The main justification for “gender-affirming care” for minors in the United States has been that “all major U.S. medical associations” support it. Critics of this supposed consensus have argued that it is not grounded in high-quality research or decades of honest and robust deliberation among clinicians with different viewpoints and experiences. Instead, it is the result of a small number of ideologically driven doctor-association members in LGBT-focused committees, who exploit their colleagues’ trust. Physicians presenting different viewpoints are silenced or kept away from decision-making circles, ensuring the appearance of unanimity.
Perhaps because it has never really depended on evidence, this doctor-group consensus has shown remarkable resilience in the face of major system shocks, including several whistleblowers, revelations from court documents that WPATH manipulated scientific evidence reviews, the Cass Review, a bipartisan commitment in the U.K. to roll back pediatric medical transition, and a growing international call for a developmentally informed approach that prioritizes psychotherapy over hormones and surgeries.
But the U.S. consensus now appears to have its first big fracture. In July, the American Society of Plastic Surgeons, a major medical association representing 11,000 members and over 90 percent of the field in the U.S. and Canada, told me that it “has not endorsed any organization’s practice recommendations for the treatment of adolescents with gender dysphoria.” ASPS acknowledged that there is “considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions” and that “the existing evidence base is viewed as low quality/low certainty.”
Malpractice premiums in this area are already rising, and some insurers outright exclude under-18 gender-transition procedures from their coverage policies.
A key question for these lawsuits is the degree to which surgeons are responsible for determining the medical necessity of the procedures that they are asked to perform.
Nazarian, the Beverly Hills surgeon, told me that surgeons in her professional network who perform gender surgeries typically defer to mental-health professionals and endocrinologists to determine for them whether minors should receive procedures like double mastectomy. That approach, she believes, is misguided, and reduces surgeons to mechanics.