Over the past several years, the growing number of medical interventions aimed at treating pediatric gender dysphoria has made its way towards the center of public policy debates. The theme of children's welfare has come up in debates on banning video games, subsidizing school lunches, universal preschool, same-sex adoption, and Drag Queen Story Hour. This is hardly the first time that "Think of the children" has been used as a rallying cry to advance a cause. The Supreme Court's decision in Skremetti v. United States last year was a reminder that we do not have to take the word of activists at face value. Last week, the American Society of Plastic Surgeons (ASPS) released a statement saying that youth gender surgery is not evidence-based. This statement exposes another crack in the framework that assumes that youth gender surgery is a safe practice and settled science.
Why This Statement Is Surprising
At face value, you would not think that ASPS would sign such a statement. If anything, you would assume that ASPS would be in favor of more youth gender surgery because they have a financial interest in performing more elective procedures. They would be the last medical association that you would expect to be against it, and here we are. And maybe that is the significance of this statement.
Plastic surgeons are sensitive to malpractice exposure. About 1,000 of these procedures are done annually, which is small considering the revenue they make from breast augmentation, face lifts, or liposuction. The procedure revenue from gender surgery is dwarfed by the liability risk. Plastic surgery is already in a delicate place with regard to reputation. Plastic surgery is seen as elective, cosmetic, or sometimes exploitative. Performing irreversible procedures on minors that lack an evidence base is a recipe for legal disaster and would only create reputational risk.
The Evidence and the Risk
This statement brings another concern to light: the plastic surgeons are the ones who are charged to treat patients who might deal with long-term side effects. In its statement, ASPS highlights the irreversible bodily changes, including loss of fertility and altered sexual function, as well as typical surgical risks like infection and the need for revisions. Then there are the mental health and developmental outcomes that are poorly understood. ASPS highlights the Cass Review or systematic reviews from European countries that have been carrying out these procedures for longer than the U.S. In addition, they add a systematic review by the ASPS and the 2025 HHS report to the evidence base.
When the people doing the surgery say that "the evidence is not there," it is insight that would be gained from lived clinical experience. Plastic surgeons profit from the surgery, tend to have a strong belief in bodily autonomy, and routinely defend elective procedures. If they are recommending that individuals under 19 do not undergo the procedure, perhaps there is a very good reason for that recommendation.
Adults versus Adolescents
There are a number of things that I think are not good life decisions, whether that is having children before getting married, entering a polygamous marriage, smoking cigarettes, eating fast food every day, or not exercising. I also believe that as long as they are not harming anyone else, adults should be allowed to make whatever decisions about their lives, regardless of what I or anyone else thinks about the decision. This issue is not about adults making a decision to undergo these surgeries with informed consent nor is this about whether transgender individuals should be treated with dignity (for the record, they should, just like everyone else).
We are talking about adolescents here, and the ASPS statement underscores an obvious point. Adolescents do not have the understanding (mens rea), maturity, or capacity to make such a decision. When a procedure is irreversible, the evidence base is against doing the procedure, and the patient is still in a developmental stage in their lives such as adolescence, this stance is both prudent and necessary.
The Ideological House of Cards
This ASPS statement is not simply a victory for evidence-based science or maybe a chance that people can trust that the medical field will value evidence and safety over ideology. It is another example of how gender ideology is teetering like a house of cards. The MTF transgender athlete debate exposes contradictions between self-identity and biological reality. Gallup polling shows that more adults are in favor of transgender individuals playing on sports teams that correspond with their biological sex (currently at 69 percent). More adults are uncomfortable with pronoun usage, with discomfort increasing from 48 percent of adults in 2021 to 54 percent of adults in 2025.
Meanwhile, acceptance of someone undergoing these procedures has declined from 46 percent in 2021 to 40 percent in 2025. Pew Research polling data from 2025 shows that 49 percent of Americans believe transgender individuals should use the bathroom corresponding to their biological sex, as well as 47 percent of adults who believe teachers should not teach students about gender identity. Add the medical risks and irreversible consequences for minors highlighted by ASPS, and it's clear as day that when ideology trumps evidence, this house of cards is not merely wobbly; it is poised to collapse. At the rate that it is going, it is simply a matter of when and how hard of a fall it will be.
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