeting
   
4. President’s Report
   
5. Financial statements
6. Election of Executive Committee members
7. General business
8. Close meeting
   

PATHA members can log in to find details of how to attend the online AGM, copies of the reports, and information about nominees for the Executive Committee.