The American Society of Plastic Surgeons has become the first medical professional association in North America to come out and recommend against medical transitioning for minors.
On February 3rd, the Society issued a new position statement on gender surgery for children and adolescents. It’s nine pages long, but here is the main point:
“[Given] the overall evidence base for gender-related endocrine and surgical interventions is low certainty, and in light of recent publications reporting very low/low certainty of evidence regarding mental health outcomes, along with emerging concerns about potential long-term harms and the irreversible nature of surgical interventions in a developmentally vulnerable population, ASPS concludes there is insufficient evidence demonstrating a favorable risk-benefit ratio for the pathway of gender-related endocrine and surgical interventions in children and adolescents. ASPS recommends that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.“
Let’s break it down.
The ASPS recognizes that there isn’t much certainty around the outcomes of medically transitioning minors. It repeatedly cites the United Kingdom’s Cass Review and the United States’ Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices. One of the central findings of both reports, which reviewed all the available evidence, was that there is simply little to no high-quality evidence to assess medical transitioning for minors. What evidence is out there is of low certainty because of small sample sizes, bias, and other methodological errors
The plastic surgeons’ society also notes the long-term harms and irreversible nature of medical transitions. Of course, these are even more immediate with surgeries than with puberty blockers or cross-sex hormones. These surgeries remove healthy organs. Mastectomies cut away breasts. Hysterectomies remove the uterus. Orchidectomies destroy testes. Penectomies chop off penises. There is no way to replace these intricate organs. Plastic surgeons can insert prosthetics or graft skin to create structures that look like breasts or a penis, but they cannot function. These surgeries are irreversible.
The ASPS statement also mentions that minors are developmentally vulnerable. In other words, their brain and body are still developing. Most physical development continues into mid- to late-teens, but the brain isn’t fully mature until around age 25. Apart from physical developments, the position statement notes that a teenager’s identity development is complex and long-term. The body, the brain, and identity are all in flux during adolescence and childhood.
The harms of gender surgeries often outweigh the benefits for minors. The position statement notes that the “available evidence suggests that a substantial proportion of children with prepubertal onset gender dysphoria experience resolution or significant reduction of distress by the time they reach adulthood, absent medical or surgical intervention.” As we’ve noted elsewhere, that figure is 80-90%. Thus, most children and adolescents will obtain the desired benefit of surgery – alleviation of gender dysphoria – without undergoing surgery at all.
Now, some gender ideologues may object that gender surgeries are about more than treating gender dysphoria. Gender dysphoria aside, a person may have “embodiment goals” related to their gender identity, and they might demand that doctors help them achieve these goals.
But the American Society of Plastic Surgeons’ position statement addresses this argument. “Patient autonomy 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. In pediatric contexts, the threshold for intervention must be higher and safeguards more stringent.”
In other words, patient autonomy means doctors can’t force a patient to undergo a particular treatment. It does not mean that patients are entitled to whatever surgery they want. Unfortunately, that is what gender medicine has become. Doctors have become vending machines for puberty suppressants, hormones, and surgeries.
Given all that is known about gender surgeries, the ASPS recommends that no surgeon provide a gender surgery for anyone under 19.
The Association’s recommendation likely isn’t binding. If a plastic surgeon does a gender surgery on a minor in the United States, they likely won’t get in trouble with the ASPS. It only recommends not doing such surgeries, after all.
It’s a step that the Canadian Society of Plastic Surgeons still refuses to follow, though it did commit to taking a closer look at the evidence and publishing a formal position. In response to the ASPS’s lengthy position statement, the CSPS issued the following statement:
“The Canadian Society of Plastic Surgeons (CSPS) is aware of the recent position statement issued by the American Society of Plastic Surgeons (ASPS) regarding gender surgery for children and adolescents.
At present, the CSPS does not have a formal position statement on this issue. The CSPS respects the physician-patient relationship and supports the role of individual surgeons in providing care that is appropriate and ethical.
The CSPS is committed to clinical decision-making focused on evidence-based medicine such as, in this area of practice, information provided by the World Professional Association for Transgender Health (WPATH).
The CSPS plans to establish a working group of Canadian plastic surgeons with expertise in this area to review the evidence and assist in the preparation of a more formal position. The CSPS remains committed to supporting its members as they navigate complex and evolving areas of practice.”
The problem, of course, is that WPATH’s guidance is not evidence-based, as the CSPS statement implies. South of the border, the American Society of Plastic Surgeons isn’t alone in recognizing this. Soon after the ASPS released its position statement, the American Medical Association voiced its support for reserving any sex-denying surgeries until adulthood.
But that’s not the end of the recent news.
Jury finds medical malpractice in medical transitioning suit
Just a week earlier, a jury awarded a woman who had a double mastectomy in her teens a $2 million award against her surgeon and psychologist for medical malpractice in the case of Varian v. Einhorn.
The details of the case are scarce as the court documents are sealed (i.e. unavailable to the public). What is known is that the plaintiff in the case, Fox Varian, struggled with her identity as a woman beginning at age 15. She began binding her breasts, changed her name, and began publicly identifying herself as a man. She visited a psychologist – the Kenneth Einhorn named in the case – for help with her medical transition, though he had no formal training in transgender-related health care. He suggested puberty blockers as the first stop in her transition, but Varian wanted a top surgery. And so, nine months after first expressing her desire to surgically transition, Einhorn referred her for surgery.
However, Einhorn never diagnosed Varian with gender dysphoria, the prerequisite for a “gender-affirming” surgery according to WPATH’s standards of care. Instead, he diagnosed her with body dysmorphia, a fixation on a perceived flaw in one’s appearance. He wrote a referral for surgery despite Varian having confided in another counsellor that she was still unsure of her gender identity. Einhorn had recommended this counsellor – or at least their organization – but never bothered to communicate with this counsellor about what these counselling sessions revealed.
Einhorn also presented a classic line of argument to Varian’s mother, Claire: if Varian didn’t medically transition and get an “affirming” mastectomy, she was at risk of committing suicide. At first, Claire opposed the idea, but the psychologist was persistent and insistent. Eventually, in what was “the hardest, most difficult, gut-wrenching” decision, Claire (and presumably Varian) consented to the double mastectomy. However, they were never informed of the “the risks, hazards, and alternatives” of the surgery and her “other psychological conditions, including anorexia, depression, ADHD, autism, and body dysmorphia” were not properly addressed prior to the surgery.
And so Vivian underwent the gender surgery at the age of 16.
It didn’t take long for her to realize her mistake. She detransitioned and launched a lawsuit against both her psychologist and her surgeon, charging that they failed to obtain fully informed consent for the surgery. And this year, at the age of 22, a jury agreed and awarded her $2 million in damages.
Although there are many more such cases in the works, this is the first case in which a detransitioner successfully sued health care professionals who facilitated a hasty medical transition. It likely won’t be the last.
With the American federal government opposed to the practice, courts upholding state bans, medical professional bodies recommending against pediatric surgeries, and now health professionals being sued over these procedures, medical transitioning for minors is increasingly restricted in the United States.
Those minors are finally getting the protections that they need south of the border. Now Canada needs to follow suit.