Kia ora Simon,

Thanks for the exchange on X. I said I would respond to this post though I'll probably cover some other things we covered. I think the useful common ground is this: the public should not have to rely on “trust us”. If the system says evidence is being monitored, patient selection is careful, and prescribing is governed, then there should be a mechanism for visibility enough for the public, young people and families/whānau to understand.

That is really the centre of my concern. I'm a paediatrician and economist, and I also run health services. In my clinical practice, I've provided care to young people and adults primarily with Disorders of Sex Development, which are typically metabolic and genetic conditions that are serious and lifelong. I support gender-affirming care, including medical care where it is clinically appropriate. But support for care does not mean “anything goes”. It means careful, accountable care. Part of my point is that this applies to all of healthcare, not just one specific area.

By clinical governance, I mean the quality and safety systems around care. In plain language: who makes the decision, who checks it, what risks and alternatives are explained, what happens if things go wrong, what outcomes are followed, and what changes when new evidence appears. Laws have a role in that, but when are introduced for the wrong reasons or issues, one of two things occur: 1) they're ignored, usually because they can't be applied in practice, and 2) Things change quickly. Laws are best to set out the platform through principles and conditions, not try to micromanage complex specific situations. A young person should be able to ask: “Why is this being offered to me? What else could I do? Who checked this decision? What will you measure? What happens if I change my mind?” Good governance means the system has clear answers. The public should be able to ask: "Is this service safe?", "Is it following best practice?", and, "Is there independent monitoring of this service, to ensure it's not getting off-track?".

That is not a special standard invented for this debate. It is ordinary health-system thinking. Health Quality & Safety Commission (Te Tāhū Hauora) describes clinical governance as accountability for quality of care, patient experience, outcomes, system safety, equity, learning and harm reduction. Ngā Paerewa (Health and Disability Services Standard, NZS 8134:2021) similarly emphasises outcomes, partnership with people and whānau, cultural safety, equity and responsiveness to Māori. The HDC Code also already requires honest information, informed choice and consent, and the ability to seek another opinion or refuse care. NZ's health standards are in a bit of disarray, and I've started to study and write on that. I can provide more info on that, if it's helpful. This post is about GnRHa therapy, but I'm explaining all of this to help readers understand the broader context. Healthcare is a complex industry and even those experienced in working it, get lost at times.

So I agree that public reassurance matters. I agree that the advisory process, evidence monitoring and prescribing oversight should be more transparent. I agree that the Tavistock experience should be taken seriously. But I would treat Tavistock as a warning about service design and governance, not as a ready-made conclusion about New Zealand services. You mentioned the Bristol Enquiry, and it's useful to consider that Bristol was about Clinical Governance, particularly as it related to practitioner credentialing and culture within a small and complex health services. In contrast, Greenlane Clinical Centre ran the equivalent service in NZ, with the likes of Keirsten Finucane- this is a world class service that didn't have the issues that Bristol had, despite being in the same area.

Where I differ is the next step. My concern is the jump from “the evidence is uncertain” to “therefore initiation should be categorically restricted for this indication”. In my NZMJ article (nzmj.org.nz/journal/vol… - individual readers can sign in and download the article for free), the argument was narrower than “this treatment is always beneficial” or “there are no risks”. I'm not saying that because the worst thing anyone could do is dismiss concerns outright, without understanding the concern and seeing if there's a way to address it). It was that uncertainty is normally managed through clinical standards, multidisciplinary assessment, monitoring, audit, consent and review. Here, uncertainty was treated as a reason to remove ordinary individualised clinical judgement for a specific group.

That distinction matters because prohibition does not remove risk. It moves risk. It may move it to untreated distress, delayed care, private workarounds, loss of trust, or less visible pathways. A governance response should reduce risk without driving care out of sight. The regulations were also badly written, and they actually don't cover all of the scenarios, so they could be readily ignored if practitioners chose to. Ministry would have been better actually engaging the clinicians involved, and it reflected fairly substantial gaps in knowledge and understanding within MoH, HNZ and certainly within the Executive.

The paper you linked by Oosthoek and colleagues is helpful here, but I do not read it as showing that gender-affirming care has “no benefit”. The authors are asking a more subtle question: what counts as an effective outcome, and have we been too narrow in treating “improvement” as the only story? They explicitly argue for clearer discussion of the aims of gender-affirming medical treatment and for research that centres young trans and gender-diverse people themselves. To me, that supports better outcome definition and better governance, not a conclusion that all care is futile. This is an important discussion across New Zealand, and for what it is worth, there are four NZ Leaders who have had particularly important roles in asking this question at system-level in NZ, Simon Upton (former Min Health under National), Helen Clark (when she was Min Health), Peter Davis (I would call him the "father" of NZ Health Safety research, though I don't know that he would like that), and Robin Gauld (whose Harkness Fellowship on Clinical Governance was key to starting to lift the conversation in NZ).

A proportionate governance model could include:

1. published national criteria for when puberty blockers may be considered;

2. multidisciplinary assessment, including gender care, paediatrics/endocrinology, child and adolescent mental health, development and neurodiversity where relevant;

3. clear consent materials explaining knowns, unknowns, risks, benefits and alternatives;

4. second opinion, peer review or case discussion where criteria are not straightforward;

5. a national audit or registry, with strong privacy protections, tracking indications, pubertal stage, co-existing needs, adverse events, discontinuation and patient/whānau-reported outcomes;

6. independent, privacy-protecting oversight and de-identified public reporting;

7. explicit review triggers: what new evidence would tighten, loosen or change the pathway;

8. this system shouldn't be a barrier for existing clinicians and patients to progress timely and appropriate care, so should be resourced appropriately.

That is the kind of public reassurance I think we should be aiming for. I would argue it would fall best under a national model of adolescent healthcare, along with work around related and complex conditions such as eating disorders and assessing/managing autism in adolescents. It would reassure the public without treating trans young people as an exceptional category for whom uncertainty automatically removes normal clinical judgement. It also supports clinicians, because a clear and independently auditable pathway is safer than forcing clinicians to operate in a politically charged fog. Their job is complex at the best of times.

So my position is:

yes to correcting errors in evidence briefs;

yes to reviewing new studies;

yes to transparent evidence monitoring;

yes to careful patient selection;

yes to better consent materials;

yes to independent audit and de-identified public reporting;

yes to changing practice when evidence changes.

But also yes to maintaining access to gender-affirming care, including medical care for carefully selected young people where the young person, whānau and clinicians agree it is clinically appropriate.

The least restrictive safe response is not “anything goes”. It is careful, monitored, accountable care. Where practice needs strengthening, strengthen it. But I do not support converting uncertainty into an exceptional prohibition on one group of young people. I hope that is useful.

References

[1]: hqsc.govt.nz/resources/… "Clinical governance framework | Health Quality & Safety Commission Te Tāhū Hauora "

[2]: health.govt.nz/regulati… "Ngā Paerewa Health and Disability Services Standard | Ministry of Health NZ"

[3]: hdc.org.nz/your-rights/… "Code of Health and Disability Services Consumers' Rights - Health & Disability Commissioner"

[4]: medsafe.govt.nz/profs/r… "Use of Unapproved Medicines and Use of approved Medicines for an unapproved purpose"

[5]: link.springer.com/artic… "Gender-affirming medical treatment for adolescents: a critical reflection on “effective” treatment outcomes | BMC Medical Ethics | Springer Nature Link"