Ministry of Health
[email protected]
Consultation on safety measures for the use of puberty blockers in young people with gender-related health needs
What is your main interest in the consultation topic?
Burnett Foundation Aotearoa is a registered New Zealand charity and non-government organisation funded through contracts with Te Whatu Ora and independent fundraising to work towards HIV and STI prevention, support for people living with HIV, and great sexual health for rainbow and takatāpui communities. Our work includes health promotion, condom distribution, testing, counselling and support, research, policy, and information services. Burnett Foundation Aotearoa advocates for healthy public policy and environments that support people living with HIV and rainbow and takatāpui communities.
Burnett Foundation Aotearoa recognises that trans and non-binary folk were not only instrumental in the gay liberation movement which benefits many in the communities we serve but have also been globally under-represented in the HIV and AIDS public health response. Since 2020, we have been reviewing how we engage with trans and non-binary folk at risk of acquiring HIV in our mahi, and invested in improvements to our services, resources and care. In 2022, our Board decided to expand our vision to include supporting great sexual health for all rainbow and takatāpui communities, and since then we have been reorientating our services and activities to ensure we are more responsive to the needs and diversity of trans and non-binary communities.
Trans communities experience barriers and inequities in access to and provision of healthcare, including sexual health. These inequities exist in relation to the persistence of cisnormativity, heteronormativity, and binary approaches to sex characteristics and gender in contemporary society. They are also further compounded for Māori who face additional inequities in healthcare access generally, including higher rates of discrimination and barriers to healthcare These inequities are likely to intersect and further increase the unmet need for trans Māori.
Burnett Foundation Aotearoa is a member of the Rainbow Support Collective (RSC), and we support and endorse the RSC statement in support of gender affirming healthcare and vital access to puberty blockers.
We also support the statement made by the Professional Association for Transgender Health Aotearoa (PATHA), and endorsed by the New Zealand Sexual Health Society which:
- Supports the continued use of puberty blockers in gender affirming care in Aotearoa New Zealand.
- Does 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.
Do you live in New Zealand?
Yes. Burnett Foundation Aotearoa is a New Zealand based organisation.
Publishing submission
We are happy for this submission to be published.
In your view, how should puberty blockers be prescribed for gender-affirming care in New Zealand?
There should be no restrictions on access to puberty blockers for the trans young people who need them. The current prescribing model based on informed consent alongside prescriber’s clinical judgement ensures puberty blockers are prescribed appropriately. There is no need for further restrictions, and any restrictions that target the rights of trans young people would be discriminatory.
Guidelines already exist to support clinicians in prescribing puberty blockers and providing gender-affirming care in New Zealand. The current national gender-affirming guidelines are robust and have been endorsed by AusPATH, PATHA, the New Zealand Sexual Health Society, the New Zealand Society of Endocrinology, and by the Ministry of Health Evidence Brief. These guidelines support medical professionals to prescribe and give high quality care on puberty blockers for trans young people and have been developed by trans healthcare specialists.
The World Professional Association for Trans Health (WPATH) has also recently updated its Standards of Care in 2024 due to increasing scientific evidence. These international standards compliment the New Zealand-specific PATHA guidelines and support the delivery of the highest standard of healthcare for trans people WPATH is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in trans health.
Under Te Tiriti, the Crown has a duty to protect the rights and wellbeing of Māori citizens, including their access to healthcare. Any regulations restricting access to puberty blockers could disproportionately affect Māori trans people due the existing health inequities. The principles of partnership, protection, and participation in Te Tiriti require that Māori are meaningfully engaged in discussions about health policies affecting their communities. Furthermore, equitable access to gender-affirming care, such as puberty blockers, is vital in ensuring that all individuals, including trans Māori, can access the care they need to thrive. Restrictions that limit such access could exacerbate existing disparities, undermining efforts to achieve health equity and Te Tiriti obligations for the wellbeing of all New Zealanders.
We are concerned that this consultation targets trans young people and not other puberty blocker users. The Ministry of Health Evidence Brief on the Impact of Puberty Blockers in Gender-Dysphoric Adolescents showed that risks and harm associated with puberty blockers is limited, in general and in trans young people. If there was evidence that puberty blockers are harmful, it is unclear why restriction should be limited to trans young people and not all young people who use puberty blockers, which gives us concern that these are not evidence-based policies, and that they may unfairly target trans young people. Furthermore, the wording of the consultation is skewed towards further regulation and restriction and does not allow for a status quo or option which would mean access to puberty blockers remains the same for trans young people.
Who do you think should be able to start patients on treatment with puberty blockers?
All clinicians who are currently able to prescribe puberty blockers to trans young people should be able to continue to be able to prescribe. In addition to this, any clinicians in a child’s care team should be able to prescribe, and anyone able to prescribe other hormone treatments should be able to prescribe puberty blockers.
Currently paediatricians, General Practitioners (GPs), and obstetricians/gynaecologists are the main prescribers of puberty blockers, however endocrinologists, Internal Medicine clinicians, nurse practitioners, sexual health/youth health physicians, urgent care clinicians, and non-vocationally registered doctors have prescribed puberty blockers in the past and are capable to do so.
All clinicians prescribing puberty blockers to trans young people in New Zealand already have access to the extensive PATHA Guidelines for Gender Affirming Healthcare.
It is important to note that the evidence published in the Ministry of Health’s own Evidence Brief indicates the use of puberty blockers is not harmful. Any changes to restrict the number of prescribing clinicians does not increase the safety of puberty blockers but instead excludes access to an important intervention for trans young people.
Which young people should be able to receive treatment with puberty blockers for gender dysphoria?
All young people who are seeking puberty blockers for gender dysphoria should be able to go through the process to receive treatment, whether they are currently receiving treatment or not. The Human Rights Act (1993) is clear that denying the use of medication to a particular group based on their gender and/or sex is sex-based discrimination.
As cited in the Ministry of Health’s own Position Statement on the use of puberty blockers in gender affirming care, young people have rights under the UN Convention on the Rights of the Child (CRC) to both identity (Article 8) and to health (physical and mental), including equitable access to health care (Article 24). These rights sit among children's wider range of holistic rights under the CRC, which also includes the right and general principle that all decisions made about/or in relation to a child must be made in their best interests (Article 3), and the right and general principle to non-discrimination (Article 2) and to life, survival and development (Article 6). The current pathway to access puberty blockers which uses informed consent models embeds a young person’s right to autonomy and agency in their care.
Restricting access to puberty blockers through a clinical trial is not appropriate and does not consider a trans young person’s individual healthcare needs. Requiring participation in a clinical trial in order to access care is unethical and would create additional barriers for young people to meet their healthcare needs.
If prescribing of puberty blockers is restricted by regulation, how might this affect you and/or the people that you represent?
Puberty blocking medicines allow time for trans young people to explore their gender identity without the pressure of irreversible physical changes. These treatments can significantly improve mental health by alleviating the distress caused by unwanted secondary sexual characteristics. Puberty blockers have been shown to be reversible, however, the alternative of going through unwanted physical changes in puberty is irreversible. Early intervention may lead to better long-term outcomes for those who pursue gender-affirming healthcare by reducing or eliminating further invasive surgeries or treatments.
There is currently an overdemand for trans healthcare, compounded by difficulties in accessing gender-affirming care depending on where you live in New Zealand. Regulating access to puberty blockers and/or restricting clinician’s ability to prescribe is likely to increase wait times for care and exacerbate health inequities for trans young people. The Identify survey showed that 13% of trans and gender diverse young people wanted to access puberty blockers but had not been able to (Fenaughty et al, 2022). This increases for general healthcare, as results from the Youth 19 Rangatahi Smart Survey (Youth19) survey found that over half (55%) of trans and gender diverse students had been unable to access healthcare in general when they needed it in the past year (Fenaughty et al, 2023).
Denying, preventing, or withholding access to gender affirming care is life threatening. A key finding and recommendation from the Counting Ourselves survey is that dismantling barriers to accessing gender-affirming care may play a crucial role in reducing mental health inequities faced by transgender youth (Tan et al, 2023). Trans young people are more likely to experience distress and life dissatisfaction if they have any unmet needs, and this includes access to puberty blockers (Tan et al, 2023). The Youth19 survey showed that 57% of trans and gender diverse young people had experienced significant depressive symptoms and the same percentage had self-harmed in the previous 12 months (Fenaughty et al, 2023). Of these trans and gender diverse young people, 26% had attempted suicide in the last year.
A recent US study into the impact of state-level anti-trans laws found increased incidents of suicide attempts among trans and non-binary young people (Lee et al, 2024). These findings highlight the importance of considering the mental health impact of anti-trans regulation, such as this consultation, which seeks to restrict trans young people’s access to puberty blockers. The focus should instead be on promoting and advancing policies that protect and support trans people.
Restricting the prescribing of puberty blockers would also have a disproportionate impact on our young trans Māori, limiting access to necessary healthcare, and hampering the Crown’s responsibility to achieve health equity.
Do you have any further views on how any regulation should be designed?
We strongly advocate that there should be no restrictions or regulations on access to puberty blockers for the trans young people who need them. The current prescribing model based on informed consent alongside prescriber’s clinical judgement is appropriate and ensures puberty blockers are prescribed appropriately. There is no need for further restrictions that target and discriminate against the rights of trans young people.
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. The Ministry of Health Evidence Brief on the Impact of Puberty Blockers in Gender-Dysphoric Adolescents concedes that any risks associated with puberty blockers are limited and inconclusive. The current research available on puberty blockers does not support the development of unnecessary and discriminatory regulation. Further research to understand the benefits and risks of puberty blockers when used for treatment of gender-incongruent and gender-dysphoric young people in New Zealand would be useful to improve access to puberty blockers and gender affirming healthcare New Zealand. The Ministry of Health must allocate adequate funds to ensure that there is adequate and timely access to puberty blockers, hormone therapies and a full range of gender-affirming healthcare options in every region.
We would also like to raise the following concerns:
- This is the first time the Ministry of Health has publicly consulted on the regulation of medicine, and it is unclear from the evidence why this issue was given exception, which suggests it may be driven by political and anti-trans narratives. This is unusual and harmful.
- The public nature of the consultation is problematic and is further compounded when international submissions can be made. There is a strong international anti-trans movement who are politically motivated to restrict and deny the rights of trans people. It is deeply concerning that a health issue should be subject to hatred and disinformation. The consultation process minimises the expertise of clinicians working on the issue, and the lived experience of trans young people and their whanau who will be directly impacted by changes in access to puberty blockers. Trans people already face barriers and discrimination in healthcare and throughout society. We recommend that the consultation should focus on those who will be directly impacted by this issue: trans young people and their supportive whānau, trans communities and community-led organisations, and clinicians who work with trans children.
- It is deeply concerning that the external advisory group that has been established by the Ministry of Health to provide strategic advice relating to gender-affirming care does not include trans people and New Zealand experts in trans health and gender-affirming healthcare. This is not best practice and signals that this consultation is a political issue not a health issue. If this process is truly about improving care and health for trans young people, it is integral that the people who will be most impacted by further regulations are actively and appropriately included in the process and listened to.
Ngā mihi,
Alex Anderson, Interim General Manager
Burnett Foundation Aotearoa
References
Fenaughty, J., Ker, A., Alansari, M., Besley, T., Kerekere, E., Pasley, A., Saxton, P., Subramanian, P., Thomsen, P. & Veale, J. (2022). Identify survey: Community and advocacy report. Identify Survey Team
Fenaughty, J., Fleming, T., Bavin, L., Choo, W.L., Ker, A., Lucassen, M., Ball, J., Greaves, L., Drayton, B., King-Finau, T., & Clark, T. (2023). Te āniwaniwa takatāpui whānui: te irawhiti me te ira huhua mō ngā rangatahi | Gender Identity and young people’s wellbeing in Youth19. Youth19 Research Group, The University of Auckland and Victoria University of Wellington, New Zealand.
Lee, W.Y., Hobbs, J.N., Hobaica, S. DeChants, J.P, Price M.N, Nath, R (2024) l. State-level anti-trans laws increase past-year suicide attempts among trans and non-binary young people in the USA. Nat Hum Behav 8, 2096–2106 (2024). https://doi.org/10.1038/s41562-024-01979-5
Tan, K.K.H., Byrne, J.L., Treharne, G.J. & Veale, J.F (2023). Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand. Journal of Public Health (Oxf), 45(2):e225-e233. DOI: 10.1093/pubmed/fdac131