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Mia Hughes: Major U.S. medical groups take science-based approach to 'gender-affirming' care

Statements against such surgeries in youths are a welcome breath of fresh air

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Recently, two major American medical groups endorsed age restrictions on gender-related surgeries, marking a dramatic shift in a debate long dominated by claims of consensus. First, the American Society of Plastic Surgeons (ASPS) issued a policy statement firmly opposing “gender-affirming” surgeries for people under 19. Then, the American Medical Association (AMA) signalled its support. These pivots deal a significant blow to Canadian activists and politicians who rely on the supposed professional consensus to defend these highly contested, unproven treatments for youth.

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The ASPS, the professional association that represents the majority of plastic surgeons in the U.S. and Canada, now recommends that “surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.” The group cites the numerous systematic reviews conducted in recent years that have all found only low to very low quality evidence to support these interventions. This development is highly relevant for Canada, given that national data confirms that these surgeries have already been performed on hundreds of minors.

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After more than a decade of the field of pediatric gender medicine being guided by ideological narratives, the nine-page ASPS statement is a veritable breath of fresh air — a much-needed return to respect for evidence-based medicine, developmental science and the traditional ethical principles of beneficence (promoting health) and non-maleficence (avoiding harm). It’s a timely one, too, coming just days after a jury in New York State awarded a young woman $2 million in damages for a “gender-affirming” mastectomy performed on her as a teenager, which she said left her disfigured. Other malpractice cases of this kind are currently moving through U.S. courts.

Noting that the “natural course of pediatric gender dysphoria remains poorly understood,” with evidence suggesting that a “substantial portion” of young people who experience gender dysphoria will “experience resolution or significant reduction of distress by the time they reach adulthood, absent medical or surgical intervention,” the ASPS advises a “precautionary approach,” given the irreversible nature and known risks of “gender affirming” surgeries.

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The policy statement also reaches beyond surgery, urging surgeons to “maintain a working understanding of the current limits of evidence regarding social transition, puberty suppression and cross-sex hormones.” In a field that involves a cascade of increasingly invasive interventions, this matters: research shows that social transitioning (a change of name and pronouns) commonly leads to puberty suppression, and puberty suppression in turn locks in gender distress, with most patients then progressing to cross-sex hormones.

Therefore, the ASPS reminds members that “diagnostic assessment, psychosocial support, endocrine intervention and surgery form a connected clinical pathway rather than a series of independent steps. Outcomes observed after surgery cannot be confidently attributed to surgery itself rather than to prior medical treatment, psychosocial factors or the natural trajectory of the condition. As a result, surgical interventions inherit the foundational uncertainties present earlier in the continuum of care.”

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Importantly, the ASPS statement draws a sharp distinction between breast reduction or gynecomastia surgery (to reduce enlarged male breast tissue), which treat physical conditions, and “gender-affirming” mastectomies or breast implants, which rest on predicting future identity and shifting “embodiment goals.”

It urges much greater caution for trans-identified youth, noting that genuine informed consent requires not just understanding a diagnosis and the surgical risks, but engaging in complex, long-term, identity-linked decision-making — precisely the domains still under “ongoing maturation” in adolescence.

The statement is also refreshingly clear on ethics. Traditionally, autonomy means a patient may accept or refuse appropriate treatment; in “gender-affirming care,” it has been warped to mean patients can request any treatment and doctors must comply. The ASPS statement explains how respect for autonomy does not mean that a patient can demand surgeries for which there is no favourable risk/benefit profile, “particularly in adolescent populations where decision-making capabilities are still developing.”

In a press release the day after the ASPS statement was published, the American Medical Association said that the evidence for “gender-affirming” surgeries for youth is “insufficient” and “the AMA agrees with ASPS that surgical interventions in minors should be generally deferred to adulthood.” The AMA had previously supported such procedures for young people.

And with that, the flimsy consensus supporting pediatric gender medicine collapsed.

To be sure, this moment was long overdue. In 2024, the U.K.’s Cass report revealed that this supposed consensus had been manufactured by the World Professional Association for Transgender Health and the Endocrine Society, which created the illusion of scientific agreement, despite a total absence of credible evidence. Their guidelines were copied by medical associations around the world, triggering a deluge of policy statements endorsing this drastic treatment protocol for healthy youth. That tangled web of empty endorsements is now finally beginning to unravel.

Undoubtedly, this course correction will be difficult. Innocent young people have been, and continue to be, harmed because every major medical association abandoned scientific and ethical principles, instead allowing small activist committees to craft policy based on ideology rather than evidence. This resulted in a cascade of confusion, with governments, media, well-meaning citizens and, worst of all, parents of trans-identified youth trusting that the experts were relying on solid science when they were not.

The truth is that wilful blindness has always been the essential ingredient in this scandal. It can only continue as long as everyone agrees not to look too closely. Nowhere is that more evident than in Canada, where, aside from Alberta, the experiment marches on unabated. When Canadian medical associations finally find the courage to do what the ASPS has done and subject this protocol to genuine scientific scrutiny, there will be only one possible conclusion: it cannot be allowed to continue.

Mia Hughes specializes in researching pediatric gender medicine, psychiatric epidemics, social contagion and the intersection of trans rights and women’s rights. She is the author of “The WPATH Files,” a senior fellow at the Macdonald-Laurier Institute and director of Genspect Canada.

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