Experience, Caring and Decision Making on the Individual Level

The clinical management of children and adolescents presenting with gender dysphoria or gender incongruence has undergone rapid change, and the American Society of Plastic Surgeons (ASPS) wishes to offer guidance to members providing gender surgery services for this population. This position statement discusses the views of ASPS on breast/chest, genital, and facial gender surgery for individuals under the age of 19.

Today’s release is very similar to guidelines issued two years ago, and has been reinforced with continued clinical research into the well being of our patients.

It should be noted that ASPS members do the vast majority of gender affirming surgery for men and women, cis and trans. This position takes into consideration both the benefits and harms that irreversible medical decisions have, specifically for the treatment of patients below the age of 19.

Clinical and Policy Evolution

Treatment models for the clinical management of children and adolescents presenting with gender dysphoria have increasingly included psychological assessment, social transition, endocrine interventions such as puberty blockers and cross-sex hormones, and surgical procedures.

Clinical practice progresses amid growing patient demand and an evolving understanding of the evidence base, particularly with respect to long-term outcomes in pediatric and adolescent populations. More recently, a number of international health systems and professional bodies initiated formal re-examinations of earlier clinical practice assumptions in response to changes in patient presentation and a growing uncertainty about the benefits of medical and surgical interventions. Systematic reviews and evidence reassessments have subsequently identified limitations in study quality, consistency, and follow-up alongside emerging evidence of treatment complications and potential harms.

ASPS Past Position

In August 2024, ASPS communicated to members that the Society had not endorsed any external organization’s clinical practice guidelines or recommendations for the treatment of children or adolescents with gender dysphoria. At that time, ASPS recognized that the evidence base informing medical and surgical interventions in this population was limited and characterized as low quality/low certainty (i.e., there was limited confidence that the intervention’s reported effects reflected the true effects). This understanding was informed by new systematic reviews published in Europe as well as the 2024 Independent Review of Gender Identity Services for Children and Young People: Final Report commissioned by NHS England and authored by Dr. Hilary Cass.

ASPS’s understanding has continued to evolve in light of additional comprehensive evidence reviews, including the 2024 Plastic and Reconstructive Surgery article Mastectomy for individuals with gender dysphoria younger than 26 years: a systematic review and meta-analysis and 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 Practices. These reviews have not resolved earlier uncertainties regarding treatment benefit.

Weighing New Evidence

In some areas they have contributed to a clearer understanding of potential harms, while also highlighting limitations of the available evidence. This includes gaps in documenting long-term physical, psychological, and psychosocial outcomes. For an evidence summary, ASPS directs members to Appendix 4 of the HHS report, 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.

Relevant to ASPS’s position and understanding of the larger patient assessment process, both the Cass Review and the HHS report emphasize that the natural course of pediatric gender dysphoria remains poorly understood. Available evidence suggests that a substantial proportion of children with prepubertal onset gender dysphoria experience resolution or significant reduction of distress by the time they reach adulthood, absent medical or surgical intervention. Evidence regarding adolescent-onset presentation, which has become increasingly common since the mid-2010s, is more limited but similarly does not allow for confident prediction of long-term trajectories.

Predicting Future Emotional Responses

Importantly, clinicians, even those with extensive experience, currently lack reliable methods to distinguish those whose distress will persist from those whose distress will remit. The HHS report underscores that this uncertainty has significant ethical implications: 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.

The concept of “patient values and preferences” has been cited as sufficient rationale for the treatment of children and adolescents in the face of very low/low certainty evidence; however, high-quality research on patient values and preferences is missing in this area of medicine. For example, it is unclear whether fully informed patients and their caregivers would endorse the current values and preferences framework that places a higher value on achieving more favorable aesthetic effects in adolescence and places a lower value on avoiding potential harm from early pubertal suppression.

Addressing Adolescent Autonomy

Respect for emerging adolescent autonomy is also cited as a rationale for the provision of care in the face of low certainty evidence. However, patient autonomy is more properly defined as the right of a patient to accept or refuse appropriate treatment; it 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. In pediatric contexts, the threshold for intervention must be higher and safeguards more stringent.

Overall, and consistent with long-standing frameworks in medical ethics, including those articulated by Beauchamp and Childress in 2019 and the American Academy of Pediatrics Committee on Bioethics in 2016, ASPS recognizes that surgeons should offer treatments that are medically indicated and supported by an expectation that the anticipated benefits outweigh potential harms. The patient education and informed consent process, which incorporates patient values and preferences and acknowledges emerging autonomy, operates within – not independently of – this evidentiary threshold.

Purpose and Scope of this Statement

This document is not a clinical practice guideline. ASPS has not undertaken a formal guideline development process, including independent systematic evidence assessment, consensus panels, or strength-of-recommendation determinations.

Instead, given the current state of the evidence and variability in legal and regulatory environments, the ASPS/PSF Board of Directors determined that a position statement, rather than a clinical practice guideline, was the most appropriate mechanism at this time.

The ASPS/PSF Board of Directors issues this position statement to provide professional guidance to ASPS members in a rapidly evolving and controversial clinical area; to clarify ASPS’s interpretation of the current evidence base as it relates to the integration of surgical care into a larger care pathway; to support members in navigating informed consent, patient selection, institutional policy, and medico-legal risk; and to articulate principles that prioritize patient welfare, scientific integrity, and professional self-regulation.

Other Important Aspects of the Position Paper

Several other important positions were restated in this paper, including respect for patient dignity, respect for the practice of plastic surgery, and opposition to criminalization of medical care.

The ASPS Code of Ethics holds that “all patients should be treated with full respect for human dignity. ASPS Members should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion.”16 ASPS affirms the inherent dignity of every patient and supports the rights of all individuals to privacy and humane medical care. This includes pediatric and adolescent patients who present with gender dysphoria, those who identify as transgender and gender non-conforming, and those who experience regret, cease treatment, or later detransition. Recognition of patient dignity is not contingent upon pursuit of a specific clinical pathway.

This position statement does not 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 Final Summary, At Least for Now

Consistent with ASPS’s August 2024 statement that the overall evidence base for gender-related endocrine and surgical interventions is low certainty, and in light of recent publications reporting very low/low certainty of evidence regarding mental health outcomes, along with emerging concerns about potential long-term harms and the irreversible nature of surgical interventions in a developmentally vulnerable population, ASPS concludes there is insufficient evidence demonstrating a favorable risk-benefit ratio for the pathway of gender-related endocrine and surgical interventions in children and adolescents. ASPS recommends that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.

I encourage every plastic surgeon and interested member of the public to read the entire ASPS position paper.

Disclaimer: The American Society of Plastic Surgeons (ASPS) is committed to patient safety, access to care and the highest quality standards of patient care. The contents of this post, selected from the ASPS Position Statement on Gender Surgery for Children and Adolescents, are not intended to serve as a standard of care or legal advice. Information and regulations may change over time and Practitioners are solely responsible for complying with current applicable law and standards of care. Practitioners are encouraged to consult legal counsel in the state of practice regarding local standards and responsibilities.