The government is halting new puberty blocker prescriptions for youth with gender dysphoria.
From 19 December, new regulations under the Medicines Act will prevent new prescriptions for this purpose, pending completion of a publicly-funded clinical trial in the UK.
In November 2024, the Ministry of Health released an evidence brief saying puberty blockers should only be prescribed by a clinician experienced in gender affirming care, and supported by an interprofessional team including mental health support.
Previous expert comments on this topic are available here.
The SMC asked experts to comment.
Dr Ben Albert, Paediatric Endocrinologist,Starship Children’s Health, Te Whatu Ora, and Senior Research Fellow, Liggins Institute, University of Auckland, comments:
“This is a disappointing decision. The young people seeking help for gender dysphoria are deeply distressed by the changes occurring to their bodies in puberty because their bodies irreversibly change towards a sex they don’t identify with. Puberty blockers halt that process, and give the young person time to age without those changes and work out what they want to do as they get older and are able to make more decisions for themselves.
“I think there is a need to be cautious about how we provide gender affirming care. We need to be generating more evidence to find out which young people benefit the most from treatment, which ones are less likely to. We need to very carefully inform patients about the effects of these medicines, and continually check in with them about whether they still want to take them. We need to make sure that next steps, like hormone therapies, are treated not as inevitable, but as another important decision to be made. But none of that means that we shouldn’t be offering treatment to young people now.
“The Cass report emphasised that there is limited high quality evidence in the area of gender affirming care, especially the type that comes from randomised controlled trials. This is important and there is a need for more research to help guide the best way to offer treatment, as there is in many aspects of medical care, especially for children and young people. However, we already know a huge amount about the effects of puberty blockers, we know what these medications do and how to use them safely. An outright ban is not justified by the state of the science.
“Puberty blockers are generally very safe medications. When used, they stop the hormonal messages from the brain that cause puberty to occur and progress. When they are stopped puberty restarts. Taking them for a long time in adolescence can lead the person to accrue less calcium in their bones, than they otherwise would have, so that there might be an impact on fracture risk when they are older. These are the sorts of things that young people should be informed of when they make decisions about puberty blockers, but not a reason not to use them at all.”
Conflict of interest statement: “No conflicts to declare.”
Dr Rona Carroll, General Practitioner; and Senior Lecturer, University of Otago, comments:
“The Government’s announcement that new patients seeking treatment for gender dysphoria or incongruence can no longer be prescribed gonadotropin-releasing hormone (GnRH) analogues from December 19th is a shockingly inappropriate overreach of politics into healthcare. Prescribing decisions should remain between clinicians, patients and their whānau.
“GnRH analogues are used by a very small number of young people to prevent irreversible and distressing bodily changes. They are prescribed with great care by interdisciplinary teams with expertise and experience in providing healthcare for young people experiencing gender incongruence and distress. Their use is supported by major medical bodies including the Endocrine Society and the Royal Australasian College of Physicians.
“There is evidence to show the benefits of GnRH analogues for people experiencing gender incongruence, however, the challenges and ethical considerations of conducting randomised controlled trials in this field mean that the available evidence has limitations. This is common in many areas of medicine, particularly paediatrics and is not unique to transgender healthcare. Other medications with similar levels of evidence continue to be prescribed. No other area of paediatric medicine is held to this standard.
“The Government media release states that “Cabinet has agreed that the Ministry of Health will review the settings for the prescribing of gonadotropin-releasing hormone analogues for the treatment of gender dysphoria or incongruence once the results of the United Kingdom clinical trial are available.” The UK trial is expected to run until 2031, and then there will presumably be a considerable time until the results are published. Whilst the results are likely to be helpful and will add to the body of existing evidence, there is no justification to ban this care while they are being awaited.
“The UK clinical trial will only monitor young people on GnRH analogues for 2 years. It is hard to see what evidence this will provide that is not already available. The benefits of preventing an unwanted puberty may not be seen for many more years as people grow older and go into adulthood. Given that GnRH analogues are often initiated at the start of puberty, after 2 years on this medication patients will not yet have experienced the benefits of preventing unwanted physical changes in adulthood. The more longitudinal arm of the UK study is observational, so will also not provide the high-quality level of evidence which the Government claim is needed.
“The Government announcement states that GnRH analogues can still be prescribed for other indications. This ban only applies to those being prescribed GnRH analogues for gender incongruence or dysphoria. This discriminatory approach shows that this decision isn’t about medication safety concerns but instead is politically motivated to prevent transgender people from accessing gender affirming medical care. Health professionals have decades of experience in using these medications. There are no concerns around the reversibility or safety of these medications when they are used in these other situations.
When considering the balance of the potential benefits and low level of identified risks, banning GnRH prescribing for people experiencing gender incongruence or dysphoria is unjustified, unethical and cruel.
“If the wellbeing of children and young people was truly at the heart of this, the Government would be supporting accessible, high-quality healthcare, and support for young people and their families to make their own informed decisions about their body and their health with the support of experienced healthcare professionals. Young people have a right to access the healthcare they need.”
Conflict of interest statement: “I am a member of the PATHA executive committee, and a GP working in gender affirming healthcare.”
Professor Paul Hofman, paediatric endocrinologist, University of Auckland, comments:
“With the latest banning of pubertal blockers in transgender youth, the Minister of Health and his advisors have demonstrated a lack of understanding about the impact their decisions can have on vulnerable groups.
“In this instance the Government media release states “Cabinet has agreed that the Ministry of Health will review the settings for the prescribing of gonadotropin-releasing hormone analogues for the treatment of gender dysphoria or incongruence once the results of the United Kingdom clinical trial are available.” As Dr Rona Carroll elegantly summarised – this is NOT a study that will answer the questions the current government are asking. It is a longitudinal study following individuals with transgender over a very short period of 2 years. It cannot answer the questions of pubertal blockers safety or efficacy – the two main issues raised. So waiting for another 6 years for study results that will be non-informative can only be seen as cynical politics. Moreover, when is a UK study an appropriate guide for New Zealand which has a very different cultural mix? Both Māori and Pacific peoples in particular have a more permissive approach to transgender and sexual diversity. We should not be taking guidance from a substandard, qualitative UK study which has minimal relevance to New Zealand and our cultures.
“Let us look at the data on that are available. Pubertal blockage has been used in medicine for over 40 years (1979) and their safety and efficacy in blocking puberty is well established. They have been used in adults for treating breast and prostate cancer and are used in paediatrics to block precocious (abnormally early) puberty and used to increase final height in short children by delaying puberty and increasing the time available to grow. Some experts are concerned that blocking puberty for 3-4 years in early adolescence changes gender identity and causes or worsens transgender feelings. There is NO data to support this assertion. In no situation in paediatrics, including the use of pubertal blockers for several years in early adolescence to increase final height has gender dysphoria been an issue/reported. Similarly, there are many children who have delayed puberty and in some societies, a failure to go into puberty is not identified until early adult life (ie no gonadal sex hormones are present). In none of these situations has gender dysphoria been reported. Gender identity is usually in place in early childhood and not related to sex steroid hormones after birth. Therefore, how would one hypothesize that delaying puberty by 3-4 years is going to change one’s gender identity? The proposal has no basis in our understanding of gender identity nor any scientific evidence to support it.
“What will happen though is, in those youth with gender dysphoria who don’t receive puberty blockers, there will be greater conflict, self loathing and mental health issues including anxiety and depression. Bullying, self-harming and suicidal ideation have been associated with being transgender and gender diverse. Indeed, access to pubertal blockade has been shown in one cross sectional study to reduce the risk of life-time suicidal ideation by 60%.
“Sadly, in my opinion, this decision is not based on medical expertise or science and appears to be a transphobic, politically driven response. My questions of the Minister and his advisors though, is when the levels of self-harm and suicidal attempts increase, as is likely the case, will they take responsibility for the consequences of their actions?”
Conflict of interest statement: “No – other than I am a paediatric endocrinologist. No other conflicts.”
Dr Massimo Giola, sexual health physician, comments:
“In my work, I see gender diverse youth after the age of 16. I am very worried about the state of their mental health at that point, and I’m worried that they might have significantly self-harmed because of allowing biological puberty to happen, rather than pausing it using these medications.
“While these medications were never subject to a randomized control trial, that is the case for many other interventions in medicine, and particularly for young people, when it’s really, really hard to perform a 100% ‘scientific’ randomized, controlled trial.
“The announcement was essentially a big surprise that we did not see that coming yesterday. There is no reference to any consultation with professionals in the press release I see. And so I’m really worried that this seems to be a purely political decision without any consultation with experts. I would really like to ask the question: what kind of consultation was undertaken before reaching this decision? Particularly because there was a technical report provided by the officials at the Ministry of Health to the minister. The recommendation in that report was that the prescription of puberty blockers should happen in a multidisciplinary context, with the involvement of all the relevant professionals, including mental health professionals. What happened to that advice?”
Conflict of interest statement: “I am a sexual health physician providing gender affirming care to over 16s. I do not prescribe medications in the context of pausing puberty.”
Dr Anna Ponnampalam, reproductive biologist, University of Auckland, comments:
“The Cass report has been primarily cited as the evidence base for this decision. This report has been criticised by experts and professional bodies around the world for many issues including methodological and conceptual errors. The report has number of inconsistencies including: 1. recommending psychosocial interventions while admitting no evidence of the benefits; 2. recommending against puberty blockers while noting that some young people benefit from it. The report is incomprehensive, including selective studies while ignoring others, and also has many incorrect reports of those studies.
“Over a decade of research has shown that puberty blockers are safe and effective. Withholding puberty blockers to treat gender dysphoria will very likely have serious adverse effects on the health and well being of young people going through gender dysphoria and transgender youth.”
Conflict of interest statement: “I do not have any conflicts of interest.”
Dr Sue Bagshaw, Senior Clinical Lecturer, Christchurch School of Medicine, University of Otago, comments:
“I am saddened to hear of more problems with assisting young people with the help they need to have time to work through the issues they might have with gender identity.
“Safeguards are important but to ignore the protective effect on mental health is not a safeguard.
“Resources to undertake research into the effects of gonadotrophin releasing analogues would be welcome and necessary before any further actions from the government are undertaken.”
Conflict of interest statement: “I was a Doctor at Te Tahi Youth one stop shop until the beginning of this year.”