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Precautionary Approach To Puberty Blockers – Expert Reaction
After reviewing the evidence around puberty blockers for children with gender dysphoria, the Ministry of Health is taking a more precautionary approach.
The Ministry has released an evidence brief which concludes there are limitations around the quality of evidence for both the benefits and risks of puberty blockers.
It says puberty blockers should only be prescribed by a clinician experienced in gender affirming care, and supported by an interprofessional team including mental health support.
The Ministry is also commissioning research into the long-term effects of puberty blockers, and Health NZ is commissioning updated clinical guidelines.
The Science Media Centre asked experts to comment. Feel free to use these comments in your reporting or follow up with the contact details provided.
Professor Paul Hofman, paediatric endocrinologist, University of Auckland, comments:
"The Ministry of Health appropriately concluded there was a lack of good quality evidence and recommended that prescribing of these medications be initiated only by clinicians experienced in providing gender-affirming care and who are part of a wider multi-disciplinary team including psychology and mental health support.
"This is a very reasonable approach to an area where there remains substantive controversy.
"Encouragingly, the evidence published to date, while of low quality, all indicates the use of pubertal blockers is safe. The effectiveness of treatment varies depending on the study and this may reflect a number of variables including the appropriate selection of patients for pubertal blockade. At a individual level there are clear reports of improvement and it would be inappropriate to withdraw the use of this medication for the (likely many) patients suffering from gender dysphoria where it could improve mental health.
"However, a more evidence based, multi disciplinary team approach is a sensible precautionary suggestion to ensure therapy is focused on those where benefit is likely. Moreover, such teams need to follow up these patients to ensure there is ongoing support and benefit from the therapy."
Conflict of interest statement: Paul Hofman was an independent reviewer for a draft of this evidence brief about 6 months ago.
Dr Massimo Giola, sexual health physician, comments:
"I personally believe the Ministry's position is reasonable. In my opinion gender care should always be delivered in a multidisciplinary context, combining relevant medical and mental health professional profiles (this is how I do gender care myself), and obviously caution should be exercised in prescribing, as in any other case.
"I think it is a well-balanced position and does not affect the way gender care is and should be delivered."
Conflict of interest statement: "I provide gender care, no other conflicts of interest to declare."
Dr Rona Carroll, General Practitioner; and Senior Lecturer, University of Otago, comments:
"I welcome the Ministry of Health’s evidence brief and position statement around the use of puberty blockers as part of gender affirming care. All young people deserve access to quality care in which clinicians take a holistic approach which includes their family and whānau, and which offers wider support services when needed. Just as with any other specialty service, this care should be provided by people with expertise, as is already the case in Aotearoa New Zealand.
"Whilst the review did not find high quality evidence of benefits for puberty blockers, it also did not find evidence of harm. However, the evidence accumulated for this position statement focussed entirely on the mental health effects and some specific negative clinical outcomes and doesn’t consider the physical benefits which are the main indication for prescribing puberty blockers in this context.
"Puberty blockers work to prevent potentially unwanted physical changes of puberty, which may result in distress to transgender people. Puberty blockers do not by themselves result in any physical changes; they simply delay the physical effects of puberty that would otherwise occur. The review focussed on identifying evidence to support puberty blockers improving mental wellbeing, but this is not necessarily an expected outcome of the treatment; mental health may not change because the potentially distressing pubertal changes are not happening. It is more important to note the adverse effects on mental wellbeing by not using puberty blockade and therefore experiencing pubertal change, and the position statement does not acknowledge this.
"Furthermore, the review does not take into account the improved outcomes for people beyond adolescence who go on to take gender affirming hormone therapy. In my experience, individuals who have used puberty blockers are more likely to see the physical changes they would like to see in adulthood from sex hormone therapy, as irreversible physical changes that occur during puberty are not present. It is at these later stages where we see the clinical benefits. Every week in my GP clinic I hear from young people and adults with gender incongruence who did not have puberty blockers, and who now suffer and struggle in ways which have a huge impact on their day-to-day life, due to the physical changes which occurred during puberty. There is little published data on this as an outcome, but it remains a primary indication for the use of puberty blockade.
"Another consideration of the narrow focus of this review is that it only reviewed evidence in relation to these medications in the context of gender affirming care. The same medications used to achieve puberty blockade in this context are widely used in other areas of healthcare such as precocious puberty and menstrual disorders. There is no evidence for sustained adverse effects from this in these areas, but this is not considered in the statement.
"When considering the balance of the potential benefits and low level of identified risks, limiting or restricting access to puberty blockers would not be an ethical approach to take. I fully support the need for high quality longitudinal data in this area, alongside continued access to holistic and interprofessional care for young people seeking gender affirming healthcare."
Conflict of interest statement: "I am a member of the PATHA executive committee, and a GP working in gender affirming healthcare."
Professor Simon Denny, Adolescent and Young Adult Physician, Director of the Mater Young Adult Health Centre, Brisbane, Australia, comments:
Note: Dr Denny trained as a Paediatrician in New Zealand and has worked for over 18 years with adolescents and young adults at the Centre for Youth Health in south Auckland.
"The Ministry of Health's evidence brief on puberty blockers for gender-dysphoric adolescents emphasizes the necessity of experienced clinicians prescribing these treatments within interprofessional teams, aligning with the World Professional Association for Transgender Health (WPATH) guidelines. However, the brief also notes a lack of high-quality evidence supporting the effectiveness and safety of puberty blockers for this purpose.
"It's important to recognize that in many medical fields, high-quality evidence is often limited. A review of Cochrane systematic reviews across various medical disciplines found that only about 13.5% reported high-quality evidence for primary outcomes, with the majority relying on moderate, low, or very low-quality evidence. This pattern is observed in areas such as anesthesia, breast cancer, cystic fibrosis, and multiple sclerosis. Therefore, while acknowledging the current limitations in evidence regarding puberty blockers, it's consistent with broader medical practice to proceed with treatments based on the best available evidence, especially when guided by experienced professionals and established guidelines."
No conflict of interest declared.
Science Media Centre NZ
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