Puberty blockers - a human wrong

Public consultation closes on 20 January.

The NZ Ministry of Health is seeking public submissions on whether puberty blockers should remain readily available or whether prescribing them should be restricted in some way by regulations.

Puberty blockers are a type of medication called Gonadotrophin-releasing hormone (GnRH) analogues. They are licensed only for use in young children (for precocious puberty) or older adults (for certain cancers).

They are not licensed for use for adolescents, and they are not licensed for gender incongruence or dysphoria.

Licensing of medicines requires a robust assessment of safety and effectiveness data. These medications have not undergone that process, which means the safety and risk implications for use with gender dysphoria have not been assessed.

(Source: UK Department of Health and Social Care.)

Those who advocate for continued easy access to puberty blockers (1) have condemned the possibility of restrictions, saying regulating the suppression of puberty is against the human rights of children and discriminatory against “transgender children”, who desperately “need” this medication.

They are woefully wrong on all counts.

Fabricated “need”

In the same way that no children are born with a belief in God but are instead raised to hold religious beliefs; no children are born with the concept that they are trapped in the wrong body. It is the adults and the society they live in that teach them to embrace the magical thinking that their sex is a matter of choice and puberty is something they can blithely opt out of.

Harmful messages are being sent to young children when puberty blockers are offered as a “healthcare” option - that unhappiness can be ‘fixed’ by altering the body; that puberty is something to be feared and can be avoided without any consequences; and that it is easy and even ‘brave’ to change sex.

Of course, none of these things is true and misleading children into believing them is reprehensible. That some people assert that there is a “need” for unregulated access to puberty blockers is not sufficient reason to allow hundreds of our children to be given life-altering medication when there is no good-quality research to confirm positive outcomes.

In March this year, NHS England took the decision not to commission the routine use of puberty blockers for the treatment of gender incongruence - informed by an evidence review conducted by the National Institute for Health and Care Excellence (NICE).

These findings were echoed in the Independent Review of Gender Identity Services for Children and Young People (the Cass Review), and accompanying systematic reviews, which found insufficient evidence to support the safety or clinical effectiveness of puberty blockers for adolescents.

The Commission on Human Medicines (CHM), an independent expert body which advises ministers on the safety and efficacy of medicines, has also advised that the current prescribing environment is unsafe, and that an indefinite ban should be put in place until a safer prescribing environment can be established.

(Source: UK Department of Health and Social Care.)

According to the Ministry of Health’s own figures, the rate of prescribing puberty blockers in New Zealand has increased dramatically – by nearly 600% – in a few short years: from 25 in 2010 to a high of 140 in 2021.

When children are so clearly being influenced by a fashionable societal trend, it is the government’s responsibility to protect them from its harms. It is not possible for children or their parents to weigh up the benefits and risks of puberty blockers when long term outcomes are largely unknown. Children cannot give informed consent to eliminating puberty because they cannot possibly understand the very complex and critical process that it is, nor the many long-term consequences of rejecting it.

False “discrimination”

Puberty blocker proponents claim that denying use of this medication to a particular group based on their gender identity is sex-based discrimination which is illegal under the Human Rights Act. Of course this is a false analogy.

Regulations restricting puberty blockers would not be made on the basis of sex or gender identity but on the basis that they do not provide the benefits promised. The regulations would protect all children from the current unsafe prescribing environment.

Regulations that protect children from impulsive and unevidenced demands for drugs to detour puberty are not discriminatory even when the same drugs are available for other purposes.

When used for precocious puberty, the drugs prevent very young girls from reaching maturity before their bone growth has been completed. At the appropriate time, normal puberty proceeds and they become fully-functioning, fertile women. In contrast, puberty blockers are used to avoid puberty altogether, with lifelong, largely unknown consequences, including possible sexual dysfunction and infertility.

It is already proven that puberty blockers prevent the genitalia of boys from growing to adult size and the hips of girls from widening enough for childbirth. Sterility, osteoporosis, early menopause, and organ failure are all known potential side effects.

That a small number of children (usually girls) may be given puberty blockers to delay puberty does not represent discrimination or a double standard. To say that all drugs have side effects and that children with precocious puberty who take puberty blockers are exposed to the same potential risks as those taking them to eliminate puberty, is simply not true.

When puberty begins at a very early age it is a medically necessary intervention to delay its effects on bone growth and height. After a short period of use, the medication is ceased and a natural puberty resumes. Conversely, the unscrupulous suggestion from advocates of puberty blockers is to deny children puberty altogether and to encourage them to begin taking wrong-sex hormones (2) well before they are physically mature.

It is not discriminatory to want the best for our children and to ethically restrict the availability of drugs that target their developing bodies and minds. All children should be given the same opportunity to grow up unhindered by drugs that are not proven to be safe or effective.

Human “wrongs”

Right to identity

In its Position Statement, the Ministry of Health references the UN Convention on the Rights of the Child which includes their right to identity and equitable access to health care.

As this convention was adopted in 1989 before the current transgender activism took hold, without doubt the “right to identity” was intended to mean the right every person has to a name and citizenship of a state. Self-identification by children into the opposite sex (or no sex) was not remotely envisaged as a “right”.

One of the most fundamental rights that belongs to children, surely, is the right to go through a natural puberty that allows them to develop the cognitive maturity needed to give proper consideration to their identity, as adults.

Equitable access to healthcare

“Equitable access to healthcare” is a meaningless phrase unless the healthcare under offer is provably beneficial.

We are talking about children here, not the euphemistic term, “young people”. Puberty for girls often starts at 10-11 years and for boys at 12-13 years. These children are too young to begin to understand the consequences of halting their natural brain and body development. Allowing unregulated access to puberty blockers under the pretext of “equity” is placing unevidenced ideological beliefs above best medical practice.

Autonomy and agency

The Charter for Healthcare Services in Aotearoa New Zealand states children have the right to participate in decision-making and to be kept safe from all harms.

When children are old enough to understand all the ramifications of a treatment, they certainly should be consulted about medical decisions. But in the case of puberty blockers, it is not possible for children to give informed consent because the Ministry has already concurred with the Cass Review that there is “remarkably weak evidence” for their efficacy or safety. Where informed consent is not possible, the Ministry of Health must step in on behalf of children and keep them safe from all harms.

The affirmation treatment for “gender dysphoria” is unique in that life-altering drugs are being given to children, simply on the basis of their subjective feelings and beliefs. In no other branch of medicine does the doctor defer to the patient’s request without investigating the cause of the distress or trying less invasive treatments first.

As reported by Dr Charlotte Paul in the NZ Herald (3) on 8 January:

Professor Paul Hofman, of Auckland University’s Liggins Institute, and colleagues examined practices of care internationally. They conclude that, over time, “guidelines across different countries were progressively shaped by a rights-based approach that removed previous safeguards and increased availability of gender-reassignment medical interventions for children and adolescents”. The rights-based rather than the evidence-based best-interests approach has been at the forefront in New Zealand. It breaches Medical Council standards.

When advocates for unregulated puberty blockers wring their hands about the desperate need that “transgender children” have for this medication, they show that they are willing to pedal powerful, experimental drugs to children to prop up their own personal belief system.

It is completely unethical that a medication that deliberately eliminates the crucial physical and cognitive development of puberty is available without regulation in NZ and has been allowed to gain a celebrity status amongst children.

We have laws against child marriage, even if condoned by parents, because children are too young to consent to such a consequential decision. Similarly, we need strict regulation against puberty blockers being used to eradicate puberty, even if parents believe they have a transgender child who “needs” such medication.

Consultation closes on 20 January

There are two ways to contribute to the consultation:

• by completing an online survey,

• or by sending your submission to pbconsultation@health.govt.nz

The online survey is little more than a poll asking whether or not puberty blockers should be regulated, who should be permitted to prescribe them, and what effect any changes might have on people you know.

We recommend sending an email if you want to contribute more than ticks in a poll.

The two most important questions to answer are:

• How should puberty blockers be prescribed for gender-affirming care in New Zealand? (Point out it is not “care” to disrupt a child’s natural puberty.)

• If prescribing of puberty blockers is restricted by regulation, how might this affect you and/or the people that you represent? (Include personal experiences that illustrate the evidence already held by the Ministry of the negative effects of our current lax prescribing practices.)

Powerful medications need to be regulated to prevent harm

The NZ Ministry of Health should stop elevating the ‘lived experience’ of those who hold an unevidenced belief in “gendered souls” and start following the very clear international evidence against the use of puberty blockers for the purpose of bypassing natural development.

Transgender ideation should be treated in the same way as any other mental health disorder – holistically and using approaches that come from a robust evidence base.

The Ministry of Health must put the welfare of children first and regulate to protect them from making immature decisions under the influence of a powerful social contagion.

Footnotes

(1) Sources cited in this pro-puberty blocker submission were generally not included in the Ministry of Health’s Evidence Brief because they were assessed to be of poor quality.

• This evidence brief is a systematic literature review. All studies published in peer-reviewed journals up to 30 September 2023 were screened for inclusion.

• Relevant quality assessment tools were used to assess the quality of quantitative and qualitative evidence.

• Evidence about the impact of GnRHa on clinical and mental health and wellbeing outcomes is scarce, with available evidence largely of poor quality.

• Finally, the quality of both quantitative and qualitative studies was poor, with the studies presenting a high risk of bias.

(2) See https://insideout.org.nz/submission-guide-for-puberty-blocker-restrictions/ , under “Risks”

“The identified potential risk of bone density development happens when there is a lack of sex hormones in one’s body. This risk can be mitigated for trans young people by putting them on sex hormones that align with their gender as soon as possible (if this is something the young person wants and can give informed consent to), not simply puberty blockers long term.”

(3) “Where do we go now with puberty blockers?” by Dr Charlotte Paul, an epidemiologist and public health expert at the University of Otago.