The American Society of Plastic Surgeons Rejects Adolescent Gender Surgery and Raises Serious Concerns Regarding All Minor Gender Transitions
ASPS Position Statement: gender surgery for minors fails the evidence test.
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About SEGM
SEGM's mission is to promote evidence-based principles in the field of youth gender medicine. Our objectives include critically appraising primary studies, translating, analyzing, and disseminating international practice guidelines and society position statements, and, importantly, developing new quality systematic reviews of evidence in partnership with major research universities. In addition to evaluating the endocrine and surgical intervention pathways (known as “gender-affirming care”), we support the development of non-invasive approaches for the care of young people with gender dysphoria.
In a watershed moment, on February 3, 2026, the American Society of Plastic Surgeons (ASPS) issued an official position statement recommending that a key step of “gender-affirming” care—surgical intervention—be delayed until the patient is “at least 19 years old.” The recommendation against performing gender-affirming procedures in minors extends to all types of gender-related surgeries, including breast/chest, genital, and facial surgeries. However, the ASPS statement goes much farther than merely advising surgeons to delay surgery. It raises serious evidentiary and ethical concerns about the entire gender-affirming treatment pathway for youth, including social transition, puberty blockers, and cross-sex hormones.
Currently, an estimated 1,000 or more mastectomies for minors reporting gender dysphoria are performed annually in the United States. The announcement by ASPS is likely to upend this practice. ASPS is a major medical organization, representing over 90 percent of all plastic surgeons in the U.S., and is the primary specialty performing mastectomies. However, ASPS’s broader conclusion that all gender-transition interventions in minors share similarly problematic risk-benefit profiles is likely to be even more consequential in its ability to influence clinical practice and policy across the field in the months and years ahead.
The 2026 ASPS position statement warrants careful reading by clinicians, researchers, policymakers, and others concerned with pediatric care and evidence-based medicine. Below, we distill its central conclusions.
1. The evidence base for youth gender transition is highly questionable
Health benefits of gender-affirming interventions in youth are highly uncertain. ASPS points out that not only the magnitude of possible health benefits of medical and surgical “gender-affirming” interventions is in question—but the very existence of any such benefits is uncertain. It notes consistent findings of uncertain benefits from several recent systematic reviews of evidence—including the mastectomy review published in the ASPS official journal. It also references the U.K. Cass Review, and the HHS Evidence Review, in addition to several other international evidence appraisal initiatives.
There is emerging evidence of harms of pediatric transition. ASPS goes beyond acknowledging the very low certainty of benefits of youth transitions and explicitly highlights emerging evidence of harm. Notably, its discussion of potentially harmful practices is not limited to surgical interventions, but also includes endocrine treatments (puberty blockers and cross-sex hormones). ASPS explicitly acknowledges detransition and regret in its statement and draws attention to the lack of long-term outcome data as a key evidentiary gap.
The risk-benefit ratio for all endocrine and surgical interventions is problematic. ASPS concludes that “there is insufficient evidence demonstrating a favorable risk-benefit ratio for the pathway of gender-related endocrine and surgical interventions in children and adolescents.”
None of the current U.S. treatment guidelines are trustworthy. ASPS notes that it has not endorsed any treatment guidelines for the care of gender dysphoric adolescents in the United States, and that none of the current guidelines and guidance documents are considered trustworthy for implementation. These include clinical guidance from WPATH, the Endocrine Society, or the American Academy of Pediatrics—all of which are poorly rated.
2. All transition steps form a connected clinical pathway with cumulative risk
Treatment effects cannot be disaggregated. ASPS points out that as the continuum of care progresses from social transition and puberty blockers to cross-sex hormones and surgery, the risks and uncertainties inherent at each stage become interdependent and cumulative.
Surgery is the final phase of a single “gender-affirming” clinical pathway with the greatest compounded risk. ASPS warns, “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.”
Each treating physician bears independent responsibility for the overall treatment outcome. ASPS advises its members not to rely on mental health referral letters and not to treat prior endocrine interventions as a proxy for determining that surgery is indicated. Instead, each provider of gender-transition interventions must conduct their own independent assessment of medical appropriateness and adolescent capacity to consent.
3. Youth gender transitions currently operate outside medico-ethical norms
Youth gender transitions are currently an outlier medical treatment. ASPS notes that gender dysphoria/gender incongruence is the only diagnosis where treatment indications for irreversible procedures are entirely “dependent on predicting future identity development or evolving embodiment goals.” It notes that the stability of the diagnosis at the population level is unknown, and that clinicians cannot predict the future for any individual child or adolescent. Further, ASPS points out that the interventions themselves may alter the course of adolescent identity development, including identity formation and psychosocial development, which compound the uncertainties, risks, and ethical challenges.
Focusing on appearance satisfaction rather than health outcomes is inconsistent with the goals of medicine. ASPS rejects claims by some proponents of gender transitions that the goal of treatments is to merely help patients meet their embodiment goals. ASPS’s position statement reinforces the standard medical premise that treatments should improve health outcomes—not simply improve satisfaction. It notes, for example, that adolescent breast reductions are only performed when there is an expectation of health benefit, which is required for the procedures to be reimbursable by insurance.
The “suicide narrative” and other crisis-based justifications for gender transitions are unacceptable. ASPS decries attempts to position gender-affirming interventions as “lifesaving” or to claim that delaying or withholding them leads to suicide—claims that are contradicted by the evidence. It notes that the only appropriate stance when it comes to demand for pediatric transitions, especially when they are justified by crisis claims, is even greater caution and more stringent safeguards.
4. Drawing false equivalences with established medical practices is misguided
Gender-related surgeries are not comparable to other plastic procedures. ASPS draws a clear distinction between gender-related surgeries in minors and other plastic procedures sometimes done in adolescence, such as breast reduction or gynecomastia surgery. In ASPS’s view, breast reduction and gynecomastia surgery usually address clear physical problems (pain, functional limitation, or distress tied to a physical condition), and the reason for surgery does not depend on predicting how a young person’s identity or long-term goals will develop. By contrast, ASPS argues that gender-related surgeries in minors are typically justified mainly by expected psychological or social benefits, even though the long-term evidence is uncertain and the procedures can have permanent effects on fertility, sexual function, and future medical needs—so the ethical threshold for proceeding should be higher.
Providing youth gender transitions based on “very low” certainty of benefits is inconsistent with medical ethics. ASPS notes that although reliance on very low/low certainty evidence is not uncommon in medicine, ethical permissibility turns on “the relationship between evidence uncertainty, anticipated benefit, potential harms, and patient vulnerability.” ASPS calls out misguided evidentiary ethical analyses by the advocates for youth gender transitions (including the Yale-based “Integrity Project referenced by ASPS) and stresses that when interventions are irreversible, the existence of the benefits is uncertain, harms may be lifelong, and minors’ identities are still developing, the precautionary principle must apply.
5. Standard bioethical principles cannot be ignored
Standard bioethical principles apply. ASPS invokes “established principles of biomedical ethics” that “dictate that physicians should offer interventions only when there is a reasonable expectation that anticipated benefits outweigh potential harms.” Irreversible procedures such surgery should not be provided to minors.
Patient autonomy and preferences alone do not justify treatment. ASPS observes that patient autonomy is best understood as the right to accept or refuse a clinically appropriate intervention, and this “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.” It also notes that patient “values and preferences” (an important concept in evidence-based medicine) have not been studied in this area of medicine. Therefore, it is unclear whether fully informed patients and families would agree with the Endocrine Society‘s ethical framing for gender-related treatments that explicitly puts a higher value on achieving enhanced cosmetic outcomes, and a lower value on avoiding medical harm. ASPS asserts that informed consent by patients resides within an evidence framework—not outside it.
Respect for patient dignity does not equate with provision of a specific treatment. ASPS affirms respect for the human dignity of individuals who identify as transgender and/or suffer from gender dysphoria. It clarifies, however, that “recognition of patient dignity is not contingent upon pursuit of a specific clinical pathway.”
ASPS Position
On the basis of all these points, ASPS “recommends that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.”
Potential implications
There are several key implications of the ASPS 2026 statement, which we briefly outline below:
The HHS Evidence Review has been accepted as valid and foundational by a major US medical association. ASPS endorses the HHS Evidence Review, directing its members to Appendix 4 “which details the types of interventions (medical, surgical, psychological), reported outcomes, magnitude and direction of effects, and overall certainty of evidence available in the published literature.” It also endorses the HHS Review’s ethics analysis, emphasizing that for adolescents, the precautionary principle should apply. The ASPS notes, “when the likelihood of spontaneous resolution 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.”
Physicians might begin to distance themselves from “gender-affirming” interventions. Until recently, the refrain that “every major medical association supports” pediatric gender transition may have discouraged individual clinicians from reexamining the evidence. A high-profile dissent from the specialty society tied to a key part of the clinical pathway is likely to signal to busy physicians—who may not have time to read lengthy evidence reviews—that pediatric gender transition is a contested area of practice. At the same time, clinicians who wish to continue to practice pediatric gender-affirming surgery may distance themselves from ASPS or other mainstream medical organizations.
Medical malpractice litigation may face fewer barriers. ASPS bluntly warns that surgery in minors carries elevated ethical, clinical, and legal risk, and that surgeons remain personally responsible for indication and informed consent—not protected by letters or protocols. Because specialty-society guidance shapes standards of care for hospitals, insurers, and courts, ASPS’s recommendation to defer surgery under 19 will likely intensify scrutiny of clinicians who continue operating on minors—especially given its view that WPATH, Endocrine Society, and AAP guidance is not sufficiently reliable. A recent New York jury award of $2 million in a malpractice case over a mastectomy at 16 underscores the growing legal focus on consent and documentation.
Insurers will likely reassess policies in light of rising risk. Given ASPS’s strong stance against surgery in minors—and its emphasis on interdependent, cumulative risks—both liability and health insurers may respond. Malpractice carriers could raise premiums as legal exposure increases, while health insurers may revisit medical-necessity criteria for surgeries and tighten oversight of endocrine interventions.
Other major medical associations may have to revisit their positions. By emphasizing that “gender-affirming” interventions are interconnected and cumulative, ASPS forces organizations to either align with its evidentiary and ethical reasoning—or reject it and articulate an alternative framework. The American Medical Association has already signaled movement, stating it agrees with ASPS in that surgery in minors should generally be deferred to adulthood. Next, the American Psychiatric Association and American Psychological Association will face scrutiny, since their members routinely provide transition referral letters—sometimes with minimal or no assessment. It remains unclear to what extent organizations like the Endocrine Society and the American Academy of Pediatrics, which have strongly endorsed these treatments, will be able to adjust.
Researchers may reconsider study designs. Several initiatives (including the UK PATHWAYS trial) treat each step of medical transition as a separate intervention. ASPS’s emphasis that the treatment should be viewed as an interconnected pathway—with benefits and risks that compound across steps—may push researchers to redesign studies to better assess the cumulative effects of the overall “gender-affirming” approach.
Vulnerable young adults may be better protected. Although ASPS limited its guidance to minors, its wording of “at least 19 years old,” along with its decisional framework—linking ethical permissibility of poorly-evidenced interventions to anticipated harm-benefit ratio and patient vulnerability—may prompt greater caution with patients in their 20s as well. Because the evidence base for adolescents and young adults is similarly weak, and their vulnerabilities often overlap due to ongoing brain development and a similarly high burden of mental health comorbidities (as the Cass Review notes), young adults could face a higher threshold for irreversible interventions and closer scrutiny of medical necessity.
SEGM Take-Away
It is no accident that plastic surgeons are the first professional association to take a strong stance against a key intervention in the “gender-affirming” care pathway for youth.
First, unlike endocrine interventions, where changes unfold gradually and the extent of irreversibility may only become clear over time, surgery is universally understood as irreversible from the outset. When the risk–benefit ratio is unfavorable, surgeons have no gray area to retreat into—they must decide whether to operate.
Second, because surgery is typically the final step in the transition pathway, surgeons inherit the cumulative risks and uncertainties of the upstream interventions. That vantage point likely contributed to why the professional association representing plastic surgeons was among the first to recognize the full scope of the problem.
Third, and importantly, plastic surgery is unusual among medical specialties in routinely providing both elective cosmetic procedures and medically necessary care. This positions plastic surgeons to distinguish between interventions that are medically indicated and those that may primarily offer patient satisfaction without improving health outcomes.
The ASPS statement on pediatric gender transition adopts an evidence-based stance in its evaluation of pediatric surgery, as such procedures have been historically asserted to be “medically necessary.” ASPS points out key foundational gaps in knowledge about adolescent gender-related distress, analyzing them through the lens of evidence-based medicine. It points out the unknown natural course of the condition absent medical and surgical interventions (i.e., “natural history”); the unclear stability of the diagnosis of gender dysphoria/gender incongruence; and the very low/low certainty of evidence for the treatment outcomes, especially in the long term. While the evidence base is highly uncertain, ASPS warns that it is “increasingly suggestive of potential harm and long-term complications” of gender-affirming interventions for minors.
The medical establishment’s gradual self-correction—reflected in ASPS’s change in position—is precisely what SEGM has advocated for since our inception. SEGM is proud to have supported this shift through focused work since 2019. We were the first organization to report that Finland broke with WPATH and issued far more cautious recommendations, and we were the organization that translated the full Finland’s PALKO/COHERE recommendations, cited by ASPS, for the English-speaking world. Finland’s full-length guidelines were the first document in the world to recognize pediatric gender transition as an “experimental practice.” We are also proud to have commissioned key independent North American systematic reviews of the evidence, including the mastectomy systematic review and meta-analysis from McMaster University, published in Plastic and Reconstructive Surgery—ASPS’s official journal—which ASPS also references as part of the basis for its decision.
Some will likely frame ASPS’s shift as a defensive reaction to recent litigation or political pressures. However, ASPS began signaling a more cautious approach in the wake of the Cass Review and has progressively indicated an intent to align practice with the best available evidence. It is our sincere hope that other medical organizations follow suit, and demonstrate to the public their willingness to move forward in a way that aligned practice with medical evidence and ethics in order to protect vulnerable youth from harm.
This article was originally published on the Society for Evidence-Based Gender Medicine’s website on February 5, 2026.
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Impossible to overstate just how momentous this moment is...and how welcome.
Myself, I think insurance companies may well decide this matter. If insurers jack up premiums on malpractice coverage to surgeons who perform these procedures, or even deny coverage altogether, lots of these providers will rethink their position.
(Having said this, I believe the "yeet the teats" surgeon in Florida does not carry malpractice insurance to prevent getting herself in a box. Without access to the deep pockets of an insurance provider, who'd bother to sue her?)
Remarkable. Clearly they are trying to resurrect the reputation of their branch of medicine.