Where do we go now with puberty blockers?: Charlotte Paul

Many European countries no longer support the use of puberty blockers. Photo / Unsplash

THREE KEY FACTS

• New prescribing of puberty blockers for Kiwi children has increased sevenfold over 15 years.
• The Ministry of Health’s evidence brief states there’s insufficient basis to claim puberty blockers are safe or reversible.
• Many European countries have stopped routine use of puberty blockers.

Over the past 15 years, new prescribing of puberty blockers for New Zealand children has increased sevenfold, to a level much higher than comparable countries. Almost all the increase will be for gender dysphoria. The Ministry of Health has finally released its evidence brief concluding there is an insufficient basis to say puberty blockers are safe or reversible.

Gender clinicians in NZ have said they agree to a more cautious approach, but I think they are severely minimising the problems. The evidence brief is also too narrow. Other countries have banned routine use and are developing guidelines for other types of care, and I think we should follow them. I give more detail below.

Gender clinicians have used their clinical experience to infer, despite the findings of the evidence brief, that puberty-blocking hormones for gender dysphoria are safe and effective. Clinical experience matters. But there are plenty of examples where such experience has proved highly misleading, especially where clinicians, as in this case, have a strong belief in the effectiveness of a treatment.

Insufficient high-quality studies have been carried out on puberty suppression for gender dysphoria for it to be approved by Medsafe. There has been inappropriate reassurance about this “off-label” use. It is not the same as using a medicine, approved for the same condition in adults, for children. In this case it is for a different condition. Similarly, extrapolating from studies of use for precocious puberty is misleading.

The English Cass Review (Independent Review of Gender Identity Services for Children and Young People) 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.

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.

But this is not only an argument about medical evidence or bad clinical practice. Even more important is that a whole new group of children and young people are suffering gender dysphoria: do we know what we are treating and would it resolve without treatment?

The condition is not new. But before the past 10 years it was rare and largely confined to boys who developed it early in life. Recently, it has become more common among natal girls – developing dysphoria around the time of puberty.

Cass concluded the recent surge in dysphoria among natal girls could not be explained by increasing social acceptability of underlying trans identities. Instead, she pointed to social media and social stresses – and as a manifestation of broader mental health challenges.

Before medical treatment was available, most children grew out of gender dysphoria.

But most of those given puberty blockers don’t and go on to cross-sex hormones. Thus, puberty suppression may alter the trajectory of development of gender identity.

Increasing numbers of young people are de-transitioning and expressing regret. Many blame the medical profession that unquestionably affirmed them.

For all these reasons, many European countries no longer support the use of puberty blockers. Sweden, Finland, Denmark and England and Wales have all stopped their routine use. Scotland has just completed its review and endorsed the English approach. The Cass Review findings are applicable to New Zealand too. It is especially relevant here because of our high rate of prescribing and our problematic rights-based approach.

Meanwhile, these children need care and support. Cass recommends the development and evaluation of psychological interventions. The Academy of Medical Royal Colleges is now developing training material for clinicians.

The Ministry of Health is consulting on proposed changes and then handing decisions over to the Government. Health authorities in Europe have made these decisions themselves, whereas in parts of the US and Canada, state/provincial bans are in place. A political decision risks greater partisan animosity: discrimination against trans people on one hand and uncritical affirmation of hormones for gender dysphoric youth on the other.

The Health Ministry has not had the courage to act. If the Government is to do so, it must consider all these wider issues and act in a non-partisan way.

Charlotte Paul is an epidemiologist and public health expert at the University of Otago

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