Gender-affirming surgery should wait until 19 say US plastic surgeons, citing UK policy

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By Erin Dean

Surgeons should delay gender-related breast, chest, genital and facial surgery until a patient is at least 19 years old, the American Society of Plastic Surgeons has recommended in a position statement.

The guidance said the clinical management of children and adolescents with gender dysphoria or gender incongruence has undergone rapid change, driven by insights from new research and the independent review in the UK into gender identity services in England.

The Cass review, commissioned by NHS England and published in April 2024, found the evidence base for youth gender interventions, particularly puberty blockers, was "weak".

It called for a holistic, care-focused approach with more research and regional hubs. 

The American Society of Plastic Surgeons (ASPS) says that over the past two decades treatment has increasingly included psychological assessment, social transition, puberty blockers, hormones and surgical procedures.

But while numbers of children seeking care has risen, both the Cass review and a major review from the US Department of Health and Human Sciences in 2025 highlighted that the “natural course” of the condition 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,” the statement said.

Even doctors with extensive experience lack reliable methods to identify those whose distress will persist.

The ASPS says that given the irreversible nature of the surgery, there is currently insufficient evidence to suggest that the benefits outweigh the risks.

The document is not a clinical practice guideline but aims to give surgeons guidance in a “rapidly evolving and controversial clinical area”.

Restrictions tightened in UK

In the UK, gender-affirming surgery is strictly prohibited for anyone under the age of 18. While patients can be referred to adult services at 17, they typically must wait until their 18th birthday for surgery.

Furthermore, NHS guidelines typically require adults to have completed at least one year of "social transition" and hormone therapy before becoming eligible for surgery.

Following the Cass review, NHS England further tightened restrictions with a ban in March 2024 on routine puberty blocker prescriptions for under-18s and a restructuring of children’s gender services to focus on holistic care.

Researchers from King's College London are leading a trial to assess the risks and benefits of puberty-blocking drugs in children who question their gender.

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