The Trump administration celebrated a recent statement from the American Society of Plastic Surgeons, which recommends that doctors delay gender-related surgery until a patient is at least 19 years old.
“Today marks another victory for biological truth in the Trump administration,” wrote Deputy Health and Human Services Secretary Jim O’Neill said in a press release. “The American Society of Plastic Surgeons has set the scientific and medical standard for all provider groups to follow.”
In an email to NPR, ASPS notes that the new position statement is not a reversal of a previous position. It is also not a new clinical practice guideline, but rather an articulation of the professional group’s recommendations “given the current state of the evidence and variability in legal and regulatory environments,” it says.
Pressure that’s working
That legal and regulatory environment is colored by 27 state bans and a White House aiming to end surgeries and all other types of gender-affirming care for minors across the country.
A week into his second term, President Trump signed an executive order declaring: “It is the policy of the United States that it will not fund, sponsor, promote, assist, or support the so-called ‘transition’ of a child from one sex to another, and it will rigorously enforce all laws that prohibit or limit these destructive and life-altering procedures.”
In the months since, HHS released a report critical of the research that supports access to this care and warned state Medicaid directors to tread carefully. The Department of Justice announced subpoenas of some children’s hospitals and threatened providers with prosecution.
In December, federal health officials proposed a rule that would withhold all Medicare and Medicaid funding from hospitals that provide gender-affirming care to children and teens. Even though it hasn’t been finalized, the specter that it will be, along with a deluge of investigations by the HHS Inspector General, has been shuttering hospital gender clinics all over the country.
Also this week, a patient won $2 million in a malpractice lawsuit against her plastic surgeon and psychologist in New York state after she had a mastectomy, or “top” surgery, as a minor and came to regret it.
The combined threat of malpractice lawsuits, state bans and hospitals ending gender programs, means that the options for transgender teenagers seeking surgery are dwindling, which is the White House’s stated goal.
One 15-year-old transgender boy in California tells NPR his plan to have top surgery is on hold since Kaiser Permanente health system stopped providing gender-affirming surgery to youth. “It’s not easy to do it out of pocket,” he says. NPR agreed not to name him because he fears for his safety.
He calls the new position from the plastic surgeons’ group “disappointing,” and points out that the Trump administration also recently sent warning letters to the makers of binders, a type of compression top that people can wear to flatten their chest. They are often used by transgender teens who can’t get or don’t want surgery.
“Which is crazy because it’s not like a binder is permanent. You can take it off anytime you want,” he says. “I was going to ask, ‘What do they want us to do?’ But I think the answer is to detransition.”
Surgery for teenagers
There’s no clear count of how many transgender teenagers have gender-affirming surgery. The full statement from the ASPS “recommends that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.” Gender surgery on people under 18 is rare, and most of the surgeries performed are top surgery.
The ASPS tells NPR the group does not gather data on precisely how many are performed. One study of a database of surgical procedures found an average of 800 top surgeries per year in patients aged 18 and younger between 2016-2020. State-level gender affirming care bans proliferated beginning in 2022, and it is unclear how the bans have affected how many transgender minors get top surgery.
Minors who are not transgender also have plastic surgery and face similar risks of complications and potential regret. In 2024, ASPS data shows that more than 9,000 girls aged 19 or younger had cosmetic breast surgery, and nearly 3,000 boys under age 19 had breast reduction surgery.
The ASPS position on breast augmentation for teenagers similarly recommends waiting until age 18 for surgery. “While both position statements address surgery in adolescents, the ethical considerations are not the same,” ASPS explained in an email to NPR. “Cosmetic procedures are generally not dependent on future identity development or long-term psychological trajectories.”
When it comes to gender-affirming surgery for transgender youth, ASPS added, “interventions are irreversible, expected benefits are uncertain, potential harms may be lifelong, and patients are minors with evolving preferences and identities who have been diagnosed with a condition of unknown stability.”
Years of waiting
A mom in California told NPR this week that her child came out to her as transgender when he was 13. She asked that NPR not use her name because she fears for her family’s safety. She says she was surprised and didn’t know much about trans issues when her son came out. “He got therapy. We got therapy. We reached out to different organizations, and over time, we’ve grown to understand better what it means.”
She says he wanted top surgery. “Like a lot of parents, the idea of doing this permanent surgery, even for us — we were really frightened to make the right decision, so we told him no,” she says. “And he tried, and we watched him trying, wearing binders and tape. After a while, it was just really hard to watch,” she says. For transgender boys who bind their chests, “it’s very painful — physically painful — trying to get their bodies to fit in a way that they can go out and just have a normal day.”
When her son turned 15, she and her husband finally agreed to look into top surgery.
“There are a lot of requirements — it’s not something you just go in and get — there is therapy, multiple meetings with different doctors,” she says. Their original surgery appointment was cancelled when the hospital got cold feet, so they had to scramble to get it rescheduled.
Her son is now 17, he had surgery two years ago, and she says he’s really blossomed. “My only regret is that we couldn’t have done it sooner,” she says. “To think that other kids who might need this — there’s so few kids that do need this — to think they have to just live in a shell and put their lives on pause is so unfair and makes me so angry and so sad.”
No sea change among other medical groups
In the wake of ASPS’s position statement and the Trump administration’s promotion of it, there have been conflicting reports about the American Medical Association’s position, and whether medical groups, which have long supported gender-affirming care, were shifting that stance.
AMA told NPR in a statement: “The AMA supports evidence-based treatment, including gender affirming care,” and added that, based on available evidence, “surgical interventions in minors should be generally deferred to adulthood.” AMA says that’s not a reversal or an endorsement of the plastic surgeon group’s new position, it’s a clarification of the group’s existing position.
Similarly, the American Academy of Pediatrics sent NPR a statement that the group “does not include a blanket recommendation for surgery for minors” and that the decision should be left to doctors and patients and their families, not politicians.
In fact, the ASPS recommendation to wait until age 19 for surgery aligns with the existing standards of care for transgender youth, which “recommend that patients reach the age of adulthood, which may vary based on where that [transgender] person lives or is seeking care, to be a candidate for gender-affirming surgery.”
When Kellan Baker of the LGBTQ think tank Movement Advancement Project read the ASPS position, it struck him as nothing new. “I’m looking at this and I’m like, ‘OK, thank you for telling me that water is wet and the sky is blue,'” he says.
Baker argues that it works to the Trump administration’s advantage to frame this as a landmark shift of the medical community towards more restrictions, without acknowledging the political pressure that the Trump administration itself has been exerting to achieve such an outcome.
