WASHINGTON — The American Society of Plastic Surgeons (ASPS) recommends that gender-affirming surgeries be delayed until a patient is at least 19 years old, the group announced in a statement Tuesday. The statement, made by the group’s board of directors, represents a break from major U.S. medical groups that have supported the care, and applies to facial, chest, and genital procedures performed for transgender and nonbinary patients.
The group, a professional association with more than 11,000 physician members, emphasized that the statement was not a clinical practice guideline but instead “professional guidance” for care the group said was “rapidly evolving and controversial.”
The plastic surgeons organization decried pursuing criminal or punitive measures against doctors providing gender-affirming care — a policy goal of Republicans nationwide — and underscored its confidence in the individual decision-making of its members.
Scot Bradley Glasberg, a past president of the group, told STAT that ASPS began evaluating the quality of evidence around gender-affirming care for minors during the Biden administration, noting that new reviews of evidence strengthened its conclusion that the data supporting care is “low quality, low certainty.”
“We felt it was time to make our position a little sounder,” he said. “For ASPS, this has been an evolution of our position.”
The announcement comes amid an unprecedented pressure campaign from the Trump administration to end gender-affirming care for those under 19. But the administration “didn’t have a role in this,” Glasberg said, adding it was “happenstance” that the guidance came out while Trump is in office. Asked if the group had met with the administration about gender-affirming care, he said he couldn’t discuss any private meetings.
The Department of Health and Human Services and health secretary Robert F. Kennedy Jr. immediately commended the group on Tuesday for “standing up to the overmedicalization lobby and defending sound science.” Deputy health secretary Jim O’Neill called the announcement “another victory for biological truth.”
The administration’s hardline agenda has included opening FBI and Justice Department inquiries into hospitals and doctors, as well as conditioning the payment of huge sums of federal money to hospitals on prohibiting the care. In response, several hospitals and provider groups said they would stop offering gender-affirming care for minors.
But up until now, major medical associations have maintained support for the care as the number of people seeking it grows. In the last year, the American Academy of Pediatrics, which published guidance that suggested gender-affirming surgeries be offered to adolescents on a case-by-case basis, has repeatedly pushed back against the administration’s campaign to end gender-affirming care for minors.
The new statement from ASPS was heralded by groups that have questioned or worked to ban gender-affirming care for minors.
“We’re encouraged to see a major U.S. medical association engage with the evolving evidence base and move toward a more cautious, science-driven approach to helping gender dysphoric minors,” said William Malone, founder of the Society for Evidence-Based Gender Medicine, a group that has persistently questioned the evidence around gender-affirming care, which Republicans have used to justify legislation restricting or banning it. The group, which funded evidence reviews referenced by ASPS, called the new guidance a “watershed moment in U.S. medicine.”
ASPS has long taken a more conservative approach than other professional medical organizations. In 2024, political scientist Leor Sapir wrote that ASPS had become “the first major medical association to challenge the consensus” on gender-affirming care, based on a statement the group made to him that “the existing evidence base is viewed as low quality/low certainty.” The group later said that the position was consistent with its history, as the group had “not endorsed any organization’s practice recommendations” and called for more high-quality research while pushing back against the idea of legal restrictions.
(Sapir has long criticized gender-affirming care, and last year, along with a Society for Evidence-Based Gender Medicine co-founder and others, co-authored the Trump administration’s report on gender dysphoria, which has fueled multiple federal initiatives to ban the care.)
The new position statement specifically cites the HHS report as well as the controversial Cass review published out of the U.K. in 2024, which both categorized the evidence base for gender-affirming care as low quality. (The European Academy of Pediatrics in 2024 took a similar approach to the procedures as ASPS, citing an interim report from Cass and her team.)
Critics of gender-affirming care often cite the field’s low-quality evidence as a key reason to restrict it, but others (including the researcher who coined the term “evidence-based medicine”) point out that the majority of existing health care is backed by similar quality research.
The internal leadership of ASPS who informed the decision included some surgeons who offer gender-affirming care, but a majority in the group don’t, Glasberg said, explaining that they tried to avoid conflicts of interest. He declined to share the number of board members who voted for and against the guidance but said he would have voted in favor of it if he were still on the board.
The group stopped short of producing full clinical practice guidelines, he said, because there wasn’t enough clear data for it.
Surgeons who perform gender-affirming procedures often work in tandem with a team of other clinicians, including surgeons from other specialties, therapists, psychologists, psychiatrists, and endocrinologists. Typically, at least one letter of recommendation from another clinician is needed for surgeons to consider performing a procedure on a trans person of any age. The statement emphasizes that surgeons “share responsibility for determining whether a minor is developmentally able to understand the nature, irreversibility, and long-term implications” of a given procedure.
People who support keeping gender-affirming surgery available to adolescents often point to the high rates of cisgender young people who receive analogous surgeries like breast reductions. A 2024 ASPS report shows that more than 23,000 people aged 19 and under received some sort of plastic surgery that year, including more than 5,300 “aesthetic patients” who received breast reductions. A study on gender-affirming surgeries among transgender adolescents found that, between 2016 and 2020, about 4,000 people aged 12 to 18 received any gender-affirming surgery.
The ASPS statement argues that there’s an “ethical distinction” between gender-affirming procedures and other plastic surgery procedures performed on minors, though it does not distinguish between top surgeries, facial procedures, and genital surgeries.
The group asserts that gender-affirming procedures can result in “lifelong medical dependency or foreclose on broad future developmental pathways” in ways that other procedures can’t, again without specifying which procedures it’s referring to. Top surgery to remove one’s breasts, the most common surgery that transgender young people receive, does not require a person to remain on hormone medications or implicate a person’s fertility, though future breastfeeding may be at risk. The statement also points to uncertainty around long-term effects, how gender-affirming care is often framed as “life-saving,” and the way it’s linked to one’s sense of identity.
“Taken together, these factors demonstrate why greater uncertainty about the evidence is ethically tolerable in some areas of pediatric plastic surgery but not in others,” the statement reads.
Correction: A previous version of this story incorrectly identified Scot Bradley Glasberg, a past president of the plastic surgeons society.
