Thousands of American girls have had elective mastectomies as part of gender-transition treatment. Between 2016 and 2020, according to the Journal of the American Medical Association, 3,215 mastectomies, 405 genital surgeries and 350 other gender-related procedures were carried out on 12- to 18-year-olds; the true number is sure to be higher. Advocates of such procedures for minors argue that they can relieve distress and even prevent suicide. Critics say the evidence for them is shoddy—and predict a flood of medical-malpractice lawsuits.
Two recent pieces of news suggest that doctors who prescribe irreversible transition procedures to adolescents should take the legal threat seriously. The first was an award of $2m to a single patient in New York on January 30th.
The case concerned a woman called Fox Varian. After a difficult childhood, during which her parents fought over custody of her, Ms Varian began to suffer from depression and anxiety. She was also diagnosed with autism. Aged 15, she started to identify as a boy. Her psychologist allegedly warned her mother that she was in danger of committing suicide if she did not have the surgery.
In December 2019, at the age of 16, Ms Varian underwent a double mastectomy. Far from improving, her mental health grew worse. By 2022 she had decided to detransition. The following year she filed a medical malpractice lawsuit against both her psychologist and her surgeon. It was the first such lawsuit by a detransitioner to come before an American jury. “I was 16 and I was really, really mentally ill, obviously,” Ms Varian told the court, according to the Free Press. The jury awarded her $1.6m for past and future pain and $400,000 for future medical costs.
The second warning came on February 3rd, when the American Society of Plastic Surgeons (ASPS), which represents over 90% of the profession in America and Canada, came out against gender-related surgery for patients under 19. In a statement, it cited “limitations in study quality, consistency and follow-up, alongside emerging evidence of treatment complications and potential harms”.
It also restated previous doubts about the trustworthiness of existing clinical guidelines for gender-related care in America, noting that there is “insufficient evidence” that the benefits outweigh the harms of prescribing cross-sex hormones or puberty blockers to adolescents. Hormone treatment can be less dramatic than surgery, but can also have permanent effects, such as sterility.
ASPS is the first American medical association to take any of these stances. The following day the American Medical Association, which represents more than 250,000 physicians, said that because “the evidence for gender-affirming surgical intervention in minors is insufficient…the AMA agrees with ASPS that surgical interventions in minors should be generally deferred to adulthood.”
All this echoes warnings issued in some European countries. In 2024 a report commissioned by Britain’s government, known as the Cass Review, concluded that evidence for the benefits (and harms) of puberty blockers and cross-sex hormones on children and adolescents was “remarkably weak”. Under President Donald Trump, America’s federal department of health and human services issued a similar report, which agreed that the evidence of benefits was flimsy and the treatment raised grave ethical concerns.
The topic is politically radioactive. Plenty of Mr Trump’s supporters say hateful things about transgender people, and some of his executive orders have targeted them. At the same time, some American liberals dismiss the HHS report simply because it was commissioned by Mr Trump. “Many Democrats associate restricting adolescent transitioning with President Trump, so they must oppose it, even though the evidence for benefits from the procedures is clearly very weak and the harms are growing,” says Zhenya Abbruzzese of the Society for Evidence-Based Gender Medicine, an NGO.
In the absence of a national health service, the American medical profession sets its own standards. Guidelines from medical associations are an important part of this. Several of the most important ones, including the American Academy of Paediatrics, continue to back adolescent transitioning. On February 4th the AAP’s head, Andrew Racine, said that “patients, their families, and their physicians—not politicians—should be the ones to make decisions together about what care is best for them.”
Americans in general tend to trust doctors but are wary of allowing these procedures for children. A New York Times poll in 2025 found that 90% of Republicans and 54% of Democrats opposed puberty blockers or cross-sex hormones being given to minors.
Proponents of adolescent transitioning have played down Ms Varian’s case, claiming the circumstances make it of limited relevance to other detransition lawsuits. Critics, by contrast, think the past week could prove a turning-point. Lawsuits have been filed by more than two dozen other detransitioners. Observers believe the damages, all told, could run into hundreds of millions of dollars. “I wouldn’t say this is the dam breaking, but this is clearly more cracks appearing in the dam,” says Leor Sapir, a co-author of the recent HHS report.