Silent treatment

How WPATH went quiet when asked about the evidence. Plus, an argument for raising the minimum age for transgender surgery

Photo by Kristina Flour on Unsplash

The gist

A good argument can be made for setting 26—roughly the age of cognitive maturity—as the minimum age for transgender surgery, according to a prominent American plastic surgeon.

Dr Scot Glasberg, a past president of the American Society of Plastic Surgeons (ASPS) and its research arm the Plastic Surgery Foundation, made the remark on July 5 at a London conference on “Rethinking Youth Gender Medicine”.

An attendee had questioned whether the society’s minimum age of 19 for gender surgery failed to protect distressed young adults, particularly those with autism or ADHD, who could be “profoundly vulnerable”.¹

Dr Glasberg said “a cogent argument” could be made for adopting 26 as a minimum age—the point at which the brain is fully developed—and in any event, trans surgery above 19 also required good evidence.²

On 3 February 2026, the ASPS became the first major American medical association to adopt a policy advising against the gender medicalisation of adolescents. After researching the issue, the society had found the evidence base to be of low quality and insufficient to demonstrate a favourable risk:benefit ratio.

“We don’t seek to minimise what these children are going through,” Dr Glasberg told the London conference on Sunday. “We believe that it’s real [distress] ... We just don’t necessarily believe that surgery is the best course of action, given the evidence.”³

Advocates for puberty blockers, cross-sex hormones and trans surgery sidestep the weak evidence base by appealing to the combined authority of “every major medical association” endorsing gender-affirming care.

Hence the title of Dr Glasberg’s talk—“Breaking the mould: How ASPS decided to follow the evidence”—at the July 5 session of the conference hosted by the Society for Evidence-based Gender Medicine (SEGM) and the Clinical Advisory Network on Sex and Gender.⁴

Dr Glasberg revealed details of the ASPS process culminating in the decision to follow the evidence and recommend that members “delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old”.

He said there was “silence for a year, no response, no emails, no phone calls, nothing” after the society contacted the World Professional Association for Transgender Health in 2021 in an effort to understand the methodology behind WPATH’s Standards of Care.

“ASPS made repeated formal outreach attempts seeking collaborative dialogue [with WPATH] on the evidence base [including a] specific request for methodology tables,” he said.

He asked why “a reputable organisation”—one that claimed to follow evidence—would “not want to show us their methodology tables?”⁵

WPATH ultimately told the society it could not discuss its methodology because of legal proceedings involving its 2022 eighth edition Standards of Care.⁶

In 2024, as Dr Glasberg recalled, court documents showed that WPATH had “buried” systematic reviews of evidence because the results did not favour confident gender-affirming medical treatment.

At the London conference, he invoked a recent Finnish registry study, which showed an increase in the need for specialist psychiatric care after medical transition.

Dr Glasberg said this study was important because it highlighted the risk that “it actually could be worse for these children” post-transition. “I thought, this is pretty telling.”

He suggested that Nordic countries such as Finland and Sweden were “10 years ahead of the US” in the gender field, and the ASPS’s more cautious position statement was not so much a break with American medical policy as a case of following the Nordic lead. He also cited the independent evidence assessment undertaken during the 2020-24 UK Cass review.

“ASPS aligned with the world’s best evidence, not US institutional inertia,” Dr Glasberg said.

The detail

Dr Glasberg said a fast-growing segment of his New York City practice involved seeing detransitioners unable to find care elsewhere, although it was “impossible” to reverse genital surgery.

Just as gender-affirming care had called for “multi-specialist groups”, so too detransitioners needed access to this kind of comprehensive health service, he said.

At the London conference, he said the closest parallel to trans surgery was frontal lobotomy.

“We’re talking about, potentially, [trans] surgical procedures and medical interventions, which we’re unable to find safety on. The best comparison is actually frontal lobotomy, right?” he said.

He was responding to a comment from an audience member that gender medicine, abortion and euthanasia were all unusual in attracting heated demonstrations, with the explosive elements being “religion and sex”.

Dr Glasberg said he believed religion was a distraction from the evidence-based focus of the paediatric transition debate. He suggested the argument for stopping under-19 trans surgery was the same for lobotomies—“there was no evidence to show that [these interventions] were of any benefit, and we were harming people in the process”.

He also emphasised the limitations and risks of trans genital surgery.

“We’re not really making a penis, we’re making a phallus,” he said. “We’re not really making a functional vagina—other than urination, that’s the one thing that we can do. But in terms of sexual function and things like that, I wouldn’t even begin to know where to assess that, because we’re not truly making a functional organ.”

Dr Glasberg cited a lack of data for “overall sexual well-being” after surgery. He had been asked a question about whether there was any data or long-term follow-up “on sexual function, sensation, orgasm, strictures, any endocrine problems that those people may have”.

With genital or “bottom” surgery, he said, “fistulas and things like that are incredibly common, and there are some studies now [showing] up to 50 per cent morbidity on bottom surgeries, and that’s pretty significant. A lot of it tracks with whether or not the patient has gotten endocrine therapy leading [into surgery].”

The ASPS policy did note in passing that hormonal treatment, like surgical interventions, suffered from a weak evidence base. The ASPS statement highlights “substantial uncertainty” about the long-term benefits of puberty blockers and cross-sex hormones.

“We didn’t call it out in our [policy] recommendation, because that’s not our expertise, but we would be foolish not to admit to the fact that we saw the same low-certainty, low-quality [evidence] in the endocrine world,” he said.

In the 2010s and early 2020s, he said, medical associations were “deferring to” a gender-affirming consensus. Although that consensus “wasn’t based on any kind of evidence”, the evidence for hormonal and surgical responses to gender distress in minors was “treated as settled”.

Dr Glasberg characterised his conference presentation as “a humbling talk, to be honest with you”. Prior to 2022, his own society’s position on paediatric trans surgery was “basically non-existent”.

But the society knew this surgery “was really taking off and continuing to exponentially grow”, and so began a process of examination and policymaking. And gender surgeons themselves, presumably not expecting a cautious approach, had asked the society for a policy statement and guidelines.

As the society worked towards its 2026 policy, it decided to advise its members to be cautious.

“We told our surgeons that they had a responsibility to evaluate [gender] patients from a mental standpoint. We do that with every other surgery. Why are we different [in the gender field]? Why are we simply relying on something that we get from a psychiatrist or a psychologist?” Dr Glasberg said.

“In the United States, you can go online and order a letter for your gender-affirming evaluation/mental health evaluation by answering a few questions,” he said.

In October 2024, as president of the Plastic Surgery Foundation, Dr Glasberg decided to convene a panel talk including a prominent gender surgeon and UK paediatrician Dr Hilary Cass, whose gender dysphoria review found the evidence for hormonal treatment of minors to be “remarkably weak”.

Dr Glasberg said the inclusion of Dr Cass “created a huge stir” and he had cancelled the panel, describing this as a postponement. “I regret that decision … I sort of caved to the pressure, and shouldn’t have.”

In early 2025, the society created a Gender Surgery Task Force—inviting people from WPATH and non-members such as psychiatrists—to test whether a consensus was possible.

However, the presence of non-members meant this task force “was never to set policy” for the ASPS. (Some task force members complained of not being consulted over the new position statement.)

With the release of the new policy, Dr Glasberg and his colleagues were “excited” and thought other medical associations might follow their example.

The American Medical Association (AMA) did make a statement that appeared to endorse the society’s new restrictive advice.

On 4 February 2026, the AMA said in a statement that because “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”.

The statement seemed to be “hedging”, Dr Glasberg said. “And for the last five months [the AMA have] done nothing but try to pull back on that [apparent agreement].”

And his own society itself came under attack.

“The fact that we’ve been called out on this [policy] is quite alarming to me. Isn’t that what we do every single day in medicine? … we decide the risk:benefit ratio for our patients.”

He said the media “attacks” included claims—

that Dr Glasberg was “driving this whole statement”, whereas he was no longer on the society board when it voted for the new policy;

that the new policy was a capitulation to the Trump Administration, which seeks to shut down paediatric medical transition;

that Dr Mehmet Oz, administrator of the US Centers for Medicare and Medicaid Services, had somehow pressured the society to act;

that many members within the society disagreed with the policy.

Dr Glasberg said a petition against the new position statement was signed by 350 surgeons, but the total membership was 9,000 in the US.

“I’m not suggesting that everyone agrees with the [policy] statement, but there’s 8,650 surgeons that decided not to sign the [petition] because they were all approached in an email chain,” he said.

Back then, Dr Glasberg defended the position statement on CNN as the result of “an iterative process that took time, with no outside pressure”.

On the society’s board there was apprehension about “mass resignations”. Letters were coming in with threats to resign. “To date, as of yesterday, we’ve had one resignation.”

Dr Glasberg said he was getting frequent inquiries from other medical associations “trying to figure out” how the ASPS had manoeuvred into a cautious position.

“Obviously, I say, follow the evidence. I wish it were that simple, because there’s politics in all of these organisations. And so, I’ve said … let me speak to them. I’ve had a few that have reached out.

“As leaders of [medical] societies, we owe it to our patients to … follow the evidence, politics aside, personal opinions aside, even things like religion aside,” Dr Glasberg said.

He recited the standard arguments used to support business as usual in the gender medicine field.

There was the claim that trans surgery was being held to a higher standard than breast reduction surgery or cosmetic rhinoplasty.⁷

“[Unlike trans surgery] we have great evidence on … both the physical and psychological benefits of a breast reduction,” he said.

“And I’m not promising anybody who gets a rhinoplasty at 16 [that] I’m going to either stop their suicidal ideation or help their mental health.

“In addition, no insurance is paying for [a rhinoplasty], they’re paying out of pocket, which incredibly changes the dynamic.”

As for not intruding on shared decision-making by surgeon and patient, this did not allow treatment indifferent to the evidence base.

Nor did doctors have to follow every request of a patient. “I had a patient come in; he asked me to shave off his fingerprints. Could I do it? Sure. Did it make sense medically? No. Did I do it? Absolutely not.”⁸

Dr Glasberg quoted an observation attributed to the philosopher Arthur Schopenhauer: “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.”

Dr Glasberg: “I’m hopeful that we are entering this last phase soon.”

1. Dr Glasberg said the minimum age of 19 was chosen because it marked the end of adolescence according to agencies such as the World Health Organisation and the American Academy of Pediatrics.

“Prefrontal cortex maturation continues into early 20s; executive function, identity stability, and risk assessment still developing at 18,” according to Dr Glasberg’s presentation slide.

2. At odds with growing concerns about vulnerable young adults, the Australian Society of Plastic Surgeons has a live application before the Federal Government for multiple taxpayer-funded trans surgeries, including risky genital procedures with high rates of complications, from age 18 with no requirement to show the distress of gender dysphoria; gender incongruence is enough. This application returns to the Medical Services Advisory Committee when it meets on 8-9 October 2026.

3. In its position statement, 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”.

4. Dr Glasberg cited as key sources of evidence the UK Cass review, the Gender Dysphoria Report commissioned by the US Department of Health and Human Services, and a McMaster University systematic review of trans mastectomy, a study commissioned by SEGM.

He said these reviews drew consistent conclusions—“Not just the uncertain magnitude of benefit, but also the uncertain existence of benefit. Emerging evidence of harm. Long-term outcome data largely absent.”

5. The revelations of WPATH’s scientific misconduct, documented in depositions for a lawsuit against Alabama’s restrictions of paediatric medical transition, have been followed by a Federal Trade Commission complaint against WPATH for enabling “medical providers to make false and unsubstantiated claims to parents in order to sell pediatric medical transition services”.

6. Referring to a recent settlement of a detransitioner’s lawsuit in February 2026, Dr Glasberg noted the defendant surgeon’s claim in the case that the WPATH “Standards of Care” did not represent the standard of care to be applied by the court. “Well, how does that work?” Dr Glasberg said. “Because everybody I know, both surgeon and otherwise, is depending upon WPATH [when making treatment] decisions.”

7. “ASPS reasoning: gender-related interventions carry lifelong medical dependency and foreclose developmental pathways; the natural history of the presenting condition [of gender dysphoria] remains uncertain, unlike cosmetic procedures.

“On the cosmetic surgery comparison (‘but you do breast reductions on 17-year-olds’): cosmetic procedures do not depend on predicting future identity development; gender-related interventions do—the ethical distinction is principled, not arbitrary,” according to Dr Glasberg’s presentation slide.

8. “In this debate, ‘shared decision-making’ and ‘patient autonomy’ are deployed not to describe medicine, but to argue that physicians must provide whatever care is requested. Autonomy was conceived as the right to refuse care, not to compel a physician to provide it.

“Shared decision-making operates within, not independently of, an evidentiary threshold. When benefit is very-low certainty and harm is irreversible and lifelong, the physician’s non-maleficence obligation cannot be delegated away by invoking patient preference,” according to Dr Glasberg’s presentation slide.