The University of San Francisco runs one of the most prestigious and well respected programs for “trans kids” in the United States. Their publication, “Health considerations for gender non-conforming children and transgender adolescents,” written by Johanna Olson-Kennedy, MD, Stephen M. Rosenthal, MD, Jennifer Hastings, MD and Linda Wesp, MSN, consists of detailed guidelines on treatment for gender dysphoric youth. It appears to be written for providers, not laypeople, with specific recommendations for GnRH analogues and hormones—when to start, options for delivery (e.g. injection, patches, gel), dosages, needle gauge sizes, and lab tests for monitoring. Other areas are addressed too, including the induction of amenorrhea in natal females and the importance of discussing infertility. Towards the end of the protocol, there is a section about genital and chest surgeries.
The authors state that current standards of care recommend waiting until patients are 18 years old for genital surgeries. But regardless of this advice, they advocate for underage surgeries in certain cases:
Both the Endocrine Society Guidelines and the World Professional Association of Transgender Health (WPATH) Standards of Care version 7.0 recommend deferring genital surgery for both transmasculine and transfeminine youth until the age of 18 years. As youth are transitioning at increasingly younger ages, genital surgery is being performed on a case-by-case basis more frequently in minors.
One of the authors of the UCSF document, Dr. Johanna Olson, has frequently argued for relaxing the over-18 guidelines on genital surgery, including earlier this year on the WPATH Facebook page.
Here’s what the UCSF guidelines have to say about “chest” surgeries aka mastectomies:
While increasing numbers of insurance companies are covering the cost of male chest reconstruction, there are often arbitrary barriers to surgery citing that youth need to be at least 18 years of age prior to undergoing this procedure. Providers should participate in appeal processes so that patients can undergo chest surgery. There are currently no available data that report the positive impact of male chest reconstruction in minors, although a study is underway now.
Gender doctors don’t have the data to back up the double mastectomies and chest contouring they are performing on minor children. But regardless, providers are instructed to recommend health insurance coverage for the procedure—including intervening in appeals processes.
Throughout the guidelines, there are a number of times it is admitted that the science of pediatric medical transition is lacking in data:
“While sparse data exist regarding the impact of puberty suppression and gender-affirming hormones administered during adolescence, there have been promising results from the Netherlands indicating that this approach in adolescents results in improved quality of life and diminished gender dysphoria.”
“While there still exists uncertainty as to which GNC children will continue into adolescence and adulthood with transgender identities and/or gender dysphoria and which will not, it is been noted in prior studies that increased intensity of gender dysphoria is a predictor of a future transgender identity.”
“While data are sparse, preliminary results from the Netherlands indicate that behavioral problems and general psychological functioning improve while youth (age 12 and older) are undergoing puberty suppression.”
“While clinically becoming increasingly common, the impact of GnRH analogues administered to transgender youth in early puberty and <12 years of age has not been published.”
“No consensus exists on the length of time GnRH analogues should continue after youth begin gender-affirming hormones.”
However, regardless of these caveats, the protocol comes across as very thorough. Eighteen different sources are cited for justification. The authors appear to be knowledgeable and capable.
But at the very end, there is this disclaimer:
And there you have it. We are relying on the “expert opinions of innovators and thought leaders” in a field that is in its infancy. “In the absence of solid evidence,” children are being given earlier and earlier irreversible medical interventions based on best guesses about the future.
As the guidelines note, though, studies are indeed underway. Olson and other gender specialists have received a $5.7-million NIH grant to study children and teens who are currently undergoing medical transition. But importantly, these studies aren’t recruiting a control group of untreated trans-identified children, and they are only set to run for 5 years. While any information is better than none when it comes to this modern experiment on youth, the long-term medical and psychological outcomes for the people who were subjected to irreversible medical interventions in their youth will remain a mystery for decades to come.