Kiwis expose puberty blocker fraud
But New Zealand's authorities want to consult before any ban on hormone suppression for puberty-averse children
In the dark
New Zealand’s Ministry of Health has acknowledged the scarcity and poor quality of evidence for puberty blockers.
And the ministry has stressed that the responsibility for safety and long-term effects falls on the doctors prescribing these drugs off-label for distressed minors who want to stop their natural development.
Before September 2022, when government webpage information about puberty blockers was quietly altered, the official position of NZ health authorities was that puberty blockers were “safe and fully reversible.”
Last week, the health ministry released its long-delayed evidence brief on puberty blockers, the novel intervention driving the unprecedented global surge in predominantly teenage females who reject their birth sex and seek these off-label hormone suppression drugs to stop “the wrong puberty.”
“The evidence brief shows a lack of good-quality evidence to back the effectiveness and safety of puberty blockers when used [with gender-distressed minors],” the ministry said.
The ministry cites “concern both here [in NZ] and overseas about the increasing use of these medicines for the treatment of gender identity issues without sufficient evidence to support their safety and effectiveness both now and in the longer-term.”
“Given the dearth and poor quality of evidence, and New Zealand-specific evidence, there is an urgent need for high-quality, longitudinal data and research to help us understand the specific needs of gender-dysphoric adolescents in New Zealand.”
“In New Zealand, in 2010, around 25 young people aged 11 and 17 years were typically started on treatment with these medicines and by 2021 the number had grown to around 140. In the last two years that number had fallen and in 2023 was 113.”—NZ health ministry, statement, 21 November 2024
Affirm, affirm
The ministry has also issued a position statement that appears to endorse the contentious “gender-affirming” treatment model1 as if it is mainstream medical and mental health care, thereby enabling advocates to claim it is gender business as usual.
“The ministry has been clear—puberty blockers can continue to be used as part of a comprehensive care plan,” said Jennifer K Shields, who describes herself as “a queer and trans artist, activist, advocate and educator,” and is president of the country’s gender medicine lobby the Professional Association for Trans Health Aotearoa (PATHA).
“The [ministry’s position] statement is not a new set of rules, but instead guidance that acknowledges the approach experts already use.”
In a personal newsletter comment, Ms Shields said this was no regulatory “slamming down on prescribing” puberty blockers, and suggested, as “satire,” that the country’s Deputy Prime Minister Winston Peters, an outspoken critic of blockers, “should no longer be allowed his heart medication—for his own safety.”
“I recognise that these medications have been used for the general population for some time, but Mr Peters is a statistically small proportion of this population using this medication for the off-label purpose of bursting blood vessels in the name of outrage-driven politics.”2
PATHA endorses a 2018 gender-affirming treatment guideline which makes the claim that, “There is good evidence that puberty blocking and gender-affirming care for trans young people significantly improves mental health and wellbeing outcomes.”
That PATHA guideline, which is not endorsed by the NZ health ministry, was rated 12/100 for the rigour of its development during an evaluation of international treatment guidelines commissioned as part of England’s 2020-24 Cass review, the world’s most comprehensive inquiry into the evidence for therapeutic responses to youth gender dysphoria.
“[The NZ health] ministry’s position statement contradicts a key recommendation of the Cass review. Dr Cass advised that care for gender-questioning adolescents be integrated into general child and adolescent mental health services where they would receive the same holistic mental health assessments as any child presenting with a problem, rather than kept separate under a gender-affirming care framework.
“This is important because one of the key risks of the gender-affirming care model, as identified by the Cass review, is that labeling a child as ‘transgender’ can overshadow underlying issues and prematurely close off exploration.”—Jan Rivers, spokesperson, Genspect NZ, 21 November 2024
Notwithstanding the verdict of “poor quality” evidence just handed down by the NZ health ministry, the country’s health department, Health NZ, has a 2023 contract with PATHA to update the low-quality 2018 treatment guideline.3
Asked about the “good evidence” claim made by the PATHA guideline, a spokesperson for the ministry told GCN: “At the time the guideline was published, its statement was in line with other accepted international guidelines in this area. The evidence base continues to evolve as new research and information is published.”
She said the Director-General of Health, Dr Diana Sarfati—who is a physician, epidemiologist and researcher—“was clear in her position statement on the need for a holistic approach to gender-affirming care with access to wrap-around support.”
The spokesperson said PATHA was not involved in the evidence brief or position statement but would take part in a “targeted consultation” announced by the ministry, thereby giving the lobby group a chance to influence future policy.
Video: Leah Panapa of The Platform talks with NZ Chief Medical Officer Dr Joe Bourne
First step
Emeritus professor of epidemiology and physician Dr Charlotte Paul, co-author of a recent article in the New Zealand Medical Journal estimating that per-capita puberty blocker use in NZ has been high by international standards, told GCN—
“It is important to acknowledge that the Ministry of Health have finally taken the first step to evaluate the clinical basis for use of puberty blockers for gender-related distress. Its review is sound and finds that such prescribing is not known to be safe or reversible—indeed there is insufficient evidence of effectiveness.
“There are limitations to the review, especially a lack of necessary context. There is nothing about the changing aims of treatment, the rapid increase in numbers and change in characteristics of those presenting with gender-related distress, the serious disagreement about reasons for the increase, the possibility that use of blockers locks children into a medical pathway, and legitimate concerns about regret. Still, it is a first step.”
Jan Rivers, spokesperson for Genspect NZ, which is critical of the gender-affirming approach, welcomed the evidence brief.
She said the result “confirms there is insufficient evidence to support claims that puberty blockers are safe and reversible, or that they provide mental health benefits. The studies reviewed rely heavily on subjective self-reports from adolescents and most were rated by the ministry as having ‘serious’ or ‘critical’ risk of bias.”
“For too long the ministry and Health NZ have relied on supposed experts from PATHA who have pushed medical interventions and unsupported claims.”
“[T]he government has released today a consultation document that proposes further restrictions [on puberty blockers] under the Medicines Act. We will have more to say at the end of that consultation.”—NZ Health Minister Dr Shane Reti and Mental Health Minister Matt Doocey, statement, 21 November 2022
Jumping the gun
Last week, the NZ health ministry issued a new puberty blocker position statement, which it described as “a more precautionary approach,” leading to a headline in The New Zealand Herald declaring that, “Puberty blockers [are] to be prescribed more cautiously...”
The ministry did note that the “UK, Finland, Norway, and Sweden have recently decided to limit the initiation of new prescriptions of puberty blockers for young people seeking gender-affirming care to clinical trials.”
However, NZ authorities have not yet imposed any such restrictions on puberty blockers, which are fully funded by the taxpayer.
The ministry’s specific measure of “caution” is to advise that prescribing be limited to clinicians experienced in “gender-affirming care”—the treatment model responsible for promoting puberty blockers as safe, beneficial and reversible, without any solid evidence base.
The ministry said it had been asked by the centre-right coalition government of Prime Minister Christopher Luxon to consult “those who may be affected” about the possibility of tighter regulation of these drugs.
“This is like asking the fox for advice on how to guard the chickens,” said the NZ Women’s Rights Party co-leader, Jill Ovens.
“Our health authorities have remained hostage to a vocal minority who have vested interests and have put our children’s health at risk of lifelong irreversible damage,” she said.
Professor Paul said that after an evidence review, the next step normally would be “for the health authorities to make a determination on the implications for clinical practice.”
“The ministry instead appears to be deferring to the government to regulate prescribing. Unfortunately, this risks politicisation of the issue. Nevertheless, given polarised views in the medical profession, it may be the only feasible way forward.”
“Leading transgender health professionals are alarmed the government is directing the Ministry of Health to consult the public over gender-affirming healthcare.”—Public broadcaster RNZ Online, news report, 22 November 2022
Who’s in the tent?
As a guide to future policy, the NZ health ministry has announced an “external advisory group.” The ministry’s spokesperson would not detail the composition beyond saying “it includes representatives with a wide range of expertise in gender-affirming care, including clinicians, researchers, and Hauora Māori [health beliefs of the Māori people].”
The ministry will also run “targeted consultation” involving PATHA and unidentified others, and it has launched an online public survey offering choices about levels of regulation, who should do the prescribing, and whether blockers should be confined to a clinical trial. This public consultation is to end on January 20 next year.
Meanwhile, the ministry advises gender clinicians to work in “an inter-professional team offering a full range of supports” and to ensure that minors and their families are “fully informed [about] the current state of the evidence” for puberty blockers.
“The Ministry of Health expects healthcare professionals to ensure that clinical conversations about puberty blockers reflect the paucity of high-quality research evidence about the benefits and risks of using these medicines.”
Although the ministry has emphasised how little is known about puberty blockers, it has also highlighted the responsibility of doctors under the Medicines Act 1981 for “the safety and long-term impacts” of these drugs being prescribed off label—without regulatory approval—for gender-distressed minors.
An NZ health practitioner, who is legally trained, said it looked like the ministry was trying to avoid liability with its pointed remarks by that the burden of responsibility falls on the doctors.
“But [the ministry] have also turned a blind eye to the problems of overprescribing [of puberty blockers] which they must realise to be a problem, and surely they contributed to that in the past,” said this practitioner, who spoke anonymously to avoid harassment by activists.
“While [the ministry] have been delaying the release of the evidence brief, they have allowed prescribing to go unchecked. And seeking more input about how to tighten up the regulatory gaps that have been in play here, is a risk—children are likely to continue being harmed.”
This practitioner said it was “not in the least” clear how doctors could apply the ministry’s advice to be cautious in prescribing puberty blockers.
“Doctors should always have been cautious when prescribing any drug, especially one that is off label and being prescribed to minors with impacts on a key stage of their development.
“An admonishment to be extra cautious now smacks of a parent saying, ‘Don’t make me reach back there,’ when the kids are playing up in the back seat of the car.
“Another point to make in this whole saga is that the public must ask themselves whether doctors in NZ are capable of self regulation.”
Asked about penalties for errant prescribers of puberty blockers, the spokesperson for the health ministry said doctors could be reviewed by the country’s Medical Council and lose their right to practice.
In the magazine North & South last December, Professor Paul noted that the council had so far “declined to investigate” the off-label use of puberty blockers with unknown long-term effects.
“There appear to be breaches of several [of the council’s Standards of Good Practice] in relation to prescribing unapproved medicines, assessing the patient’s condition before prescribing, practising in the patient’s best interests, assessing capacity to give consent, and responsibilities to provide accurate and balanced information,” she wrote.
Ask the insurers
GCN sought comment from three medical indemnity funds—MPS, Medicus and NZMII—on the implications of the health ministry’s new position on puberty blockers.
Medicus chairman Dr Richard Stubbs said his firm had “not had reason to consider [the ministry’s position] in any depth.”
“Doctors must always act responsibly and within their scope [of practice] and be mindful of the evidence behind what they are doing,” he said.
“There are many areas of legitimate practice for which there is imperfect evidence of knowledge of long-term outcomes. This [use of puberty blockers] is one example of this.”
As for MPS, it was “reviewing” the material from the ministry, said Rebecca Imrie, regional general manager for Australia and New Zealand.
“Members should act in line with their training and experience in this area, and in accordance with local regulatory and clinical guidance,” Ms Imrie said.
“These [PATHA-endorsed NZ] guidelines … were strongly influenced by the rights-based approach, and they dropped previous safeguards … While noting that cross-sex hormones should, in general, not be available until age 16, the 2018 guidelines state that there may be ‘compelling reasons’ for starting younger. These guidelines establish no lower age limit for accessing puberty-blocking hormones. Although it includes assessment for gender dysphoria, mental health assessment is not mandatory.”—Kozlowska et al, journal article, 2 November 2024
Misguided
The health ministry’s announcement last week appears to recommend the PATHA-approved 2018 gender-affirming guidelines.
The new position statement from the ministry says: “These guidelines set out the key considerations for health teams, including the prescribing of puberty blockers.”
The PATHA guidelines say: “Health teams need to be aware of the positive impact of puberty blockers (GnRH agonists) on future well-being...
“Puberty blockers are considered to be fully reversible and allow the adolescent time prior to making a decision on starting hormone therapy.”
There is no good evidence to support these claims, according to multiple systematic reviews of the scientific literature undertaken independently since 2019 in Finland, Sweden, Germany and the UK.
The PATHA guideline does acknowledge the risk of puberty blockers to healthy bone density and to fertility—“For those starting on a blocker in early puberty [around age 10-12], sperm storage [to preserve future fertility] may not be possible.”
The guideline consent forms imply that natural puberty is a health risk, claiming that, “Withholding the use of blockers may cause additional distress leading to anxiety and depression.”
“Not using blockers can also lead to irreversible unwanted physical changes.”
Noting the lack of NZ legislation specific to puberty blockers, the health ministry says there are “good practice guidelines to enable clinicians to support and manage individuals on [blockers].”
Here, the ministry refers to the 2022 standards of care, known as SOC-8, from the World Professional Association for Transgender Health (WPATH), a US-based advocacy organisation besieged by scandals.
Although WPATH claimed there was too little research data to undertake a systematic review of the evidence to support its treatment advice for adolescents, SOC-8 nonetheless makes bold claims—
“Since [puberty blocker] treatment is fully reversible, it is regarded as an extended time for adolescents to explore their gender identity by means of an early social transition. Treatment with GnRHas [puberty blockers] also has therapeutic benefit since it often results in a vast reduction in the level of distress stemming from physical changes that occur when endogenous puberty begins.”
Both the WPATH and the NZ guidelines were judged to be of low quality and not fit for use by the evaluation project linked to England’s Cass review.
Last week, the NZ health ministry confirmed that Health NZ was “developing an updated set of guidance to support clinicians providing gender-affirming care, including the use of puberty blockers. The evidence brief [of the ministry, which came after the contract was agreed] will be available to inform those guidelines.”
It is not clear how the contradictions between the PATHA guideline project—which had its origins in 2021—and last week’s evidence brief can be resolved.
Genspect NZ director Simon Tegg said Health NZ’s 2023 contract with PATHA for the update “explicitly requires alignment with WPATH’s 2022 standards of care.”
“If you follow overseas news, you’ll know that WPATH has been caught suppressing the publication of systematic reviews, lying about conflicts of interest, and admitting that the evidence for puberty blockers is poor,” he said.
“In evidence-based medicine, treatments [such as puberty blockers] with poor-quality evidence with ‘serious’ or “critical” risk of bias do not achieve recommendation in credible guidelines.
“Any guideline that endorses such treatments forfeits its claim to being trustworthy. This principle is unequivocal among evidence-based practitioners, and a supposedly ‘holistic’ assessment prior to treatment does not make a speck of difference.”
“The minister should drop the PATHA guidelines and start afresh from scientific principles. It’s just going to get more embarrassing for the government as these contradictions stack up and the wellbeing of adolescents is put at risk.”
Ms Ovens says the Women’s Rights Party had been calling for an inquiry into the Health NZ-PATHA contract, given the severe judgment passed on the 2018 NZ treatment guidelines by the Cass review.
What about the brain?
The health ministry’s evidence brief appears to underplay the risk that puberty blockers may have harmful effects on still maturing adolescent brains, an issue of increasing international concern and one that calls into question the claimed reversibility of hormone suppression at a crucial stage of human development.
The ministry brief offers what can be read as a categorical and reassuring conclusion about blockers and the brain: “There was no evidence of any effect on … executive function.”
This claim rests on analysis of a single 2015 study by Staphorsius et al in which, according to the NZ ministry’s evidence brief, there was no significant difference in “performance scores” on the Tower of London Test of the brain’s executive function between 20 puberty-blocked adolescents and a control group with untreated gender dysphoria.
However, the 2023 Swedish systematic review of Ludvigsson et al—a source elsewhere relied on by the NZ evidence brief—adds a qualification to the Staphorsius study—“…because no before-after [puberty blocking] therapy analyses were performed, the study could not investigate potential cognitive effects of hormone therapy.”
A literature review by British neuropsychologist Sallie Baxendale, published just after the NZ ministry’s final search of the evidence base in May 2024, assessed not only Staphorsius but also other studies for relevance to cognitive impacts of puberty blocking.4
“While no means conclusive due to the poor quality of evidence, studies examining the impact of puberty suppression in young people indicate a possible detrimental impact on IQ,” Professor Baxendale wrote.
“These findings accord with the wider literature on [Gonadotropin hormone-releasing hormone, GnRH] expression and brain structure and function. Studies in mice, sheep and primates indicate an impact of GnRH suppression [by puberty blockers] on behavioural analogues of cognitive function, effects that are often sex specific.
“While there is some evidence that indicates pubertal suppression may impact cognitive function, there is no evidence to date to support the oft-cited assertion that the effects of puberty blockers are fully reversible. Indeed, the only study to date that has addressed this in sheep suggests that this is not the case.”
The Baxendale review was welcomed as making “a strong case” for urgent studies of the effects of puberty blockers on the brain by a leading Swedish clinician and researcher, Professor Mikael Landén, who was an author of the 2023 Ludvigsson review cited by the NZ health ministry.
In its documents, the ministry foreshadows a longitudinal cohort study of patients on blockers—there is no mention of a treatment alternative—and an audit of puberty blocker use in NZ over the last five years, an implicit acknowledgment of inadequate data collection.
The NZ evidence brief does not discuss a key 2020 paper on the possible neurodevelopment effects of puberty suppression, although that paper is cited by the Cass-commissioned systematic review Taylor et al relied on by the NZ brief.
That 2020 paper—Consensus Parameter: Research Methodologies to Evaluate Neurodevelopmental Effects of Pubertal Suppression in Transgender Youth—involved 24 international experts in fields including neurodevelopment and adolescence working together to identify the key research questions to elucidate the unknown effects of puberty blocking on cognition.
The paper documents the range and complexity of relevant but unanswered questions about blockers and the brain.
“The pubertal and adolescent period is associated with profound neurodevelopment, including trajectories of increasing capacities for abstraction and logical thinking, integrative thinking (for example, consideration of multiple perspectives), and social thinking and competence,” the paper says.
“The combination of animal neurobehavioural research and human behaviour studies supports the notion that puberty may be a sensitive period for brain organisation: that is, a limited phase when developing neural connections are uniquely shaped by hormonal and experiential factors, with potentially lifelong consequences for cognitive and emotional health.”
In contrast to the seemingly reassuring verdict of the NZ evidence brief on executive function, the systematic review paper by Taylor et al says: “No conclusions can be drawn about the impact [of puberty blockers] on gender dysphoria, mental and psychosocial health or cognitive development.”
Yet the NZ health ministry says it “acknowledges that there are strong and varied views relating to the area of gender-affirming healthcare.”
On Twitter, Mr Peters noted the track record of his NZ First party in calling for restrictions on puberty blockers. “The lack of any evidence about the safety and long term effects of puberty blockers on children has been gathering momentum around the world,” he said.
Policy discussions leading to the 2023 contract for the guideline update began in 2021 and the project was financed in the 2022 NZ budget, apparently before health ministry officials became aware of serious concerns about the gender-affirming treatment approach.
Professor Baxendale does regard Staphorsius as relevant, but highlights a nuance not found in the NZ evidence brief—“While the groups [of puberty-blocked adolescents and untreated adolescents] did not differ with respect to reaction time on the Tower of London Test, suppressed male to females had significantly lower accuracy scores compared to the control groups. This pattern remained significant after controlling for IQ. Despite this, the reaction time finding has been subsequently been reported as evidence for no detrimental effects on performance in citations in the subsequent literature and in policy documents.”
It looks like Australia will be the last country in the world to have an independent inquiry into Gender Medicine or restrict the practice in any way.
Poor fellow, my country.
. . . and the ministry has stressed that the responsibility for safety and long-term effects falls on the doctors prescribing these drugs off-label for distressed minors who want to stop their natural development.
I would suggest that the NZ Ministry review the following summarised studies:
CURRENT CONCERNS ABOUT GENDER-AFFIRMING THERAPY IN ADOLESCENTS
The evidence base for gender-affirming interventions is sparce and of very low quality. While the evidence of benefits is highly uncertain, the harms to sexual and reproductive functions are certain, and many uncertainties about the long-term health effects exist. As a result, it is hard to ethically justify continuing to use hormones and surgeries as first-line treatment for gender dysphoric youth.
LONG-TERM FOLLOW-UP OF TRANSSEXUIAL PERSONS UNDERGOING SEX
REASSIGNMENT SURGERY: COHORT STUDY IN SWEDEN
Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.
ALL-CAUSE & SUICIDE MORTALITIES AMONG ADOLESCENTS AND YOUNG ADULTS
WHO CONTACTED SPECIALISED GENDER IDENTITY SERVICES IN FINLAND 1996-2019
Analysed overall mortality and suicide among gender-referred young people in Finland over a 25-year time span. The study found no convincing evidence that gender-referred youth have statistically significantly higher suicide rates as compared to the general population, after controlling for psychiatric needs (BMJ Mental Health)
TRANSGENDER IDENTITY AND SUICIDE ATTEMPTS & MORTALITY IN DENMARK
These observations suggest that not only is the suicide narrative frequently used to justify medically transitioning minors greatly exaggerated, but that medical gender transition is not an effective suicide-prevention measure. The results also suggest that treatment should focus on better control of co-occurring psychiatric illness and on evidence-based suicide-prevention measures in particular for individuals deemed at high risk for suicide.