The American Society of Plastic Surgeons (ASPS) is the first major American medical body to oppose gender-affirming surgeries for minors. This is not a political issue. It is a patient safety issue and falls under the ethical standards set forth in the Hippocratic oath often distilled as three words, “Do No Harm.”
ASPS issues its recommendations on the surgical treatment of Gender Dysphoria on the playground, Plastic Surgery use and prepubescent gender-dysphoric patients.
The decision is based on decades of plastic surgery practice. Plastic surgeons have always and continue to perform the majority of gender affirming surgery. They have a singularly unique perspective offered by their experiences. It should be noted this applies not only to people with gender dysphoria, but all people. For example, Plastic Surgeons do not perform Rhinoplasty for minors, because the anatomy is still changing and growing and the results are impaired by this. Since women develop faster than men, we wait for women to be 16-17 years-old and men 17-18 years-old to get the best reproducible results from their cosmetic nose surgery.
How Many Minors are Getting Gender Affirming Surgery
An article recently published in the Journal of the American Medical Association (JAMA) entitled: Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US gives us an idea, but it should be noted these are 2019 numbers, when only patients, loved ones, pediatricians, psychiatrists, plastic surgeons, ob/gyns and urologists were involved, and strict standards were the rule.
The study sample included over 47 million adults, and almost 23 million minors, of which almost 4 million minors (16.8%) were aged 15 – 17 years, almost 3 million (11.9%) were aged 13 – 14 years, and over 16 million (71.3%) were aged 12 years or younger. The rate of undergoing a gender-affirming surgery with a TGD-related diagnosis was 5.3 per 100,000 adults compared with 2.1 per 100,000 minors aged 15 – 17 years, 0.1 per 100,000 minors aged 13 – 14 years, and 0 procedures among minors aged 12 years or younger.
What Gender-Affirming Surgeries Were Performed?
Of gender-affirming surgical procedures identified among adults and minors, 1,591 of 2,664 (59.7%) and 82 of 85 (96.4%) were chest-related procedures, respectively. Of the 636 breast reductions among cisgender males, transgender and gender diverse adults, 507 (80%) were performed on cisgender males. Of the 151 breast reductions among cisgender male, transgender and gender diverse minors, 146 (97%) were performed on cisgender male minors.
In other words, in 2019, 1,073 adult and 5 minor transgender and gender diverse people had breast reduction. New diagnosis of gender dysphoria tripled in the US between 2017 and 2021. It should be noted all persons in the study had insurance coverage. The number of people paying out-of-pocket is not known.
Why Would Plastic Surgeons Oppose Something They Are Paid to Do?
A few years back, Aetna published their opinion that Breast Reduction for women had no proven benefit, because the data showing benefit came from self-serving doctors who get paid to do surgery. The reaction from surgeons and patients was swift, because my Breast Reduction patients are some of my happiest due to the pain relief it often provides. If you want to see the hoops Aetna makes their patients jump through for breast reduction insurance coverage they are available here.
Using the insurance industry’s logic, why would plastic surgeons come out against a procedure they get paid to do? It has to do with Dr. Hilary Cass. Dr. Cass is the Chair of the Independent Review of gender identity services for children and young people for the NHS England.
The National Health Service England’s Review
The NHS England Review was commissioned by NHS England to make recommendations on how to improve NHS gender identity services, and ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care that meets their needs, is safe, holistic and effective.
Dr. Cass’s final report states: For the majority of young people, a medical pathway may not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems. That’s how I was taught.
There are few longitudinal outcomes studies on the subject, and those that have been published have small numbers and large drop out rates. However, as of March, 2024, children with gender dysphoria will no longer receive puberty-suppressing hormones, also known as puberty blockers, as routine practice after an NHS England review concluded there was insufficient evidence for their safety and effectiveness. In other words, the harm outweighs the benefits.
ASPS is Fighting the Current for our Patients’ Safety
The ASPS’s decision sets it apart from other medical bodies, including the American Academy of Pediatrics and the American Medical Association, which support the procedures as medically necessary and safe. Maybe they’re more afraid of getting canceled than doing what is best for their patients?
The ASPS supports transgender patients’ constitutional protections and right to dignity, privacy and humane medical care. The subject of gender-dysphoria is complex and spans every medical disciple. A multi- disciplinary team including professionals, patients and their support is needed to help determine the best approach for the individual patient. When it comes to irreversible surgical intervention in minors, the evidence does not show that the benefits outweigh the risks. Offering intervention early is risky as patients are not physically or emotionally mature. In general, waiting a few years for the body to complete development provides safer, more predictable results.
This is true for cis-individuals also. Breast implants are rarely placed before 18-years of age. Exceptions are made on an individual basis. The same individual care should be applied to trans-individuals as well. Hormone blockers and surgery are not magical cures. They have significant downsides, and we must fully consider what is known and what is not known. Like all medical care, decisions must be tailored to the individual. Below is a copy of the full ASPS statement on gender-affirming care for minors:
- “ASPS has not endorsed any organization’s practice recommendations for the treatment of adolescents with gender dysphoria. ASPS currently understands that there is considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions for the treatment of adolescents with gender dysphoria, and the existing evidence base is viewed as low quality/low certainty. This patient population requires specific considerations.
- ASPS is reviewing and prioritizing several initiatives that best support evidence-based gender surgical care to provide guidance to plastic surgeons.
- As members of the multidisciplinary care team, plastic surgeons have a responsibility to provide comprehensive patient education and maintain a robust and evidence-based informed consent process, so patients and their families can set realistic expectations in the shared decision-making context.”