Nick lies down on the clinic bed with earphones in, distracting himself from the injection he’s about to have.
Despite the numbing cream on his stomach, Nick still feels a sting as the needle goes in. It’s a local anaesthetic to dull the pain of the next jab. But when the second, much thicker, needle penetrates the skin on his tummy it still causes discomfort for the 13-year-old.
“I’m shaking,” Nick tells his mum. She kisses his head as the nurse finishes the procedure and applies a dressing to the injection site.
This isn’t the first time Nick has had this treatment, but it doesn’t get any less uncomfortable.
It’s an intervention he hates but knows he needs because Nick wasn’t born a boy and in order to become who he needs to be this injection is necessary.
The college student from Auckland receives puberty blocking injections every three months and has done so since he was 11.
Also known as Gonadotropin-Releasing Hormone (GnRH) Agonist, the injection turns off sex hormone production, bringing puberty to a halt. This means no breast development, periods, and for a boy no facial or body hair growth, genital development, and the voice doesn’t drop.
Puberty blockers are reversible, unlike hormone treatments. It’s a treatment given to children on the cusp of puberty, like Nick, who from an early age didn’t identify as the gender they were born as.
For Nick, the idea of puberty caused him a huge amount of anxiety. “He’s checking himself in the mirror and he’s starting to freak out,” says mum Sharon.
With the consent of his parents, he has chosen to use the blockers to stop his puberty from going forward.
In New Zealand, puberty blockers are a legal treatment a young person may have before starting hormone therapy, which they can begin from around 16 years of age.
However, in some countries the treatment is controversial. Following a High Court ruling in the UK last year, trans children and their families, in most cases, will have to seek permission from the court to access puberty blockers.
The High Court ruled a child under 16 would not be competent enough to make the decision to use puberty blockers.
“It is highly unlikely that a child aged 13 or under would be competent to give consent to the administration of puberty blockers. It is doubtful that a child aged 14 or 15 could understand and weigh the long-term risks and consequences of the administration of puberty blockers,” the ruling reads.
The High Court also recommended that clinicians seek a court order to administer such drugs to children aged 16 or older.
One of the claimants in the case was Keira Bell who began using puberty blockers when she was 16 after she made the decision to transition to a male.
She was prescribed puberty blockers before proceeding onto cross-sex hormone treatment, eventually having a double mastectomy when she was 20.
But in 2019, when she was 22, Keira began to de-transition saying she regretted that she had gone down the “wrong path” by choosing to become a man.
Now at 23, she is left with no breasts, facial hair, a deep voice, and possible infertility.
Speaking to UK media following the court ruling on puberty blockers, Keira said if she had been protected from the “devastating experiment of puberty blockers” her life would be different.
She claimed there was a “complacent and dangerous culture” in the treatment of young people who are transgender in the UK, and she believes the High Court decision shows “common sense has prevailed with the safeguarding of children”.
Keira said she felt like she was used as part of an experiment, arguing the clinic that treated her should have challenged her decision to transition to a man more.
“It’s heartbreaking to realise I’d gone down the wrong path,” Keira said.
The British court’s ruling caused outrage from the World Professional Association for Transgender Health, including the Professional Association for Transgender Health Aotearoa (PATHA).
The association strongly disagreed with the High Court’s judgement saying it would “result in significant harm to the affected children and their families”.
“We oppose this ruling and urge that this ruling be appealed and overturned,” their complaint read. The case in the UK is now under appeal and will likely be heard in April this year.
Paediatrician and specialist in adolescent sexual health Dr Rachel Johnson doesn’t believe puberty blockers set young people on a trajectory towards hormone treatment or surgery.
Working for Counties Manukau District Health Board, she specialises in gender diverse children and young people across Auckland.
“Currently we’ve got around 300 young people and we’re supporting not just the young person, but also their families. We see young people from the ages of 12 to 24.”
Johnson says in her experience of treating children and young people she has only seen benefits from using puberty blockers.
“When we are supporting young people to access puberty blockers, there is a clear need and a clear benefit.”
She argues not giving young people access to the treatment could “potentially be very harmful for trans youth”.
Putting puberty on hold for a young person gives them time to think about what the next step in their transition will be without rushing onto hormone treatments which aren’t reversible, she says.
Deciding to treat a child with puberty blockers isn’t taken lightly. “With this area it’s always a benefits-versus-risks, so there needs to be a clear benefit from going on that blocker for that child.”.
Like any other medical treatment involving a child, the consent of the parents and child must be given. “They should never feel pressure to go down any set path. And, certainly within our services we’ve had young people that have gone onto blockers and then realised that it wasn’t what they needed.”
Two clinicians, psychological services, a youth health nurse or a social worker are also involved with the child and their family, over what can be years. “We want to ensure they’re not rushing into things,” says Johnson. “If you chose to come off [puberty blockers], which occasionally people do, puberty would just continue.”
According to an adolescent health survey in 2019, 1.2 per cent of Kiwi teenagers identify as transgender, and twice as many (2.5 per cent) aren’t sure of their gender.
In New Zealand, trans and non-binary people suffer from high or very high psychological distress at rates nine times higher than the general population. It’s even higher for gender diverse youth and disabled people. “Being trans is not an easy journey, it’s not a pathway that someone chooses. It’s about being true to who they are, but that still can, you know often, be a really difficult journey,” says Johnson.
Distress that can be experienced by a trans young person is called gender dysphoria.
“Gender dysphoria is the experience of distress or discomfort related to someone’s gender when that doesn’t fit necessarily with their sex assigned at birth,” says Johnson.
“And not all trans people experience gender dysphoria and, in the same way, not all trans folk need access to hormones or medication. It’s a really unique journey,” says Johnson.”
She’s also quick not to use labels on young people who are questioning their gender or experiencing gender dysphoria. “I’m trying to give a message to trans kids that there is nothing wrong with them.”
Wellingtonians Tineke and Phil had a baby boy they called Levi in 2011. As soon as he could express himself however, he started saying he was in the wrong body.
Having their toddler dress up in tutus, favouring pink over blue or wanting a princess cake for his fourth birthday wasn’t something his parents thought of as unusual.
“We just went with it and thought ‘well it’s a phase’ and if we allow this, he’ll grow out of it and you know it’s not causing any harm,” Tineke says.
She became more concerned once conversations with her son turned from wanting to wear dresses to harming himself.
“He started talking about wanting to harm himself and cut certain pieces off his body and would tuck in the bathtub and say, ‘look Mum I really am a girl’,” says Tineke. “It was quite shocking; I can’t imagine feeling like that about your body. It was quite a challenge to accept that was how he felt about himself.”
“When I asked for his sixth birthday what do you want for your birthday present, he was like ‘I just want to be a girl’,” Tineke says.
Through research and speaking to their paediatrician, Phil and Tineke have been able to help their son Levi slowly transition.
When he turned seven Levi became Jess.
“I started looking on the internet. We’d been watching stories and just trying to understand [it] and at one point I showed Jess the video of a girl called Jazz who was very open about her journey from transitioning as a boy to a girl.” That video was a “light bulb moment” for Tineke who saw how her son resonated with Jazz.
“She watched the video, and she was like, ‘Mum, I’m not the only one’. She was so happy and animated. It was a life-changing moment because it really did kind of cement that what we were going through was the kind of gender dysphoria.”
However, the transition from Levi to Jess hasn’t been easy for the couple, who are open about the struggles of raising a transgender child.
“There’s been many a night that I, initially, that I really struggled with it and you know there’s a grief cycle that you go through. We lost a son, and our children lost a brother, but we also gained a much happier healthier daughter,” says Phil. “When we allowed Jess to develop, she is confident, she is happy, she is vibrant, she is thriving,” Tineke says.
Now aged nine Jess is flourishing at school and loves spending time with her friends and family. As for what happens in the future, Phil and Tineke say it’s up to Jess to decide if she wants to undergo treatment such as puberty blockers or eventually hormone treatment.
“We certainly won’t be putting her on hormones, or through surgery, or anything like that. She’ll be doing that when she’s an adult,” says Tineke.
There are some unknowns about puberty blockers and what the long-term effects are on those who take them.
“We know that bones, while someone is on a blocker, they’re just not building up in the same way they usually would do in adolescence. We still don’t know when you’re 60 or 70, whether that might have an impact,” says Johnson.
These unknowns are what concern critics about the treatment. It’s also one of the main arguments against using a treatment which, opponents say is largely experimental on young people under the age of 16.
Research carried out by the University of Otago this year, which collated studies over the last 10 years on the use of puberty blockers, found that psychosocially the treatment was of benefit to transgender young people.
The research concluded that the use of puberty blockers improved the mental and social wellbeing of individuals with gender dysphoria and saw a reduction in suicidal thoughts and actions.
However, it also pointed out the lack of information on long term physical effects. Johnson says she hasn’t experienced any harmful side effects of using puberty blockers during her career of treating trans young people.
“We’ve been using them for some years and certainly the benefits that we are seeing, alongside the emerging evidence, reflects positively.”
Johnson doesn’t recommend using them for long periods of time, but says it gives a young person time to grow and mature without making the drastic decision to get hormone treatment or undergo surgery.
“While you’re on a blocker it doesn’t stop people growing, or maturing, you know they’re going on in their lives, which means that without dysphoria, or reducing the dysphoria, they can grow and mature. That helps them move forward in their life.”
Awa Puna is an actress, filmmaker, writer, director and storyteller.
A documentary, Born This Way: Awa’s Story, following Awa’s transition, won multiple awards when it screened on SUNDAY in 2017.
Four years later the 21-year-old has completed a degree at Toi Whakaari New Zealand Drama School and is making a name for herself in a range of onscreen roles.
Back in 2017, Awa was in her final year of high school and was transitioning from male to female. She still remembers the distress she went through before she transitioned.
“It drove me to harming myself...I ended up in hospital at one point,” she says. “I did what I did because there was no escape.”
For Awa puberty felt like an “alien taking over” her body. Once she had the courage to tell her family that she wanted to become a woman, Awa was referred to a psychologist and an endocrinologist to talk about her options for halting puberty.
At 15, Awa made the decision to start hormone treatment. She acknowledges this irreversible decision isn’t for everyone questioning their gender identity but feels the process to access treatment for trans young people is not done lightly in New Zealand.
“I know for my process it was extremely thorough.” A process that didn’t come without its personal challenges. “I appreciate that it needs to be thorough, but there was also that point of interrogating and feeling like you’re absolutely insane for just wanting to be your true self,” Awa says.
“It was a lot of hoops to jump through to just be my authentic self.”
She believes the British court ruling restricting treatment for young people under 16 is a “sad” turn of events for trans youth who can’t choose how they feel about their bodies.
For Awa, having access to hormone treatment has been lifesaving. “When I started taking my hormone treatment, I started feeling completely within myself. It was just like this light had turned on inside of me and I felt comfortable in myself.”
She would like to see an attitude change towards trans youth and the struggles they go through with their identity. “We need to be thinking about our young Kiwis and the way they think about themselves.” For herself, Awa’s greatest wish is to be treated as a normal woman.
“I don’t want me being a transwoman to be something that defines me.”
Cisgender (cis): A person whose gender aligns with their sex assigned at birth
Gender or Gender Identity: One’s actual, internal sense of being male or female, either of these, or both. A person’s gender is not fixed or immutable
Gender Binary (male/female binary): The (incorrect) assumption that there are only two genders (girl/boy or man/woman)
Gender dysphoria: A sense of unease that a person may have because of a mismatch between their biological sex and their gender identity. Gender dysphoria is not a mental illness, but some people may develop mental health problems because of gender dysphoria. Gender dysphoria is not related to sexual orientation.
Gender euphoria: The experience of comfort, connection and celebration related to our internal sense of self and our gender. The pride of feeling and being affirmed as who we are.
LGBTQI+: An acronym for lesbian, gay, bisexual, trans, queer, and intersex, and the “+” on the end denotes other gender and sexual identities. The combination and number of letters can vary
Non-binary: People who do not define themselves as having a "binary" identity (male or female). For them the concept of gender is not relevant to their identity
Puberty blockers: prescribed to some children who are experiencing gender dysphoria, to temporarily stop their bodies developing. The drugs suppress the release of hormones produced in much bigger quantities during puberty, pausing breast development, periods, facial hair and voice breaking
Transgender (trans): Umbrella term for people whose gender identity and/or gender expression differs from what is culturally typically associated with the gender/sex they were assigned at birth.
Trans man: A transgender person who was assigned female at birth but identifies as male
Trans woman: A transgender person who was assigned male at birth but identifies as female
Transitioning: The process from being seen as one’s birth assigned gender to one’s actual gender
Transsexual: This term tends to be used by older generations and is generally considered by younger people to be outdated. It may refer to a person who has changed their body to affirm their gender or is in the process of doing so
Further glossaries found below:
Further resources below:
Adult and youth services for the public and health professionals
Helpful for Families:
Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand:
Helpful tips for whanau to help navigate their own gender journey in order to best support their child
Resources for families and young people. Rainbow Youth have a peer support worker who can also provide support and direct you to helpful information:
OUTline is a national service helping LGBTQI+ New Zealanders and their families access support, information and a sense of community. They also provide whanau counselling:
Resource guide for parents of Trans Youth:
https://takatapui.nz/ Takatapui resource Hub
Includes links to Takatāpui: Part of the Whanau by Elizabeth Kerekere.
Ministry of Education: