I am one of the 85 signatories to an open letter to James Palmer, NHS England’s National Medical Director for Specialised Services. We are raising serious concerns about the recent NHS evidence reviews of hormone therapy for trans youth, and subsequent prescribing policy and public consultation.
The letter has been published and sent to Palmer by Trans Actual – you can read more about it on their site here. In my signature, I note that I was a 2023 recipient of the NHS England LGBT+ Advisor Award. Unfortunately, in subsequent years, NHS policy on LGBT+ healthcare seems increasingly shaped by ideology and political pressure, rather than patient experience, expert advice, and evidence. In meetings I attended with Palmer in the early 2020s, I personally heard him share various forms of disinformation about young trans people, such as the factually inaccurate claim that recent cohorts of adolescents presenting with gender dysphoria represent a distinct population from young people referred to the same clinics in earlier years.
For a longer and more detailed critique of the NHS evidence reviews, see this excellent analysis by Kim Hipwell: A Medical Mess: An Analysis Of The NHS’s Proposal To Ban Hormone Therapy For Trans Youth.
The public consultation is open until 7 June, and you can submit a response here.
Dear James Palmer,
We are a group of clinicians, researchers, and academics working in gender care, paediatrics, and related fields of healthcare, medicine, and science.
We are writing to lay out our serious concerns with NHS England’s recently-published evidence reviews into the use of gender-affirming hormone therapy (GAHT) by children and adolescents.
1. Lack of Clear Rationale
The Cass Independent Review previously commissioned a systematic evidence review into GAHT for under-18s.
Based on this peer-reviewed and published analysis, Dr. Cass recommended that “NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution.”
In 2024, NHS England reviewed and updated their GAHT policy accordingly.
A “living systematic review” – also recommended by Dr. Cass – is now underway, to consolidate the evidence base and keep it up-to-date. This work is being conducted by EPPI-Centre and others, funded by the National Health and Care Research Institute (NIHR), and includes an ongoing review of evidence for GAHT for under-18s.
Therefore, it remains entirely unclear why – having previously wholeheartedly accepted the Cass Report – NHS England has now launched a separate evidence review that was never recommended by Dr. Cass and which duplicates other research already commissioned and underway.
2. Lack of Peer Review
None of the NHS England evidence reviews have been peer reviewed or written to meet publication standards. Instead, NHS England released the reviews only as part of a public consultation process and has asked the general public to “check that draft policies are well evidenced” and to determine whether “all of the relevant evidence [has] been taken into account”.
Consultation is not a substitute for formal academic review, and risks conflating technical evaluation with public opinion.
3. Methodological Limitations and Risk of Bias
Rather than address a single, clinically meaningful research question, NHS England subdivided the GAHT for under-18s evidence review into 10 separate and extremely narrow PICOs (population, intervention, comparison and outcome search parameters).
We have confirmed that this methodological decision was made by NHS England’s “Policy Working Group”, prior to instructing the “independent” researchers, Solutions for Public Health (SPH).
This methodological approach explicitly goes against the gold-standard guidance outlined in the Cochrane Handbook, which cautions that fragmentation of PICOs is likely to result in “sparse” evidence and “could be chosen by review authors to produce a desired result.”
As a result of these overly-narrow search parameters, the researchers had to exclude some of the most significant studies on gender-affirming care for young people, such as Chen et al., 2023, the largest NIH-funded prospective study of trans youth ever conducted.
Ultimately, the researchers could find only 11 eligible studies across all 10 PICOs, with 0 (zero) studies found for 6 of the 10 reviews. In contrast, the University of York evidence review commissioned by Dr Cass found 53 studies, 34 of which were assessed as moderate- or high-quality.
As an example, studies were deemed “out of scope” if participants had received GnRH analogues in the context of puberty suppression prior to receiving gender-affirming hormones (despite the fact that this was the standard treatment protocol internationally for many years, including in the UK).
According to the published reviews, as a result of this methodological decision alone at least 38 studies were excluded that would otherwise have been eligible (and potentially many more at title/abstract stage). These studies could, at the very least, have provided information on the risk profile of GAHT, a factor which NHS England claims to be central to their policy decision making.
NHS England has published no rationale at all for this – and other– methodological decisions. In response to an FOI request, NHS England indicated that studies involving GnRHa puberty suppression “cannot be included” in the PICOs because of “legal issues”, an “ongoing research trial in this area” and “lack of new evidence” – reasons that we find scientifically unsound.
Additionally, in contexts where limited evidence is available for a paediatric intervention, it would be typical for researchers to consider extrapolating data from research into adults, something that NHS England again chose not to do.
In effect, NHS England has adopted a methodological approach that predictably minimises the available evidence base, then cites this manufactured scarcity as a justification for restrictive policy conclusions.
4. Misreporting and Misapplication of Findings
Especially in paediatrics, clinical policy and decision-making is commonly based on evidence considered limited and/or “low-quality” as recognised under the GRADE system. There is therefore no reason why the purported lack of evidence reported in these reviews should automatically lead to the policy position that gender-affirming hormones are so unsafe and/or ineffective for 16- and 17 year olds that they must be immediately withdrawn.
Even when looking only at the 11 studies included in this NHS England evidence review, we believe the overall pattern of evidence suggests that the benefits of GAHT for under-18s outweigh any harms. We believe this is also the case in the University of York review.
We have also found that at least one of the studies included in the SPH reviews that apparently found evidence of “harm” (Grannis et al., 2003) was entirely misreported. The evidence review states that those taking oestrogen had significantly higher depression, suicidality and social anxiety scores than those not on hormones. In fact, Grannis et al. found no statistically-significant differences on these measures.
5. Impacts of Treatment Withdrawal
As far as we are aware, NHS England has no plan to monitor the impact of this withdrawal of gender-affirming healthcare on patient outcomes. This is despite evidence that removal of gender-affirming care is associated with adverse mental health outcomes, including increased suicidality among trans youth.
A decision to withdraw a treatment must consider what alternatives will be provided. Psychotherapy or psychosocial support alone – all that is currently available via the NHS – has not been demonstrated to be an effective treatment for those with a diagnosis of gender dysphoria. Nonetheless, as far as we know, NHS England has no plans to conduct a similar evidence review of
this intervention.
6. Conclusion
In summary, a drastic and potentially devastating policy change that runs counter to international standards of care has been advanced:
- without any clear rationale,
- on the basis of a methodologically-flawed process,
- in the absence of peer review,
- and without plans for monitoring impact or mitigating harm.
We therefore urge NHS England to:
- pause and reverse implementation of any policy changes arising from this flawed review process,
- publicly acknowledge and take into consideration the existing University of York systematic review into gender-affirming hormones and the existing EPPI-Centre study,
- ensure any clinical commissioning policy on gender affirming hormones for under-18s reflects established international best practice,
- and incorporate patient and clinician consensus and testimony into any decision about transgender healthcare.
A full list of signatories can be found here.
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Dr Ruth Pearce 