Gender-affirming surgeries rarely performed on transgender youth

closeup of a hand waving a transgender pride flag on a green background

July 8, 2024—A new study by researchers at Harvard T.H. Chan School of Public Health found little to no utilization of gender-affirming surgeries by transgender and gender-diverse (TGD) minors in the U.S. The study also found that cisgender minors and adults had substantially higher utilization of analogous gender-affirming surgeries than their TGD counterparts.

The study was published on June 27 in JAMA Network Open. According to the researchers, it is the first quantitative comparison of gender-affirming surgery utilization between cisgender and TGD populations.

Previous research has consistently demonstrated that gender-affirming care for TGD people can be lifesaving in mitigating negative mental health outcomes such as depression, anxiety, and suicidality. Data has been limited, however, around the rates at which TGD youth are undergoing gender-affirming care, including surgery. Despite this uncertainty, in recent years, twenty-five states have banned gender-affirming care for TGD minors. This fall, the Supreme Court will rule on whether such bans are constitutional.

In the context of this lack of data—and this contentious political climate—the researchers used the most recently available data from a 2019 nationally representative pool of medical insurance claims to identify individuals who received a gender-affirming surgery with a concurrent TGD-related diagnosis. Cases where patients had any other medical indications for surgery outside of gender-affirmation, such as breast cancer, were excluded from the analysis. The researchers also compared the relative use of breast reductions by cisgender men and TGD people. Breast reduction surgery was chosen as a point of comparison given that it is the only gender-affirming surgery that is commonly covered by insurance for minors and adults.

The study found no gender-affirming surgeries performed on TGD youth ages 12 and younger in 2019. This was expected, the researchers said, as current international guidelines do not suggest any medical or surgical intervention for TGD individuals prior to puberty. For teens ages 15 to 17 and adults ages 18 and older, the rate of undergoing gender-affirming surgery with a TGD-related diagnosis was 2.1 per 100,000 and 5.3 per 100,000, respectively. A majority of these surgeries were chest surgeries. When considering use of gender-affirming breast reductions among cisgender males and TGD people, the study found that cisgender males accounted for the vast majority of breast reductions, with 80% of surgeries among adults performed on cisgender men and 97% of surgeries among minors performed on cisgender male teens.

“We found that gender-affirming surgeries are rarely performed for transgender minors, suggesting that U.S. surgeons are appropriately following international guidelines around assessment and care,” said co-author Elizabeth Boskey, instructor in the Department of Social and Behavioral Sciences.

Lead author Dannie Dai, research data analyst in the Department of Health Policy and Management, added, “Our findings suggest that legislation blocking gender-affirming care among TGD youth is not about protecting children, but is rooted in bias and stigma against TGD identities and seeks to address a perceived problem that does not actually exist.”

The authors noted limitations to the study, including its reliance on diagnostic and procedure codes in claims data to determine clinical justifications for surgery and the TGD or cisgender identity of patients. Their analyses also did not capture self-paid surgeries.

Maya Brownstein

Photo: iStock/nito100