A protest last year in the southern US state of Tennessee which bans hormone therapy, puberty blockers and gender transition surgery for those under the age of 18. Photo / Kevin Dietsch, AFP
The American Society of Plastic Surgeons has issued a broad recommendation against gender transition surgeries for youths, becoming the first major medical association in the United States to narrow its guidance on paediatric gender care amid a crackdown by the Trump Administration.
A statement sent today to the group’s 11,000 members and obtained by the Washington Post recommends surgeons delay gender-related chest, genital and facial surgery until a patient is at least 19.
Fewer than 1000 minors in the US receive such surgeries every year, according to research published in JAMA, the American Medical Association’s journal, and the vast majority of the procedures are mastectomies, not genital surgeries.
But there’s an intense debate over when young people should be able to get medical interventions as more have sought gender transition and some systematic reviews have suggested the evidence for the benefits and risks of paediatric transition is insufficient.
Supporters of transition care for youths have pointed to the widespread endorsement by US medical organisations.
“This is a vulnerable, adolescent population,” said Scot Bradley Glasberg, past president of ASPS who did not vote on the new guidance but has been involved in discussions about the group’s stance. “We are mindful that some of these surgeries are irreversible.”
The group, which represents plastic surgeons primarily in the US, has evolved its stance on the issue.
In 2019, the group opposed attempts by states to restrict transition care and said that “plastic surgery services can help gender dysphoria patients align their bodies with whom they know themselves to be and improve their overall mental health and wellbeing”.
In August 2024, the group said it was crafting guidance for plastic surgeons, citing “considerable uncertainty” about the long-term benefits for chest and genital interventions.
The new guidance says that “there is insufficient evidence demonstrating a favourable risk-benefit ratio for the pathway of gender-related endocrine and surgical interventions in children and adolescents”.
It cites “substantial uncertainty” about the long-term benefits and harms of hormones and puberty blockers more routinely prescribed for gender transition but does not give any specific recommendations for those treatments.
US Health Secretary Robert F. Kennedy jnr, who is leading efforts to restrict medical interventions for youth gender transition, said in a statement that he commends the group for “standing up to the overmedicalisation lobby and defending sound science”.
The Human Rights Campaign, an LGBTQ+ advocacy group, says in some rare cases, teenagers under 18 have received transition surgeries “in order to reduce the impacts of significant gender dysphoria, including anxiety, depression, and suicidality”.
The American Medical Association and the American Academy of Paediatrics recommend transition surgeries primarily for adults but say adolescents can receive them on a case-by-case basis.
Glasberg said the new recommendation is based on an evaluation of several recent reviews of evidence for paediatric gender medicine.
He cited three systematic reviews by researchers at McMaster University in Ontario, who found evidence for the impact of puberty blockers and hormone therapy is limited and researchers need to conduct larger, longer-term randomised trials to assess the benefits or drawbacks of transition care for young people.
Glasberg also cited the Cass Review, a 2024 report in Britain that didn’t directly address surgeries but concluded evidence supporting the use of puberty blockers and hormone treatment is “remarkably weak”.
The report led to England’s National Health Service banning the treatments for minors except in trials. The US Department of Health and Human Services released a report reaching similar conclusions.
None of those reviews looked extensively at the effects of surgeries on young people. But Glasberg said the overall lack of evidence on paediatric gender care prompted ASPS to revise its position.
“There has been a continuing evolution of the data,” Glasberg said. “As each of these systematic reviews came out, we felt compelled to enhance the position we had previously taken.”
Glasberg said the group chose age 19 as the cutoff because it’s a “developmental landmark” when puberty has generally concluded.
He pointed to FDA restrictions on getting silicone breast implants before age 22 because they can hinder breast development.
Debate over paediatric gender transition care has been deeply fraught as the ranks of young people seeking to transition have swelled in the US and abroad.
A number of countries, including Finland, Sweden and New Zealand, have shifted towards a more cautious approach on puberty blockers and hormones and for the most part don’t provide surgeries until someone is at least 18.
Nearly half the states in the US, all led by Republicans, have passed measures restricting paediatric transition services.
In December, US President Donald Trump’s Administration proposed regulations to eject medical providers from major federal health insurance programmes if they offer transition care to youths.
Leading medical associations in the US have largely stuck by their broad endorsement of a range of transition care services for youths, including surgeries.
Transition procedures can feminise or masculinise the face and include “top” surgeries where breasts can be removed or constructed, and, rarely, “bottom” surgeries including vaginoplasty or phalloplasty.
The World Professional Association for Transgender Health, which sets transgender care guidance, has supported surgeries in some circumstances and came under fire for excluding age minimums in its latest guidance.
WPATH proposed draft guidelines in 2021 that recommended age minimums of 14 for hormonal treatments, 15 for mastectomies, 16 for breast augmentation or facial surgeries and 17 for genital surgeries or hysterectomies.
Biden administration officials asked WPATH to remove the age criteria, saying they feared it would threaten access to treatment and fuel state bans, according to unsealed court documents.
The guidelines recommend patients reach “the age of adulthood” before getting surgery but say the specific age may vary based on where the patient lives and stress individualised treatment.
“We realise that we are potentially going in a different direction from other organisations,” Glasberg said. “We’re focused on the science, the data and the evidence going forward.”
Gender transition procedures nearly tripled from 2016 to 2020, largely among people in their teens and 20s, according to the JAMA research published in 2023.
The vast majority got puberty blockers or hormones, and surgery was rare. Over the five years studied, 3215 people under age 19 had chest surgery and 405 had genital surgery, according to the study, although the authors warned the numbers could be an undercount.
Glasberg said he has started performing more operations for people seeking a reversal of transition surgeries.
Last week, a jury in New York awarded US$2 million in damages to a woman who, after detransitioning, sued her plastic surgeon for providing her with a mastectomy at age 16.
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