Consensus shatters

America's surgeons lead the way towards a more cautious position on paediatric gender transition

Photo by Simon Maage on Unsplash

Put down the knife

The American Society of Plastic Surgeons (ASPS) has become the first major US medical association to adopt a cautious stance on paediatric gender medicine, citing the weak evidence base and potential long-term harm to young people.

In its new position statement, the ASPS recommends “that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.”

At least 5,200 American teenage girls had breasts surgically removed as part of a gender transition from 2017 to 2023, according to a Manhattan Institute analysis of insurance claims.

Last month, a young woman named Fox Varian was awarded $2 million in damages for the trans double mastectomy performed on her at age 16. Hers was the first claim by an American detransitioner to reach a jury verdict. There are 27 other known lawsuits filed by US detransitioners, according to journalist Benjamin Ryan.

“It’s so hard to face that you are disfigured for life. No amount of reconstruction is ever going to bring back what I lost.”—Fox Varian, The Free Press, 2 February 2026

It’s not just the surgery

The ASPS statement, issued on February 3 but officially approved on January 23, goes beyond surgery, stating that puberty blockers and cross-sex hormones also lack “a favourable risk-benefit ratio”, and highlighting the inability to predict which minors will see their gender dysphoria resolve naturally as they mature.

“[W]hen the likelihood of spontaneous resolution [of gender dysphoria] is unknown and when irreversible interventions carry known and plausible risks, adhering to the principles of beneficence and non-maleficence (i.e., promoting health and well-being while avoiding harm) requires a precautionary approach,” the ASPS statement says.

It also stresses the risks arising from the role of surgeons in the multidisciplinary treatment pathway beginning with social transition, blockers and hormones.

“Because the evidence base for this care pathway is [of low or very low] certainty and increasingly suggestive of potential harm and long-term complications, downstream surgical decision-making carries heightened ethical, clinical, and legal risk,” the statement says.

“Plastic surgeons should maintain a working understanding of the current limits of evidence regarding social transition, puberty suppression, and cross-sex hormones…”

In the absence of high-quality scientific evidence, gender clinicians and trans activists have made much of the appearance of consensus among major US medical associations in favour of the gender-affirming treatment approach. That consensus represents the activist capture of small policymaking committees, according to critics of gender ideology.

On February 3, however, the American Medical Association (AMA), a prominent promoter of “gender-affirming care”, reportedly shifted position on trans surgery.

In a statement to National Review, the AMA said “the evidence for gender-affirming surgical intervention in minors is insufficient for us to make a definitive statement … the AMA agrees with ASPS that surgical interventions in minors should be generally deferred to adulthood.”

“When the medical ethics textbooks of the future are written, they’ll look back on sex-rejecting procedures for minors the way we look back on lobotomies. I applaud the American Society of Plastic Surgeons for placing itself on the right side of history by opposing these dangerous, unscientific experiments.”—Centers for Medicare & Medicaid Administrator Dr Mehmet Oz, HHS statement, 3 February 2026

Unreliable guides

The gender-affirming approach is codified in guidelines from the World Professional Association for Transgender Health and the Endocrine Society, as well as a position statement from the American Academy of Pediatrics.

Unlike other medical associations, the ASPS had not endorsed those gender-affirming documents.

In its new statement, the ASPS notes these documents “did not meet accepted criteria for high-quality, trustworthy clinical practice guidelines” following a peer-reviewed evaluation of international guidelines commissioned by the UK Cass review.

The ASPS statement also acknowledges the influence of systematic reviews of the (low certainty) evidence for hormonal and surgical treatment of gender distress in minors, as well as the emergence of more cautious therapeutic policies in Finland and Sweden, plus the 2025 gender dysphoria report of the US Department of Health and Human Services (HHS).

In the domain of ethics, the ASPS statement challenges the activist claim that “patient values and preferences” and “emerging adolescent autonomy” can justify these medical interventions when the evidence base is poor.

“The patient education and informed consent process, which incorporates patient values and preferences and acknowledges emerging autonomy, operates within—not independently of—this evidentiary threshold,” the statement says.

“[Patient autonomy] 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.”

The ASPS statement also takes issue with the marketing of gender surgery as “lifesaving”.

“Because the best available evidence indicates suicide deaths are fortunately rare and the incremental impact of surgery on suicide prevention is unknown, ethical decision-making should not be driven by crisis claims. Instead, the ethically appropriate posture for plastic surgeons is greater caution,” the statement says.

“This is a thoughtful and highly professional document. Bravo to ASPS.”—Dr Stanley Goldfarb of Do No Harm, X/Twitter, 4 February 2026

A watershed

The Society for Evidence-based Gender Medicine (SEGM), a critic of the poorly evidenced gender-affirming model, welcomed the ASPS statement as “a watershed moment in US medicine”.

“ASPS is the first major American medical association to recommend against gender-related surgical interventions for patients under 19, including chest, genital, and facial procedures,” said SEGM co-founder Dr William Malone.

“This position recognizes serious gaps in foundational knowledge in the field, including the absence of reliable long-term evidence, as well as increasing indications of potential harm and lasting complications for minors from the entire ‘connected clinical pathway’ of gender-affirming care, including social transition, puberty blockers, and cross-sex hormones—and culminating with surgery.

“SEGM welcomes this call for heightened scrutiny, precaution, and medical self-correction, reflecting the growing recognition that irreversible interventions in adolescents demand far stronger evidence, clearer safeguards, and truly evidence-based clinical guidance.”

The Manhattan Institute’s Leor Sapir, a co-author of the HHS gender dysphoria report, said a key question in the months ahead would be whether new concern about trans surgery would also extend to blockers and hormones.

“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?” Sapir said.

He pointed out that prominent gender clinicians are among the membership of the ASPS, including plastic surgeon Loren Schechter, the incoming president of WPATH.

In Fox Varian’s medical negligence trial, Dr Schechter testified that “Surgery in and of itself is not a treatment or a mechanism to prevent suicide,” reported journalist Benjamin Ryan.

However, in a previous Florida case involving a minor seeking trans surgery, Dr Schechter gave evidence in 2022 that such surgery was “medically necessary” and that “the denial of necessary medical care is likely to perpetuate gender dysphoria and create or exacerbate other medical issues, such as depression and anxiety, leading to an increased possibility of self-harm, negative health outcomes, and even suicide.”¹

News of the Fox Varian damages award is reaching large audiences, with coverage in The New York Times, New York Post, The Free Press, The Epoch Times and Daily Mail. The new ASPS policy has been covered by The Washington Post, The New York Times, Reuters and The Hill.

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1. This inconsistency was picked up by MIT philosopher Alex Byrne, who was a co-author of the HHS gender dysphoria report.