1. United States
2. Mich.
3. Letter

Do not cite NHS England's recent hormone therapy reviews to justify restrictions on transgender healthcare in the United States. These reviews are methodologically flawed and designed to produce a predetermined outcome. NHS England excluded 97% of studies examined by splitting one question into 10 artificially narrow reviews. This "salami slicing" approach is explicitly warned against in the Cochrane Handbook and is considered research malpractice. They excluded Chen et al 2023, the largest NIH-funded prospective study of trans youth ever conducted and published in the New England Journal of Medicine with 315 participants. They excluded Tordoff et al 2022 from JAMA Network Open, which found 60% lower odds of depression and 73% lower odds of suicidality with hormone therapy. They systematically excluded the Dutch Protocol studies that form the foundation of modern transgender care worldwide. Gordon Guyatt, who coined the term "evidence-based medicine" and helped develop the GRADE framework NHS England claims to use, called using systematic reviews to justify banning gender-affirming care "egregious and unconscionable." A low GRADE rating reflects study type, not whether treatment works. Over 90% of pediatric medicine lacks "high-quality evidence" by this standard. These reviews are politically manufactured pseudoscience. Reject any attempt to import this methodology into American policy.