Dozens of children questioning their gender, including some under 13 years old, were inappropriately prescribed medication by a Brighton GP practice, an NHS safety investigation has found.
A year-long inquiry into the WellBN clinic found that 78 young patients were potentially harmed after puberty-blocking drugs and cross-sex hormones were prescribed without proper checks.
More than 20 children were given medication without a face-to-face appointment between February 2023 and December 2025.
In a website statement, WellBN said it recognised "the seriousness and sensitivity of the matters raised" and that its priority remained providing "compassionate, safe and effective care for all patients".
NHS England has told the clinic it must stop offering new prescriptions to children, and said a number of current and former clinicians had been referred to medical regulators.
One of the doctors identified in the report has been suspended from working as an NHS GP while further investigations are ongoing.
Dr Christopher Tibbs, regional medical director for NHS England, said that young people were put at a high risk of harm because clinicians provided "specialist diagnosis, care and treatment that they were neither qualified, nor commissioned to deliver".
"Under no circumstances should this have happened," he added.
In 2020, WellBN opened a transgender health hub in Brighton and, by last year, around 2,000 patients of all ages had registered, many from outside the city.
The service was set up in part because patients were facing extremely long waits to be seen by one of the three specialist gender services that now operate in England.
The investigation, run by five independent clinicians appointed by NHS Sussex, began in June 2025 after several families had complained about the services the clinic was offering to under 18s, and after a civil legal case had started against the clinic and the NHS.
One father told the BBC that his 16-year-old child was given hormones without his knowledge in what he describes as a "medical scandal" while another said the stress of the situation had left him suicidal.
The final report said that 78 children under 18 years old were prescribed gender medication by the clinic from 2023 to late 2025.
Some were given drugs designed to delay or suppress puberty, while others were given cross-sex hormones, also known as masculinising and feminising hormones.
These help a person develop physical characteristics associated with their identified gender rather than their biological sex. This can lead to irreversible changes such as a deeper voice or breast development.
The report found that:
Data in the report shows that 44 children aged 16 and under were prescribed drugs designed to delay or suppress puberty. That number included 12 children under the age of 13, one of whom was aged 11.
In total, 51 children aged 16 and under, including four under the age of 13, were given cross-sex hormones.
The report also said it was "clearly evident" that the practice staff had a "genuine desire and commitment to help distressed children" facing long waits for specialist care.
Dr Charlotte Canniff, joint chief medical officer for Surrey and Sussex ICB, said that most young patients registered at the clinic had now been referred to specialist NHS gender services for treatment.
A group made up of local parents, school governors and social workers says it began raising concerns about WellBN in 2023 as part of a wider campaign about health education.
Rachel Cashman, who co-founded PSHE Brighton, says the stress of the situation had "ruptured" families, leaving some parents estranged from their children.
"It's not just the medical damage, but the collateral damage for relationships and families that is far greater than people have ever really thought to examine," she adds.
Cashman says some of the children prescribed hormone treatments had also been diagnosed with conditions such as autism and ADHD, and the focus on gender medication risked overshadowing their wider health needs.
The report found that 53 of the 78 cases reviewed had possible neuro-developmental issues.
The BBC has spoken to three parents of children who were treated at WellBN. All have been anonymised to protect their identities.
One father, who is taking separate legal action against the clinic, told the BBC his 16-year-old son forged his mother's signature to access hormone treatment and was prescribed oestrogen without his parents' knowledge.
Another parent says he found out his daughter was given testosterone a few weeks after she turned 16. He felt families were given an "impossible choice" – either sign up for medical treatment or face "suspicion and ostracism just for asking to slow things down".
A third parent said his daughter was 13 years old when she decided she wanted to live as a boy and tried to order hormones over the internet.
She was prescribed testosterone aged 16 at WellBN, something her father did have concerns about at the time but "welcomed compared to the [online] alternatives".
A year later, his daughter stopped taking the hormone after it "didn't make her happy" and is now living as a girl again.
In April 2024, a landmark review into gender services by the paediatrician Dr Hilary Cass found the scientific evidence for treating children with medication was "remarkably weak" and called for a "fundamentally different service model".
That led to a ban on new prescriptions of puberty blockers for gender questioning children in the UK outside of clinical trials. Those already on the drugs were allowed to continue.
In 2024, NHS England also tightened some of the rules around cross-sex hormones.
It said prescriptions of testosterone and oestrogen should only be offered to young people from around the age of 16 with "extreme caution" after being signed off by a national team of specialists.
In March 2026, new prescriptions were paused completely for 16- and 17-year-olds in England while a public consultation is being carried out.
In a statement on its website, WellBN said it would like to reassure its patients that it provides "safe, high-quality care and support to our community".
"We are committed to working closely with NHS partners and regulators to address any recommendations identified within the report and to continue strengthening the services we provide," it added.
