Response ID ANON-5H8E-S45G-W Submitted to Interim Clinical Policy: Puberty suppressing hormones for children and adolescents who have gender incongruence/dysphoria Submitted on 2023-08-18 15:01:34 About you 1 In what capacity are you responding? Other If you have selected 'Other', please specify:: NHS employed research biologist 2 Are you responding on behalf of an organisation? No If you have selected "Yes", which organisation are you responding on behalf of?: Interim clinical policy 3 Has all the relevant evidence been taken into account? No If you selected 'No', please give details:: The NICE review omits many studies, in some cases explanations for omitting these studies is provided but in many cases the explanation is categorically false. For example Achille et al 2020 was rejected because GnRHa treatment was not reported separately but it is, table 4 does exactly this. The 2014 DeVriers paper specifically examines long term effectiveness and safety of puberty blockers and would reasonably be considered among the most relevant studies for this consultation but was also omitted. Jensen et al 2019 looked specifically at side effects from puberty blockers alone and again would reasonably be considered highly relevant to this review but was omitted. The omitted studies seem to overwhelmingly support the use of puberty blockers which has had the effect of biasing the results. There is a lack of evidence from wpath which is hard to understand as an international body that examines specifically standards of care for trans patients. There is a lack of contribution from endocrinologists or biologists about hormones and puberty in general. There is a lack of appropriate comparators. Which is to say that most evidence examines teenagers who want puberty suppression and obtain it versus teenagers who do not want it. There is no evidence specifically examining the effects of denying the medical care, particularly despite it being available in almost every other modern country which is what the NHS is actually proposing to do. There is no evidence on the risks of unregulated puberty either, some people have hormone levels that are outside of that which will lead to good health outcomes. For example, high testosterone puberty may often lead to a growth level associated with a significant risk of back problems later in life, as well as strongly predicting heart issues etc. 4 Does the equality and health inequalities impact assessment reflect the potential impact that might arise as a result of the proposed changes? No If you selected 'No', please give details:: The continued use of drugs for a different condition is justified largely through a claim that that use 'is not contested' the politics around trans people should obviously not influence medical decisions and whether something is contested or not should be of no relevance. The comment about puberty blockers being 'off label' seems to entirely misunderstand pediatric medicine where a huge number of frequently prescribed drugs are similarly off label. The arguments for why the proposal doesn't discriminate against people with a gender reassignment characteristic are bizarre and self-contradicting. That people on the wait list may not have the characteristic is true, but then indirect discrimination would apply, the proposal also isn't for people on the wait list it must necessarily be for people wanting blockers which would clearly fall into the protected group, a point even made by the equalities proposal when trying to justify why indirect discrimination does not apply. There is no mention of how this will impact the right to bodily integrity, while not a legal right in the UK at this time it is a well-recognized international human right as shown in the Universal Declaration of Human Rights and the International Covenant on Civil and Political Rights. It is reasonable to expect an equalities assessment to consider how the proposal would clearly deny a protected group the right to control over their own body. 5 Are there any changes or additions you think need to be made to this policy? Are there any changes or additions you think need to be made to this policy? : I do not think the policy needs to be changed, it needs to be abandoned. The supporting evidence review incorrectly omitted relevant studies, the equalities review contains basic logical flaws as well as omitting relevant questions and the proposal does not put intervention and non-intervention on an equal footing but rather preferences non-intervention which is biologically unsound and unscientific.