In a major development, the American Society of Plastic Surgeons, a medical association representing some 11,000 members and over 90 percent of the field in the U.S. and Canada, has come out unequivocally against “gender-affirming” surgeries in adolescents under age 19. “Systematic reviews and evidence reassessments,” the ASPS states, “have . . . identified limitations in study quality, consistency, and follow-up alongside emerging evidence of treatment complications and potential harms.”
Today’s statement represents an escalation by the group against the view of other organizations that these procedures are safe and effective for minors. A Manhattan Institute analysis of insurance claims from 2017 to 2023 found that a minimum of 5,200 teen girls had had their breasts removed as part of a gender transition procedure. The real number is likely quite a bit higher. Harrowing testimonies from detransitioners have raised public awareness about the absence of safeguards and the dangers of medicine shaped by ideological commitments.
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Notably, the ASPS statement raises strong concerns about not just surgeries but also the use of puberty blockers and cross-sex hormones, though it limits itself to advising its members on surgeries. As such, it directly challenges other medical associations, including the American Academy of Pediatrics, the Endocrine Society, and the American Psychiatric Association, that have endorsed hormonal “treatments” for children and teens distressed about their developing bodies.
In August 2024, I sent ASPS an inquiry about its view of the U.K.’s Cass Review and revelations of scientific misconduct by the World Professional Association for Transgender Health. The group’s media relations manager responded, stating that the group “has not endorsed any organization’s practice recommendations for the treatment of adolescents with gender dysphoria” and “currently understands that there is considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions,” adding that “the existing evidence base is viewed as low quality/low certainty.” ASPS later clarified that it opposed “government-sanctioned penalties and criminalization” against doctors as well as “any attempts at legal encroachment into the practice of medicine.”
However, in a follow-up interview with a prominent plastic surgeon and transgender activist, ASPS’s then-president, Steven Williams, refused to commit to opposing state age-minimum laws. At one point, Williams, a black man, gave the example of the Tuskegee experiments, which, he said, show the dangers of blindly trusting the medical profession to self-regulate.
ASPS’s new position, announced today, is presented in a formal, nine-page position statement. It is more forceful and comprehensive. Among other things, the ASPS:
- makes explicit and positive mention of the Cass Review and the U.S. Department of Health and Human Services’ report Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices (of which I was a coauthor). ASPS highlights the peer-reviewed HHS report’s careful analysis of evidence (in an “umbrella review”), agrees with its ethics analysis, and concurs with its and the Cass Review’s assessment of the untrustworthiness of existing clinical guidelines in the United States;
- acknowledges the lack of research on the natural course of gender dysphoria in pediatric populations, the absence of reliable assessments for predicting the course of a minor’s identity development, and the dangers of performing irreversible interventions with life-altering consequences;
- warns against the misuse of the patient autonomy principle, which is “more properly defined as the right of a patient to accept or refuse appropriate treatment; it does not create an obligation for a physician to provide interventions in the absence of a favorable risk–benefit profile, particularly in adolescent populations where decision-making capabilities are still developing.” This is a key point, as appeals to autonomy have served as a central justification, in the absence of clinical evidence, for letting minors or their parents consent to endocrine or surgical interventions.
The ASPS clarifies that it “does not seek to deny or minimize the reality of any patient’s distress, and it does not question the authenticity of any patient’s experience. Instead, ASPS affirms that truly humane, ethical, and just care, particularly for children and adolescents, must balance compassion with scientific rigor, developmental considerations, and concern for long-term welfare.”
The ASPS further emphasizes that its statement is “not a retroactive judgment but a forward-looking response to evolving evidence,” meaning that the group will not view members who have already performed these procedures on minors as culpable of unprofessional conduct. The ASPS “advises Members to remain aware of state laws . . . that may impact their practices” and opposes “criminalization of medical care,” adding that “regulation” of care is “best achieved through professional self-regulation.” This part of the statement will likely draw differing interpretations, with transgender activists insisting that the ASPS is opposed to age-minimum laws and critics pointing to ASPS’s presumably deliberate choice of the words “criminal law or punitive legislative approaches.” At present, most states with age-minimum laws do not impose criminal penalties on providers that perform medical transition on minors.
The ASPS statement contains an important section on “shared responsibility in multidisciplinary care.” The responsibility of surgeons to assess patients for contraindications (reasons not to operate) and competence to consent came up recently in a detransitioner lawsuit, which resulted in a $2 million verdict against the providers. The surgeon in the case was found less liable than the psychologist (30 percent versus 70 percent) due to the former having not received the full information about the 16-year-old girl’s mental state from the latter, who in turn failed to obtain case notes from an LGBT center where the girl had been treated.
The timing of the ASPS statement is thus fortuitous, and the organization does not mince words: “plastic surgeons cannot rely on the presence of a prior medical intervention, referral, or letter of support as a proxy for surgical indication or adolescent readiness. Psychological and psychiatric assessments play an essential role in multidisciplinary care, but surgeons retain an independent professional responsibility to understand how uncertainty in diagnosis, natural history, and the effects of prior treatment may bear directly on surgical risk-benefit assessment.”
A key element in ASPS’s reasoning is the irreversibility of surgery, particularly in the context of very low-certainty evidence for benefit and more plausible evidence for potential harm. Surgeries are also inarguably the component of “gender-affirming care” that the lay public finds most shocking. Perhaps that is why even the Biden administration, in its last few months in office, agreed that surgeries should not be offered to minors.
But it is not only surgery that is irreversible. Puberty blockers, whether alone or in conjunction with cross-sex hormones, also have some known and some expected irreversible effects on physical appearance and on health. Most notably, when administered according to the Dutch Protocol, they can induce sterility.
Thus, one key question in the months ahead is this: If other medical groups or individual doctors who have endorsed pediatric medical transition agree with the ASPS on surgeries, on what grounds can they continue advocating for puberty blockers and cross-sex hormones, given that these interventions also have an unfavorable risk-benefit profile and are given to minors whose sense of self is still developing?
The new ASPS statement is a major step in the right direction, and one that undoubtedly required courage and integrity from the organization’s leaders. The ASPS is the professional association of leading figures in the world of gender medicine, including Loren Schechter, the incoming president of the World Professional Association for Transgender Health (WPATH). The hope is that leaders of other medical associations who see the same pattern of ideological capture in their own organizations can draw inspiration from their ASPS colleagues and take steps to restore public trust in medicine.
Photo by Wiktor Szymanowicz/Future Publishing via Getty Images