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Activist GPs are offering ‘affirmative gender care’ and bridging prescriptions for hormones. With no age limits on who can attend these special clinics, we’re concerned that once 18 young people will be able to access cross-sex hormones without any oversight. Shelley Charlesworth looks at just one of these clinics, The Bridge clinic in south London, and asks who is going to tackle the problem of activism posing as medicine.  

The enormous task of returning the NHS to normal standards of healthcare for children and adolescents with gender distress has begun.

At the macro level we have the ground-breaking final report of the Cass Review which has had a worldwide effect, showing there is a very low evidence base for puberty blockers and cross-sex hormones. The ban on puberty blockers by the NHS and Department of Health both show serious intent to protect children from harmful hormonal treatments. There’s to be a new oversight body headed by the independently-minded clinician Professor Simon Wessely which will oversee wider research.

But at surgery and clinic level there are still too many activist doctors and nurses working hard to undermine the turn to reality. And at all levels there are trans activists who seek to obstruct the reforming work of the Cass Review. Some sit on national bodies advising the NHS on both children’s and adult services, which oversee commissioning. The presence of activists from Mermaids and Transactual on the National Programme Board for Gender Services is a glaring example.

Activism in General Practice

The example of The Bridge Clinic in Southwark shows how unevidenced and ideological care is being promoted at ground level. Despite its name it is not a standalone clinic, but a one evening a month service operating within a GP surgery. This surgery is itself part of a federation of 18 GP surgeries run by Improving Health Ltd (IHL). There are no displays of gender allegiance on IHL’s website, no rainbow messaging or pronouns in bios. Details about the clinic, which was set up in 2022, are signposted discreetly with an email address and this explanation:

“A new primary care clinic has opened for the trans, non-binary and gender non-conforming community. We provide routine GP services and can offer some gender-affirming care, such as bridging hormones. We also have a health and wellbeing coach working as part of the team. It will run a monthly clinic in South Southwark.”

The story of how the clinic was set up illustrates how just a few people can persuade a large GP federation into offering ‘bridging hormones.’  A nurse called Flora Cohen was the driving force behind its inception. Her LinkedIn profile highlights her role and her other activist jobs: 

“I established and run London’s first Transgender primary care service….I provide training sessions on improving trans healthcare and have spoken at a number of conferences. I have a number of projects I am involved with, including acting as consultant with Stonewall for a small trans support service in Bristol, and research projects around healthcare for trans people.”

Unreliable data and sources

Cohen wrote in May 2024 in the Royal College of Nursing’s journal Primary Health Care that Southwark was an ideal place for such a clinic as  “1% of the population indicated their gender identity was different from their sex registered at birth in the 2021 Census.” This is true but completely misleading. In fact, although Southwark was ranked the 5^th overall local authority to record trans and non-binary identities, data breakdown shows the result was more likely due to poor understanding of the census question in a couple of wards. Southwark Council itself has not joined the dots:

“Over 1 in 12 (8.1%; about 600) residents in Southwark’s Burgess Park neighbourhood area (extending across Faraday and Old Kent Road) identified as trans/non-binary; this was the highest trans/non-binary prevalence in England (far ahead of 3.8% in East Central Oxford and 2.4% in Manor Park, Newham).”

“In the centre of Southwark, particularly around Faraday and Old Kent Road, as many as one-quarter (24%) of all residents have low or no English proficiency.”

This is hardly a minor detail as it forms part of Cohen’s argument that the clinic is needed to fill a “critical gap in transgender healthcare” in Southwark.

The Bridge clinic offers prescriptions for bridging hormones for patients waiting for NHS gender clinic appointments, suggesting the name of the clinic was chosen deliberately. It sees patients of any age.  

Cohen boasts in the RCN article about the data they are gathering in response to what she says is a lack of research on trans health inequalities. However, despite sharing some data on ethnicity, there is no reference to the age or sex of those attending the clinic. Furthermore, Cohen’s reliance in the article on surveys and news by GenderGP, Stonewall, TransActual and Pink News, raises questions about her capacity to interpret data.

As most of those on the waiting lists for adult gender clinics are female and under 25, it’s a reasonable assumption that The Bridge reflects that same demographic. The Cass Review highlighted the 17-25 years-old cohort as needing follow-through care in adult services, arguing that this group of young people with gender distress will likely remain fluid in their experience of gender until their mid-twenties. It’s significant that Cohen’s article makes no reference to the Cass Review.

Activist approach to informed consent

Treatment is offered on the informed consent model which Cohen says is based on WPATH’s redundant 2012 guidance, reported by the BMJ to ‘lack developmental rigour and transparency’. Those critical of the informed consent model, such as the Society for Evidenced Based Gender Medicine, say there are three areas which undermine consent: poor quality diagnostic evaluations, wrong assumptions by clinicians about the safety of their treatments and inaccurate information given to patients.

In other words a patient’s consent is dependent on a doctor’s understanding of a particular treatment. Informed consent fails when the doctor or nurse is uninformed or is following a non-medical belief system. For informed consent for cross-sex hormones to be meaningful, a GP has to explain the long-term health risks of cancer, cardio-vascular disease, lack of sexual function and infertility.

Cohen follows an activist narrative in her RCN piece, ascribing the high rates of mental health comorbidities among trans identified patients to the prevalence of discrimination and transphobia:

“The current societal attitude to transgender people further complicates the situation. For example, there has been an increase in transphobic rhetoric in politics …Consequently, in the author’s opinion, increasing numbers of the public, including healthcare professionals, are questioning the rights and, in some cases, the existence of transgender people.”

The Cass report and RCGP guidance ignored

The section on bridging prescriptions for hormones is a careful cherry-picking of the guidance for GPs. Cohen cites the GMC’s advice and bizarrely for a London based practice, that of the Northern Ireland’s branch of the Royal College of GPs, written in 2017 with the collaboration of LGBT activists. Ideological language such as ‘birth-assigned sex’ and ‘cisgender’ informs the latter, alongside links to trans activist groups such as GIRES. The GMC guidance on prescribing hormone treatments is out-of-date as it contains no reference to the latest NICE review on cross-sex hormones or to the final Cass report.

Much more relevant and up-to-date, but omitted by Cohen, is the Royal College of GP’s statement in May 2024 on the role of the GP in transgender care. This cites the Cass review on the need to exercise extreme caution in prescribing masculinising/feminising hormones, concluding: “We feel that in view of this, prescribing of gender-affirming hormones should generally only be done by specialists.”

Post-Cass and in a ‘peer-reviewed’ article for a prestigious nursing journal there is no excuse for this bias towards the discredited affirmative approach which ignores the latest research about cross-sex hormones.  

Setting up The Bridge clinic

Cohen was enabled in setting up the The Bridge clinic by a GP of 20 years’ experience, a partner at one of the 18 surgeries in the IPL network and its clinical director, Dr Rebecca Stephens. In a blog written for the NHS Confederation in May 2023, Dr Stephens described meeting Flora Cohen during the pandemic, describing her as a “strong advocate for the trans/non-binary community.” Cohen then introduced Dr Stephens to a world of trans health activism:

“I attended the CliniQ conference, which Flora and our GP colleague Max had helped set up, and had a lightbulb moment. Listening to the many amazing speakers, I was surprised and upset to learn more about the inequalities faced by gender non-conforming patients, but excited that GPs were more empowered to help than I had realised.”

Like Cohen, Dr Stephens says little about the patient cohort except:

“20 per cent of patients were self-medicating with hormones and 30 per cent were accessing private gender-affirming hormone prescriptions without access to adequate monitoring. We have now taken over prescribing and put monitoring in place.”

An account of another CliniQ conference in April 2023 by the blogger Sarah Stuart records the other GP involved in The Bridge, Dr Max Kelen, saying:

“The service had seen 30 new patients, of which roughly half were of the male gender and half female (presumably self-identified gender)…Eighteen out of the 30 new patients had gotten brand new hormone prescriptions. One referral for ‘top surgery’ was made.”

Dr Stephens has moved in just a few years from thinking that she didn’t have the knowledge to prescribe hormones to disdain for normal standards of evidence and expertise. She spoke at a trans health event in Parliament in February 2024. Nancy Kelley wrote about the meeting:

“Becky (Dr Stephens) shared that as a GP she once thought only Gender Identity Clinics could provide trans healthcare, and now she realises that it’s more straightforward than providing care for people with diabetes.”

Dr Stephens seems unaware that her own professional body has advised extreme caution in prescribing cross-sex hormones, stating that it must only be done by specialists. Dr Stephens has written of networking with “very famous (in the trans world) activists” and that The Bridge clinic has “very active links” with TransActual and the Trans Solidarity Alliance, among others. TransActual is a company set up by Helen Belcher, Jane Fae, Chay Brown and others to influence NHS practice.

The father of an autistic 18-yr-old, who was being assessed at the clinic for cross-sex hormones, has described how TransActual influences The Bridge’s clinical practice. He said: “The doctor painted a very rosy picture – it wasn’t balanced, objective or reflecting the latest evidence. The clinic provided us with an activist briefing which calls the Cass Report ‘fundamentally flawed’ and perpetuates misinformation about the Cass Review’s use of evidence.” This was a briefing published by TransActual that calls NHS England’s adoption of Cass’s recommendation as “cause for huge concern”.

Links to other NHS activists

CliniQ has also played an important role in setting up The Bridge. Dr Kelen the second GP involved with The Bridge also worked at CliniQ. Cohen describes the central role that both clinics place on bridging prescriptions:

“A relationship was developed with CliniQ, which led to several meetings between the lead nurse, GP, director and clinical lead of the company. During these meetings primary care was identified as well placed to ‘bridge’ the gap in care for transgender people, as GPs can prescribe bridging hormones and provide routine primary care services which are often inaccessible to the transgender community.”

The “clinical lead” referenced above is Dr Michael Brady, a consultant at King’s and the NHS’s National Advisor for LGBT Health. The Bridge’s operating model mirrors that of CliniQ, the latter offering a weekly 3hr clinic at King’s College Hospital. CliniQ at King’s opened in 2019 with the backing of Michael Brady.

The evolution of The Bridge clinic is disturbing. The clinic adheres to a belief in gender affirmative care that is politically driven, rather than evidence-based. It follows guidance set by discredited WPATH gender lobbyists and the 2017 guidance written with trans activists for GPs in Northern Ireland.

Those ultimately responsible for the clinic, Improving Health Ltd, should ask Drs Stephens and Kelen why they are not following the latest guidance from the Royal College of GPs. IHL needs to implement the recommendations of the Cass Review’s Final Report which now has the support of the NHS, the RCGP, and the two main political parties.

Research commissioned by the Cass Review concluded that there was “a lack of high-quality evidence to support the initiation of hormones for masculinisation or feminisation in adolescents experiencing gender dysphoria/incongruence.” Adolescents and young adults, the 17-25 yr-old cohort, were identified by Dr Cass as in need of holistic care through a period of gender fluidity. They are also most likely to be the groups accessing care at The Bridge.

NHS England has begun a wide-ranging review of adult gender dysphoria healthcare, highlighting the

“lack of a robust evidence base; being mindful that the majority of referrals to the adult gender clinics are of natal females who are aged between 17 and 25 years, and that the historical evidence base that has informed clinical practice relates to an older cohort of natal males; limited information on short and long-term outcomes…[and] an increasing incidence of individuals seeking to ‘detransition’ following previous gender affirming interventions.”

As de-transition rates increase, The Bridge clinic and similar GP practices could in the future find themselves facing compensation claims for harms done by the prescribing of cross-sex hormones to a vulnerable group of young people.