gender reassignment surgery on minors

Young Children Do Not Receive Medical Gender Transition Treatment

By Kate Yandell

Posted on May 22, 2023

SciCheck Digest

Families seeking information from a health care provider about a young child’s gender identity may have their questions answered or receive counseling. Some posts share a misleading claim that toddlers are being “transitioned.” To be clear, prepubescent children are not offered transition surgery or drugs.

Some children  identify  with a gender that does not match their sex assigned at birth. These children are referred to as transgender, gender-diverse or gender-expansive. Doctors will listen to children and their family members, offer information, and in some cases connect them with mental health care, if needed.

But for children who have not yet started puberty, there are  no recommended  drugs, surgeries or other gender-transition treatments.

Recent social media  posts   shared  the misleading  claim  that medical institutions in North Carolina are “transitioning toddlers,” which they called an “experimental treatment.” The posts referenced a  blog post  published by the Education First Alliance, a conservative nonprofit in North Carolina that says  many schools are engaging in “ideological indoctrination” of children and need to be reformed.

The group has advocated the passage of a North Carolina bill  to restrict medical gender-transition treatment before age 18. There are now  18 states  that have taken action to restrict  medical transition treatments  for  minors .

A widely shared  article  from the Epoch Times citing the blog post bore the false headline: “‘Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges.” The Epoch Times has a history of publishing misleading or false claims. The article on transgender toddlers then disappeared from the website, and the Epoch Times published a new  article  clarifying that young children are not receiving hormone blockers, cross-sex hormones or surgery. 

Representatives from all three North Carolina institutions referenced in the social media posts told us via emailed statements that they do not offer surgeries or other transition treatments to toddlers.

East Carolina University, May 5: ECU Health does not offer gender affirming surgery to minors nor does the health system offer gender affirming transition care to toddlers.

ECU Health elaborated that it does not offer puberty blockers and only offers hormone therapy after puberty “in limited cases,” as recommended in national guidelines and with parental or guardian consent. It also said that it offers interdisciplinary gender-affirming primary care for LGBTQ+ patients, including access to services such as mental health care, nutrition and social work.

“These primary care services are available to any LGBTQ+ patient who needs care. ECU Health does not provide gender-related care to patients 2 to 4 years old or any toddler period,” ECU said.

University of North Carolina, May 12: To be clear: UNC Health does not offer any gender-transitioning care for toddlers. We do not perform any gender care surgical procedures or medical interventions on toddlers. Also, we are not conducting any gender care research or clinical trials involving children. If a toddler’s parent(s) has concerns or questions about their child’s gender, a primary care provider would certainly listen to them, but would never recommend gender treatment for a toddler. Gender surgery can be performed on anyone 18 years old or older .

Duke Health, May 12: Duke Health has provided high-quality, compassionate, and evidence-based gender care to both adolescents and adults for many years. Care decisions are made by patients, families and their providers and are both age-appropriate and adherent to national and international guidelines. Under these professional guidelines and in accordance with accepted medical standards, hormone therapies are explicitly not provided to children prior to puberty and gender-affirming surgeries are, except in exceedingly rare circumstances, only performed after age 18.

Duke and UNC both called the claims that they offer gender-transition care to toddlers false, and ECU referred to the “intentional spreading of dangerous misinformation online.”

Nor do other medical institutions offer gender-affirming drug treatment or surgery to toddlers, clinical psychologist  Christy Olezeski , director of the Yale Pediatric Gender Program, told us, although some may offer support to families of young children or connect them with mental health care. 

The Education First Alliance post also states that a doctor “can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.” But simply playing with a certain toy would not meet the criteria for a diagnosis of gender dysphoria, according to the medical diagnostic manual used by health professionals.

“With all kids, we want them to feel comfortable and confident in who they are. We want them to feel comfortable and confident in how they like to express themselves. We want them to be safe,” Olezeski said. “So all of these tenets are taken into consideration when providing care for children. There is no medical care that happens prior to puberty.”

Medical Transition Starts During Adolescence or Later 

The Education First Alliance blog post does not clearly state what it means when it says North Carolina institutions are “transitioning toddlers.” It refers to treatment and hormone therapy without clarifying the age at which it is offered. 

Only in the final section of the piece does it include a quote from a doctor correctly stating that children are not offered surgery or drugs before puberty.

To spell out the reality of the situation: The North Carolina institutions are not providing surgeries or hormone therapy to prepubescent children, nor is this standard practice in any part of the country.

Programs and physicians will have different policies, but widely referenced guidance from the  World Professional Association for Transgender Health  and the  Endocrine Society  lays out recommended care at different ages. 

Drugs that suppress puberty are the first medical treatment that may be offered to a transgender minor, the guidelines say. Children may be offered drugs to suppress puberty beginning when breast buds appear or testicles increase to a certain volume, typically happening between ages 8 to 13 or 9 to 14, respectively.

Generally, someone may start gender-affirming hormone therapy in early adolescence or later, the American Academy for Pediatrics  explains . The Endocrine Society says that adolescents typically have the mental capacity to participate in making an informed decision about gender-affirming hormone therapy by age 16.

Older adolescents who want flat chests may sometimes be able to get surgery to remove their breasts, also known as top surgery, Olezeski said. They sometimes desire to do this before college. Guidelines  do not offer  a  specific age  during adolescence when this type of surgery may be appropriate. Instead, they explain how a care team can assess adolescents on a case-by-case basis.

A previous  version  of the WPATH guidelines did not recommend genital surgery until adulthood, but the most recent version, published in September 2022, is  less specific  about an age limit. Rather, it explains various criteria to determine whether someone who desires surgery should be offered it, including a person’s emotional and cognitive maturity level and whether they have been on hormone therapy for at least a year.

The Endocrine Society similarly offers criteria for when someone might be ready for genital surgery, but specifies that surgeries involving removing the testicles, ovaries or uterus should not happen before age 18.

“Typically any sort of genital-affirming surgeries still are happening at 18 or later,” Olezeski said.

There are no comprehensive statistics on the number of gender-affirming surgeries performed in the U.S., but according to an insurance claims  analysis  from Reuters and Komodo Health Inc., 776 minors with a diagnosis of gender dysphoria had breast removal surgeries and 56 had genital surgeries from 2019 to 2021.

Research Shows Benefits of Affirming Gender Identity

Young children do not get medical transition treatment, but they do have feelings about their gender and can benefit from support from those around them. “Children start to have a sense of their own gender identity between the ages of 2 1/2 to 3 years old,” Olezeski said.

Programs vary in what age groups they serve, she said, but some do support families of preschool-aged children by answering questions or providing mental health care.

Transgender children are at increased risk of some mental health problems, including anxiety and depression. According to the WPATH guidelines, affirming a child’s gender through day-to-day changes — also known as social transition — may have a positive impact on a child’s mental health. Social transition “may look different for every individual,” Olezeski said. Changes could include going by a different name or pronouns or altering one’s attire or hair style.

Two studies of socially transitioned children — including one with kids as young as 3 — have found minimal or no difference in anxiety and depression compared with non-transgender siblings or other children of similar ages.

“Research substantiates that children who are prepubertal and assert an identity of [transgender and gender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance,” the AAP  guidelines  say, adding that differences in how children identify and express their gender are normal.

Social transitions largely take place outside of medical institutions, led by the child and supported by their family members and others around them. However, a family with questions about their child’s gender or social transition may be able to get information from their pediatrician or another medical provider, Olezeski said.

Although not available everywhere, specialized programs may be particularly prepared to offer care to a gender-diverse child and their family, she said. A child may get a referral to one of these programs from a pediatrician, another specialty physician, a mental health care professional or their school, or a parent may seek out one of these programs.

“We have created a space where parents can come with their youth when they’re young to ask questions about how to best support their child: what to do if they have questions, how to get support, what do we know about the best research in terms of how to allow kids space to explore their identity, to explore how they like to express themselves, and then if they do identify as trans or nonbinary, how to support the parents and the youth in that,” Olezeski said of specialized programs. Parents benefit from the support, and then the children also benefit from support from their parents. 

WPATH  says  that the child should be the one to initiate a social transition by expressing a “strong desire or need” for it after consistently articulating an identity that does not match their sex assigned at birth. A health care provider can then help the family explore benefits and risks. A child simply playing with certain toys, dressing a certain way or enjoying certain activities is not a sign they would benefit from a social transition, the guidelines state.

Previously, assertions children made about their gender were seen as “possibly true” and support was often withheld until an age when identity was believed to become fixed, the AAP guidelines explain. But “more robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the guidelines say.

Mental Health Care Benefits

A gender-diverse child or their family members may benefit from a referral to a psychologist or other mental health professional. However, being transgender or gender-diverse is not in itself a mental health disorder, according to the  American Psychological Association ,  WPATH and other expert groups . These organizations also note that people who are transgender or gender-diverse do not all experience mental health problems or distress about their gender. 

Psychological therapy is not meant to change a child’s gender identity, the WPATH guidelines  say . 

The form of therapy a child or a family might receive will depend on their particular needs, Olezeski said. For instance, a young child might receive play-based therapy, since play is how children “work out different things in their life,” she said. A parent might work on strategies to better support their child.

One mental health diagnosis that some gender-diverse people may receive is  gender dysphoria . There is  disagreement  about how useful such a diagnosis is, and receiving such a diagnosis does not necessarily mean someone will decide to undergo a transition, whether social or medical.

UNC Health told us in an email that a gender dysphoria diagnosis “is rarely used” for children.

Very few gender-expansive kids have dysphoria, the spokesperson said. “ Gender expansion in childhood is not Gender Dysphoria ,” UNC added, attributing the explanation to psychiatric staff (emphasis is UNC’s). “The psychiatric team’s goal is to provide good mental health care and manage safety—this means trying to protect against abuse and bullying and to support families.”

Social media posts incorrectly claim that toddlers are being diagnosed with gender dysphoria based on what toys they play with. One post  said : “Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!!”

There are separate criteria for diagnosing gender dysphoria in adults and adolescents versus children, according to the Diagnostic and Statistical Manual of Mental Disorders. For children to receive this diagnosis, they must meet six of eight criteria for a six-month period and experience “clinically significant distress” or impairment in functioning, according to the diagnostic manual. 

A “strong preference for the toys, games or activities stereotypically used or engaged in by the other gender” is one criterion, but children must also meet other criteria, and expressing a strong desire to be another gender or insisting that they are another gender is required.

“People liking to play with different things or liking to wear a diverse set of clothes does not mean that somebody has gender dysphoria,” Olezeski said. “That just means that kids have a breadth of things that they can play with and ways that they can act and things that they can wear . ”

Editor’s note: SciCheck’s articles providing accurate health information and correcting health misinformation are made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation.

Rafferty, Jason. “ Gender-Diverse & Transgender Children .” HealthyChildren.org. Updated 8 Jun 2022.

Coleman, E. et al. “ Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 .” International Journal of Transgender Health. 15 Sep 2022.

Rachmuth, Sloan. “ Transgender Toddlers Treated at Duke, UNC, and ECU .” Education First Alliance. 1 May 2023.

North Carolina General Assembly. “ Senate Bill 639, Youth Health Protection Act .” (as introduced 5 Apr 2023).

Putka, Sophie et al. “ These States Have Banned Youth Gender-Affirming Care .” Medpage Today. Updated 17 May 2023.

Davis, Elliott Jr. “ States That Have Restricted Gender-Affirming Care for Trans Youth in 2023 .” U.S. News & World Report. Updated 17 May 2023.

Montgomery, David and Goodman, J. David. “ Texas Legislature Bans Transgender Medical Care for Children .” New York Times. 17 May 2023.

Ji, Sayer. ‘ Transgender’ Toddlers as Young as 2 Undergoing Mutilation/Sterilization by NC Medical System, Journalist Alleges .” Epoch Times. Internet Archive, Wayback Machine. Archived 6 May 2023.

McDonald, Jessica. “ COVID-19 Vaccines Reduce, Not Increase, Risk of Stillbirth .” FactCheck.org. 9 Nov 2022.

Jaramillo, Catalina. “ Posts Distort Questionable Study on COVID-19 Vaccination and EMS Calls .” FactCheck.org. 15 June 2022.

Spencer, Saranac Hale. “ Social Media Posts Misrepresent FDA’s COVID-19 Vaccine Safety Research .” FactCheck.org. 23 Dec 2022.

Jaramillo, Catalina. “ WHO ‘Pandemic Treaty’ Draft Reaffirms Nations’ Sovereignty to Dictate Health Policy .” FactCheck.org. 2 Mar 2023.

McCormick Sanchez, Darlene. “ IN-DEPTH: North Carolina Medical Schools See Children as Young as Toddlers for Gender Dysphoria .” The Epoch Times. 8 May 2023.

ECU health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

UNC Health spokesperson. Emails with FactCheck.org. 12 May 2023 and 19 May 2023.

Duke Health spokesperson. Email with FactCheck.org. 12 May 2023.

Olezeski, Christy. Interview with FactCheck.org. 16 May 2023.

Hembree, Wylie C. et al. “ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline .” The Journal of Clinical Endocrinology and Metabolism. 1 Nov 2017.

Emmanuel, Mickey and Bokor, Brooke R. “ Tanner Stages .” StatPearls. Updated 11 Dec 2022.

Rafferty, Jason et al. “ Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents .” Pediatrics. 17 Sep 2018.

Coleman, E. et al. “ Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 .” International Journal of Transgenderism. 27 Aug 2012.

Durwood, Lily et al. “ Mental Health and Self-Worth in Socially Transitioned Transgender Youth .” Journal of the American Academy of Child and Adolescent Psychiatry. 27 Nov 2016.

Olson, Kristina R. et al. “ Mental Health of Transgender Children Who Are Supported in Their Identities .” Pediatrics. 26 Feb 2016.

“ Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression .” American Psychological Association website. 9 Mar 2023.

“ What is Gender Dysphoria ?” American Psychiatric Association website. Updated Aug 2022.

Vanessa Marie | Truth Seeker (indivisible.mama). “ Three medical schools in North Carolina are diagnosing TODDLERS who play with stereotypically opposite gender toys as having GENDER DYSPHORIA and are beginning to transition them!! … ” Instagram. 7 May 2023.

Database: More than 13,000 gender reassignment procedures on minors between 2019 and 2023

40% were performed in just four states: california, new york, washington and ohio.

Sex reassignment procedures and surgeries on children have gained national prominence in recent years, and half of U.S. states now have laws passed either restricting or banning them.

Newly released data provided by the nonprofit Do No Harm indicates that the number of procedures overall has increased since at least 2019.

While many of those procedures from 2019 through 2023 occurred in states known for championing the right of juveniles to have irreversible medical procedures done even without parental knowledge or consent, such as California and Washington, some states that have since placed restrictions or outright bans on the procedures also have some of the highest numbers.

According to Do No Harm, between 2019 and 2023, there were at least 13,394 gender reassignment procedures nationwide on individuals 17.5 years old or younger, with the youngest 7 years old. 

“Procedures” are defined as either the use of puberty or hormone blockers, or gender reassignment surgeries such as mastectomies and penile reconstruction. The organization reports that of those, there were 4,160 breast removal procedures on minors and 660 phalloplasty procedures.

Do No Harm Director of Programs Michelle Havrilla said in a statement that "body modification surgeries such as so-called vaginoplasties and phalloplasties are irreversible. The majority of these patients will end up with life-long complications related to these procedures."

Phalloplasty is a complex surgery that involves constructing or reconstructing a penis using other skin parts, according to John Hopkins Medicine, while in vaginoplasties, "tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva."

"Phalloplasties carry uncertain long-term health risks; these may include fistulas, chronic infection, the need for a colostomy, atrophy, and complete loss of sensation, sexual or otherwise," Havrilla said.

Do No Harm is a nonprofit group of physicians and other medical professionals that gets its name from the Hippocratic oath: "First, do no harm." According to its website, Do No Harm is "fighting to curtail the unscientific and individually harmful practice of so-called 'gender affirming care'" for children.

“'Gender-affirming care' is based on the dangerous premise that any child who has distress that he or she thinks is related to their sex should automatically be treated with social transition to the sex of their choice followed by hormonal interventions and then possibly surgery to remove healthy body parts," it says. "Underlying mental health problems are usually not addressed."

According to Do No Harm's data, 2022 was the highest year for every state except for one when it came to the number of puberty or hormone blockers prescribed; the outlier was Alabama, which had 10 in both 2022 and 2023. 

When it came to the total number of transgender surgeries on minors, 21 out of 50 states had increases from 2022 to 2023.

Surgeries in California — which recorded the most gender reassignment procedures during the time period — dropped from 344 to 266 between 2022-23, while the number in Washington fell from 90 to 67 during the same time period. 

Nationwide, 42 states had higher puberty or hormone blocker prescriptions given to minors in 2023 than 2019, while 31 states had a higher number of surgeries in 2023 compared to 2019.

Do No Harm says its data was obtained through a variety of sources including “claims clearinghouses, data aggregators, payors, health systems, CMS, and multiple open data sources. The final product includes data from commercial insurance, Medicaid, Medicare, and VA claims.” Do No Harm says it was conservative when counting the number of procedures on children; if there was any doubt whether a procedure involved sex reassignment on a minor, it was excluded.

Of those procedures involving a minor, almost 40% were performed in just four states — California, New York, Washington, and Ohio. California had the highest number of total procedures at 2,083.

California was not among the top 10 states for procedures per capita, however. While Ohio ranked fourth in total procedures (1,020), it also ranked seventh in procedures per capita, at one per 11,568 residents. California’s per capita was one procedure per 18,981 residents, which was less than New Hampshire’s one per 10,678 residents.

Washington ranked third for both total procedures performed (1,082) and the number of procedures per capita, at one procedure per 7,121 residents.

The state with the highest gender reassignment procedure rate per capita was Oregon, which had 899 procedures but with a population of 4.2 million constituted one procedure per 4,713 residents. Hawaii, with a population of 1.46 million and 15 procedures, had the lowest rate at one procedure per 291,054 residents.

Though it ranked eighth for the number of total procedures (718), Massachusetts medical centers billed the third most for gender reassignment procedures on minors at $10 million. That's compared to $7 million in total charges in Washington, which had 364 more procedures. New York billed $19 million, while California medical providers billed the most at $29 million.

Although states such as Montana and Alabama enacted bans on those procedures in 2022, and Arkansas in 2021, Do No Harm’s data shows that all three states continued to have medical providers billing for these procedures into 2023.

Ohio now has a ban on gender reassignment surgery and hormone blockers. That law passed in January, beyond the scope of Do No Harm’s data timeframe. The law was upheld by a judge in August. Before the law went into effect, hospitals in Ohio treated 1,004 minors, including 224 surgeries.

Do No Harm also published a new database listing the hospitals where these procedures were conducted the most. According to Do No Harm's database, called "Does my hospital transition kids?", the hospitals where the most sex reassignment procedures and surgeries on children were conducted were at the Children's Hospital of Philadelphia, Connecticut Children's Medical Center, Children's Minnesota, Seattle Children's, and Children's Hospital Los Angeles.

The database, which is searchable by state, lists 225 hospitals where such procedures have occurred.

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States are banning gender-affirming care for minors. What does that mean for patients and providers?

More than 20 u.s. states have banned or severely limited treatment to align a young person’s body with their gender identity. that leaves some doctors caught between breaking the law and providing what they say can be lifesaving medical care..

The impact on providers

Legislation restricting GAC can have serious consequences for providers as well, including being deemed a felon in five states .

And such laws are unnecessary, some physicians argue, since mechanisms — including malpractice lawsuits and review by state medical licensing boards — already exist to sanction doctors who fail to meet accepted standards of care. “Unless states are going to legislate every aspect of medicine, I don’t see why we need laws specifically around this,” says Toby Smith*, MD, who provides GAC in a state that restricts it.

The laws also can be confusing and can require extensive — and rapid — contact with institutions’ lawyers to understand and avoid breaching them.

Even if a proposed piece of legislation doesn’t pass, its initiation can throw physicians into a flurry of preparatory activity.

Part of the work entails determining how to communicate with patients and the public. In some states, that includes crafting careful messaging so as to not risk the ire of legislators responsible for funding — or not funding — state hospital systems.

Scott recalls the painful process of telling families about care that would end. “We had to have these conversations over and over. Parents and kids were brought to tears. Staff were brought to tears,” she says.

“It was terrifying to think people in my building could have something happen to them because of the treatment we provide.” Deanna Adkins, MD Duke Health

The laws also bring fear into doctors’ offices. For one, there is worry over “secret shoppers,” people posing as families seeking care who instead aim to catch doctors they think are breaking the law.

The fear extends beyond landing in legal trouble, says Adkins.

“After the legislation was proposed, we immediately saw social media attacks against providers... Some groups put up billboards with doctors’ faces on them.”

“We also had some people using threatening language toward our clinic,” Adkins adds. “It was terrifying to think people in my building could have something happen to them because of the treatment we provide.”

Working to support patients

In states that restrict or ban GAC for minors, providers have been working to help patients as best they can.

At Scott’s clinic, that meant calling roughly 300 people when her state passed legislation in 2023. “We contacted every patient so they wouldn’t have to make a sometimes four-hour drive just to be told all we could do is provide information about out-of-state options,” she says.

At Adkins’ clinic, staff rushed to add appointments for new patients in the time — seven weeks — between the law’s passage and its effective date so as to leverage its “grandfather” clause allowing patients already receiving GAC to continue doing so. Because the legislation prohibited Medicaid coverage of GAC for minors, staff also helped some grandfathered patients apply for nonprofit grants and hospital charity care.

Another goal has been expediting out-of-state treatment for patients. At Duke Health, staff have been performing such preliminary steps as the physical and psychological assessments necessary for GAC, which are not illegal.

But connecting patients to out-of-state care isn’t simple. Waitlists are sometimes months or even years long. And in eight states , making such connections could be deemed aiding and abetting a crime, according to a Kaiser Family Foundation analysis.

Providers are also working to help those patients who are required to ease off GAC medication. Scott provides an example: “When someone who identifies as male ceases puberty blockers, their menstrual periods will start again, which can cause a lot of dysphoria. So we discuss birth control and other ways to stop periods.”

But sometimes all a doctor can do is explain what to expect as prescribed hormones subside. “For those patients, it’s just a matter of waiting anxiously until they turn 18,” Scott says.

Some providers worry that even that option will wither as GAC opponents work to expand restrictions. Bills prohibiting GAC medical care for young people up to age 26 have been introduced in at least four states in the past year.

As all this unfolds, supporters of GAC are pushing back in court. Plaintiffs in 16 states have challenged laws and policies limiting GAC for minors with some success . The Biden administration also has asked the Supreme Court to weigh in.

Meanwhile, the temptation to move to a more “friendly” state is real, but many providers, including Kroll, say they’ll stay as long as their young patients need them.

“Whenever you’re doing any kind of care that is under political attack, there’s always a risk-benefit balance,” he says. “Leaving a hostile place would be easier, but I want to try to do as much good as possible for as many of the people here who need me.”

*Several individuals in this article requested anonymity to protect themselves, their families, or their institutions from personal or political retribution.

July 8, 2024—A new study by researchers at Harvard T.H. Chan School of Public Health found little to no utilization of gender-affirming surgeries by transgender and gender-diverse (TGD) minors in the U.S. The study also found that cisgender minors and adults had substantially higher utilization of analogous gender-affirming surgeries than their TGD counterparts.

The study was published on June 27 in JAMA Network Open. According to the researchers, it is the first quantitative comparison of gender-affirming surgery utilization between cisgender and TGD populations.

Previous research has consistently demonstrated that gender-affirming care for TGD people can be lifesaving in mitigating negative mental health outcomes such as depression, anxiety, and suicidality. Data has been limited, however, around the rates at which TGD youth are undergoing gender-affirming care, including surgery. Despite this uncertainty, in recent years, twenty-five states have banned gender-affirming care for TGD minors. This fall, the Supreme Court will rule on whether such bans are constitutional.

In the context of this lack of data—and this contentious political climate—the researchers used the most recently available data from a 2019 nationally representative pool of medical insurance claims to identify individuals who received a gender-affirming surgery with a concurrent TGD-related diagnosis. Cases where patients had any other medical indications for surgery outside of gender-affirmation, such as breast cancer, were excluded from the analysis. The researchers also compared the relative use of breast reductions by cisgender men and TGD people. Breast reduction surgery was chosen as a point of comparison given that it is the only gender-affirming surgery that is commonly covered by insurance for minors and adults.

The study found no gender-affirming surgeries performed on TGD youth ages 12 and younger in 2019. This was expected, the researchers said, as current international guidelines do not suggest any medical or surgical intervention for TGD individuals prior to puberty. For teens ages 15 to 17 and adults ages 18 and older, the rate of undergoing gender-affirming surgery with a TGD-related diagnosis was 2.1 per 100,000 and 5.3 per 100,000, respectively. A majority of these surgeries were chest surgeries. When considering use of gender-affirming breast reductions among cisgender males and TGD people, the study found that cisgender males accounted for the vast majority of breast reductions, with 80% of surgeries among adults performed on cisgender men and 97% of surgeries among minors performed on cisgender male teens.

“We found that gender-affirming surgeries are rarely performed for transgender minors, suggesting that U.S. surgeons are appropriately following international guidelines around assessment and care,” said co-author Elizabeth Boskey , instructor in the Department of Social and Behavioral Sciences .

Lead author Dannie Dai, research data analyst in the Department of Health Policy and Management , added, “Our findings suggest that legislation blocking gender-affirming care among TGD youth is not about protecting children, but is rooted in bias and stigma against TGD identities and seeks to address a perceived problem that does not actually exist.”

The authors noted limitations to the study, including its reliance on diagnostic and procedure codes in claims data to determine clinical justifications for surgery and the TGD or cisgender identity of patients. Their analyses also did not capture self-paid surgeries.

— Maya Brownstein

Photo: iStock/nito100

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Biden Officials Pushed to Remove Age Limits for Trans Surgery, Documents Show

Newly released emails from an influential group issuing transgender medical guidelines indicate that U.S. health officials lobbied to remove age minimums for surgery in minors because of concerns over political fallout.

By Azeen Ghorayshi

Health officials in the Biden administration pressed an international group of medical experts to remove age limits for adolescent surgeries from guidelines for care of transgender minors, according to newly unsealed court documents.

Age minimums, officials feared, could fuel growing political opposition to such treatments.

Email excerpts from members of the World Professional Association for Transgender Health recount how staff for Adm. Rachel Levine, assistant secretary for health at the Department of Health and Human Services and herself a transgender woman, urged them to drop the proposed limits from the group’s guidelines and apparently succeeded.

If and when teenagers should be allowed to undergo transgender treatments and surgeries has become a raging debate within the political world. Opponents say teenagers are too young to make such decisions, but supporters including an array of medical experts posit that young people with gender dysphoria face depression and worsening distress if their issues go unaddressed.

In the United States, setting age limits was controversial from the start.

The draft guidelines, released in late 2021, recommended lowering the age minimums to 14 for hormonal treatments, 15 for mastectomies, 16 for breast augmentation or facial surgeries, and 17 for genital surgeries or hysterectomies.

The proposed age limits were eliminated in the final guidelines outlining standards of care , spurring concerns within the international group and with outside experts as to why the age proposals had vanished.

The email excerpts released this week shed light on possible reasons for those guideline changes, and highlight Admiral Levine’s role as a top point person on transgender issues in the Biden administration. The excerpts are legal filings in a federal lawsuit challenging Alabama’s ban on gender-affirming care.

One excerpt from an unnamed member of the WPATH guideline development group recalled a conversation with Sarah Boateng, then serving as Admiral Levine’s chief of staff: “She is confident, based on the rhetoric she is hearing in D.C., and from what we have already seen, that these specific listings of ages, under 18, will result in devastating legislation for trans care. She wonders if the specific ages can be taken out.”

Another email stated that Admiral Levine “was very concerned that having ages (mainly for surgery) will affect access to care for trans youth and maybe adults, too. Apparently the situation in the U.S.A. is terrible and she and the Biden administration worried that having ages in the document will make matters worse. She asked us to remove them.”

The excerpts were filed by James Cantor, a psychologist and longstanding critic of gender treatments for minors, who used them as evidence that the international advisory group, referred to as WPATH, was making decisions based on politics, not science, in developing the guidelines.

The emails wer e part of a report he submitted in support of Alabama’s ban on transgender medical care for minors. No emails from Admiral Levine’s staff were released. Plaintiffs are seeking to bar Dr. Cantor from giving testimony in the case, claiming that he lacks expertise and that his opinions are irrelevant.

Admiral Levine and the Department of Health and Human Services did not respond to requests for comment, citing pending litigation.

Dr. Cantor said he filed the report to expose the contents of the group’s internal emails obtained by subpoena in the case, most of which remain under seal because of a protective order. “What’s being told to the public is totally different from WPATH’s discussions in private,” he said.

Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the president of WPATH, rejected that claim. “It wasn’t political, the politics were already evident,” said Dr. Bowers. “WPATH doesn’t look at politics when making a decision.”

In other emails released this week, some WPATH members voiced their disagreement with the proposed changes. “If our concern is with legislation (which I don’t think it should be — we should be basing this on science and expert consensus if we’re being ethical) wouldn’t including the ages be helpful?” one member wrote. “I need someone to explain to me how taking out the ages will help in the fight against the conservative anti-trans agenda.”

The international expert group ultimately removed the age minimums in its eighth edition of the standards of care, released in September 2022. The guidelines reflected the first update in a decade and were the first version of the standards to include a dedicated chapter on medical treatment of transgender adolescents.

The field of gender transition care for adolescents is relatively new and evidence on long-term outcomes is scarce. Most transgender adolescents who receive medical interventions in the United States are prescribed puberty blocking drugs or hormones, not surgeries.

But as the number of young people seeking such treatments has soared, prominent clinicians worldwide have disagreed on issues such as the ideal timing and criteria for the medical interventions. Several countries in Europe, including Sweden and Britain, have recently placed new restrictions on gender medications for adolescents after reviews of the scientific evidence. In those countries’ health systems, surgeries are only available to patients 18 and older.

The email documents were released by the U.S. District Court for the Middle District of Alabama, in a challenge to the Alabama ban brought by civil rights groups including the National Center for Lesbian Rights and the Southern Poverty Law Center on behalf of five transgender adolescents and their families.

Transgender rights groups have turned to the courts to block laws, like Alabama’s, that have been approved in more than 20 Republican-controlled states since 2021, but the courts have been split in their rulings.

On Monday, the Supreme Court announced that it would hear a challenge to Tennessee’s ban on youth gender medicine, which makes it a felony for doctors to provide any gender-related treatment to minors, including puberty blockers, hormones and surgeries. The petition, filed by the Department of Justice, cited the WPATH guidelines among its primary “evidence-based practice guidelines for the treatment of gender dysphoria.”

Additional emails cited in the new court filings suggest that the American Academy of Pediatrics also warned WPATH that it would not endorse the group’s recommendations if the guidelines set the new age minimums.

In a statement on Tuesday, Mark Del Monte, chief executive of the American Academy of Pediatrics, pointed out that the medical group, which represents 67,000 U.S. pediatricians, had not endorsed the international guidelines because it already had its own in place.

He said the academy had sought to change the age limits in the guidelines because the group’s policies did not recommend restrictions based on age for surgeries.

Last summer, the pediatrics academy reaffirmed its own guidelines, issued in 2018, but said that it was commissioning an external review of the evidence for the first time.

The numbers for all gender-related medical interventions for adolescents have been steadily rising as more young people seek such care. A Reuters analysis of insurance data estimated that 4,200 American adolescents started estrogen or testosterone therapy in 2021, more than double the number from four years earlier. Surgeries are more rare, and the vast majority are mastectomies. or top surgeries. In 2021, Reuters estimated that 282 teenagers underwent top surgery that was paid for by insurance.

Gender-related surgeries for minors have been a focal point for some politicians. Gov. Ron DeSantis, Republican of Florida, has argued that surgeons should be sued for “disfiguring” children. In Texas, where parents of transgender children have been investigated for child abuse, Gov. Greg Abbott, a Republican, has called genital surgeries in adolescents “genital mutilation.”

The final WPATH guidelines state that distress about breast development in particular has been associated in transgender teenagers with higher rates of depression, anxiety and distress.

“While the long-term effects of gender-affirming treatments initiated in adolescence are not fully known, the potential negative health consequences of delaying treatment should also be considered,” the guidelines state.

“Gender-affirming surgery is valued highly by those who need these services — lifesaving in many cases,” Dr. Bowers said.

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

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Each bar represents the number of people in each age group who received a gender-affirming surgery associated with a TGD-related diagnosis, per 100 000 total people in that age group in 2019.

Each bar represents the proportional use of gender-affirming breast reductions by people with a TGD-related diagnosis and cisgender males without a TGD-related diagnosis. Breast reductions conducted on those with a TGD-related diagnosis within 6 months of the surgery are assumed to have occurred in a TGD population, and those without are assumed to have occurred in a cisgender population.

eTable. Gender Affirming Procedure Codes by Procedure Type

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Dai D , Charlton BM , Boskey ER, et al. Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US. JAMA Netw Open. 2024;7(6):e2418814. doi:10.1001/jamanetworkopen.2024.18814

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Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US

• 1 Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• 2 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
• 3 Division of Gynecology, Boston Children's Hospital, Boston, Massachusetts
• 4 Departments of Behavioral and Social Sciences and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• 5 Department of Behavioral and Social Sciences and Epidemiology, Brown School of Public Health, Providence, Rhode Island
• 6 Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts

Gender-affirming health care aims to align an individual’s physical gender expression with their intrinsic gender identity. An example is breast reduction for cisgender males with gynecomastia. Recently, there have been increased legislative efforts restricting gender-affirming health care specifically for transgender and gender diverse (TGD) people. 1 Proponents of these efforts express concerns that TGD minors may be too commonly using gender-affirming surgical procedures. Given stringent clinical standards for gender-affirming care, 2 , 3 use of gender-affirming surgical procedures by TGD minors is expected to be low. However, there are limited national data; while 1 study provided national estimates, it did not capture minors under the age of 12 years and did not exclude procedures with clinical justifications outside of gender affirmation. 4 Therefore, using a national dataset, we evaluated the extent to which TGD minors and adults received gender-affirming surgical procedures in 2019. Additionally, in line with a recent publication from bioethicists to acknowledge that gender-affirming care is used by people of all genders, 5 we provide a novel characterization of the relative use of 1 gender-affirming surgery—breast reductions—by TGD and cisgender populations.

This cross-sectional study was approved by the institutional review board at the Harvard T.H. Chan School of Public Health. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. Informed consent was waived because data were deidentified. Using medical claims from Inovalon Insights, we identified TGD people who received a gender-affirming procedure using previously validated sets of diagnostic and procedural codes in 2019. 6 We then calculated the rate of people who received a gender-affirming procedure with a TGD-related diagnosis per 100 000 total people in the following categories: adults (18 years or older) or minors (15 to 17 years, 13 to 14 years, and 12 years or younger). Next, given that breast reduction for male cisgender adults and minors can be considered gender-affirming care and can be covered by insurance, we compared the proportion of breast reductions used by cisgender males—males without a TGD-related diagnosis— and TGD people. Importantly, all surgical procedures among patients with indications of differences in sex development or patients with other medical indications for surgery (eg, cancer, injury) were excluded (eMethods and eTable in Supplement 1 ). Analyses were performed with Microsoft SQL 2019 (Microsoft). Data analysis was conducted from June 2023 to January 2024.

In 2019, the sample included 47 437 919 adults who were insured and 22 827 194 minors who were insured, of which 3 835 726 minors (16.8%) were aged 15 to 17 years, 2 708 166 (11.9%) were aged 13 to 14 years, and 16 283 302 (71.3%) were aged 12 years or younger. The rate of undergoing a gender-affirming surgery with a TGD-related diagnosis was 5.3 per 100 000 total adults compared with 2.1 per 100 000 minors aged 15 to 17 years, 0.1 per 100 000 minors aged 13 to 14 years, and 0 procedures among minors aged 12 years or younger ( Figure 1 ). Of gender-affirming surgical procedures identified among adults and minors, 1591 of 2664 (59.7%) and 82 of 85 (96.4%) were chest-related procedures, respectively. Of the 636 breast reductions among cisgender male and TGD adults, 507 (80%) were performed on cisgender males. Of the 151 breast reductions among cisgender male minors and TGD minors, 146 (97%) were performed on cisgender male minors ( Figure 2 ).

In this cross-sectional study of a national insured population in 2019, there were no gender-affirming procedures conducted on TGD minors aged 12 years and younger, and procedures on TGD minors older than 12 were rare and almost entirely chest-related procedures. Additionally, when considering breast reductions among cisgender males and TGD people—a surgery that can be considered gender-affirming among both populations—most were performed on cisgender males. Thus, these findings suggest that concerns around high rates of gender-affirming surgery use, specifically among TGD minors, may be unwarranted. Low use by TGD people likely reflects adherence to stringent standards of gender-affirming care. 2 , 3

This study is limited by the reliance on diagnostic and procedure codes in claims data to assume clinical justifications for surgery and the TGD or cisgender identity of patients. These methods may lead to potential misclassifications. Additionally, our findings are limited to insurance-covered use and not self-paid use.

Accepted for Publication: April 24, 2024.

Published: June 27, 2024. doi:10.1001/jamanetworkopen.2024.18814

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Dai D et al. JAMA Network Open .

Corresponding Author: Jose F. Figueroa, MD, MPH, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 ( [email protected] ).

Author Contributions: Mx Dai had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Dai, Charlton, Hughes, Hughto, Figueroa.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Dai.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Dai, Hughes, Orav.

Obtained funding: Figueroa.

Administrative, technical, or material support: Dai, Boskey, Hughto, Figueroa.

Supervision: Charlton, Boskey, Hughes, Hughto, Figueroa.

Conflict of Interest Disclosures: Dr Figueroa reported receiving grants from Robert Wood Johnson Foundation, Commonwealth Fund, National Institute of Health, Episcopal Health, Arnold Ventures and receiving personal fees from Humana, Project Hope, and Inter-American Development Bank outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Charlton was supported by grant R01MD015256 from the National Institutes of Health.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: We recognize the attempted erasure of Indigenous gender traditions that predate colonial gender binaries. We extend respect to all Indigenous people currently living on this land and their ancestors who have lived on this land for over 500 generations. We affirm that these words are insufficient and are only a small step towards building a culture of accountability and respect towards Indigenous people and their lands.

Additional Information: The study was conducted on the territory of the Massachusett People. We recognize the repeated and continued violation of sovereignty, land, and water by settler colonialism.

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