The American Society of Plastic Surgeons (ASPS), the largest professional association for plastic surgeons in the US has recommended that “gender-affirming surgery” be delayed until patients turn 19, because there is insufficient evidence that the benefits of breast, genital and facial surgery on minors experiencing gender dysphoria outweigh the risks.1
“Gender-affirming” surgery includes, in females, removal of breasts (double mastectomy); in males removal of testicles and inversion of penis to line a cavity to create a false vagina (vaginoplasty); in females, removal of tissues from, usually, the arm to create a false penis (phalloplasty), as well as facial surgery on both sexes to create masculine or feminine features more typical of the opposite sex.
According to an article published in the Journal of the American Medical Association (JAMA) 2, 3678 minors in the US aged 12 to 18 years received gender transition surgery, over 3000 of which were mastectomies on girls, between 2016 and 2020.
The ASPS position statement said:
“This position statement doesn’t seek to deny or minimize the reality of any patient’s distress, and it does not question the authenticity of any patient’s experience. Instead, 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.”
The ASPS statement says that gender-related surgical interventions depend on assumptions about the persistence of gender dysphoria over time, and there are currently no validated methods that allow clinicians to reliably distinguish children and adolescents whose distress will persist from those whose distress will resolve without medical or surgical intervention.
The ASPS explains that the ethical distinction between gender-related surgical interventions for minors (e.g., mastectomy, vaginoplasty) and other plastic surgical procedures occasionally performed on adolescents (e.g., breast reduction, gynecomastia surgery) is not explained by the level of evidence alone, but by the interaction between the uncertainty of the evidence and the ethical risk across several dimensions.
According to the position statement:
“gender-related surgery procedures intervene directly in the processes of identity formation and psychosexual development. These are areas of ongoing maturation during adolescence that warrant particular ethical caution as surgeons assess adolescent medical decision-making capacity.”
Gender-related surgical interventions carry profound and enduring consequences including impact on sexual function, psychosexual development, fertility and capacity to breast feed, and often create lifelong medical dependency.
The lack of evidence for benefit of these interventions was highlighted:
“When uncertainty concerns not just the magnitude of benefit but the existence of benefit in and of itself, and when potential harms are irreversible and identity-defining, the principles of beneficence and non-maleficence require a more precautionary approach.”
The statement cites many useful references including a systematic review of the evidence on mastectomy in gender dysphoric patients3; the 2025 report from the U.S. Department of Health and Human Services (HHS) titled Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices4; the UK Cass Review5,; international systematic reviews of evidence about youth gender transition interventions; research on neurocognitive6, psychosexual development, consent7 and decision making capacity in youth; and medical ethics8.
The statement is advisory and not a clinical guideline, the document notes, but is nevertheless very significant as it is the first medical organisation in the US to depart from the apparent consensus among US medical organisations about “gender-affirming” care of minors and urge caution due to lack of evidence of benefit and its failure to outweigh known risks.
The decision has relevance for the UK, not because gender surgeries are performed in minors in the UK, but because many of the ethical considerations of lack of evidence of benefit to balance the known harms apply to gender affirming surgeries in adults.
References
(this is a selection of relevant references, for full list see the ASPS position statement)
1 American Society of Plastic Surgeons. ASPS statement to press regarding gender surgery for adolescents. 2024 Aug 14. Available from: https://www.plasticsurgery.org/reconstructive-procedures/asps-statement-regarding-gender-surgery-for-adolescents
2 Dai D, Charlton BM, Boskey ER, Hughes LD, Hughto JMW, Orav EJ, Figueroa JF. Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US. JAMA Netw Open. 2024 Jun 3;7(6):e2418814. doi: 10.1001/jamanetworkopen.2024.18814. PMID: 38935380; PMCID: PMC11211955.
3 Miroshnychenko A, Roldan YM, Ibrahim S, Kulatunga-Moruzi C, Dahlin K, Montante S, et al. Mastectomy for individuals with gender dysphoria younger than 26 years: a systematic review and meta-analysis. Plast Reconstr Surg. 2025;155(6):915–23. doi:10.1097/PRS.0000000000011734. Epub 2024 Sep 10. PMID: 39252149.
4 U.S. Department of Health and Human Services. Treatment for pediatric gender dysphoria: review of evidence and best practices. [Internet]. Washington (DC): HHS; 2025 Nov. Available from: https://opa.hhs.gov/gender-dysphoria-repor5
5 Cass H. Independent review of gender identity services for children and young people: final report. 2024. Available from: https://webarchive.nationalarchives.gov.uk/ukgwa/20250310143933/https://cass.independent-review.uk/home/publications/final-report/
6 Baxendale S. The impact of suppressing puberty on neuropsychological function: a review. Acta Paediatr.2024;113:1156–67. doi:10.1111/apa.17150. PMID: 38334046.
7 Levine SB, Abbruzzese E, Mason JW. Reconsidering Informed Consent for Trans-Identified Children, Adoles-
cents, and Young Adults. J Sex Marital Ther. 2022;48(7):706-727. doi:10.1080/0092623X.2022.2046221. Epub
2022 Mar 17. PMID: 35300570.
8 Beauchamp TL, Childress JF. Principles of biomedical ethics 8th ed. New York (NY): Oxford University Press;
2019.