Social media has been abuzz the last few days with the release of a trailer advertising the upcoming third season of “I Am Jazz.” It’s only a two-minute clip, but it packs a wallop. We see Jazz crying while saying “I just really hate myself” which is intense enough (given Jazz’s admission in the prior season of being suicidally depressed). But the big news is Jazz’s desire to seek bottom surgery. In the trailer, we see Jazz in three different doctors’ offices. The news isn’t good.

Doctor #1: You’re about to turn 16 so…I think it’s feasible that you could have bottom surgery.

Doctor #2 : We’re just now getting children who have been on puberty blocking hormones. When it comes to the surgery, we don’t have the raw materials we need.

Doctor #3: Testosterone suppression did you two big favors here (gestures at his chest, pantomiming breasts) but it didn’t do you any favors “down there.”

The “raw materials” down there are, of course, the child-like male genitals Jazz would have, having been on puberty blockers (since age 10) and estrogen (since at least age 12), according to the first episode of “I Am Jazz” in Season 1. The most commonly performed procedure in the United States to create a facsimile of female genitalia, called “one-stage penile inversion” is more complicated and requires more steps when the male genitalia are the size of a prepubescent child.

A prior 4thWaveNow post, “Age is Just a Number,” touched on a few points from an April 2017 article in the Journal of Sexual Medicine co-authored by gender therapist Christine Milrod and USPATH head and UCSF gender psychiatrist Dan Karasic, which discussed exactly Jazz’s situation: “bottom surgery” for minor boys. The prior post emphasized some surgeons’ belief that minors should have the procedure done while still in high school so that their parents can ensure compliance; even be “active” in the dilation routine required to keep the neovagina open to “maintain the vaginal depth involved” before the teen becomes distracted by college.

But there is much more to say about not only the surgeons who operate on minors, but also those who recommend SRS for puberty-blocked preadolescents.

Of the 20 (anonymous) surgeons surveyed in the Milrod-Karasic article, 11 admitted to operating on boys under the age of 18. Unless Jazz seeks the procedure overseas, it’s highly likely it will be one of these surgeons who will do Jazz’s “bottom surgery,” should it take place before age 18.

From the get-go, co-authors Christine Milrod and Dan Karasic make clear that the growing trend of operating on minors is out of compliance with the current WPATH Standards of Care (SOC 7). But it’s evident from this and other writings that Milrod and Karasic –both proponents of “affirmative gender care” for minors—are interested in changing those standards for the next version (SOC 8). And they are not alone; lowering the age for genital surgery is a very popular topic among top gender clinicians like Johanna Olson-Kennedy and others.

Who are these 11 surgeons? Not even one has ever published on the issue:

The surgeons who perform the procedure on transgender minors have, without exception, refrained from publishing any peer-reviewed outcome data or technical articles on this small but increasingly important population….

…When asked about the lack of published data on surgery in minors, most participants asserted that GCS in all age groups had been a very small part of surgical medicine until very recently and that data on large volumes of procedures were not yet available. Some also cited the perceived “taboo” or outright stigma in performing the surgery and therefore a certain reluctance to share results or specific techniques.

But there are a few surgeons (whether they are part of the group surveyed for this article, we don’t know) who have been featured in news articles about genital surgeries on males under the age of 18. One of them, cited by Milrod and Karasic in a footnote, is Dr. Gary Alter, who in 2014 performed vaginoplasty on a 16-year-old.

Dr. Gary Alter first removed the testicles and inserted a tissue expander (similar to an internal balloon) in the scrotum several months prior to the final sex change. The expander was progressively filled with fluid through a port during several follow-up visits in order to stretch the scrotal skin and yield enough skin as a graft to line the neovagina. The expander thus enabled the patient to avoid taking skin harvested from the flanks with the resulting unsightly scars. After 2.5 months, the expander was removed during the vaginoplasty and clitoral creation.

Just as Jazz’s doctors said: without the necessary “raw material” of a mature penis and scrotum, surgical fashioning of an approximation of female genitalia requires some rejiggering.

Interestingly, the article about Dr. Alter tells us that the 16-year-old’s psychotherapist was none other than Christine Milrod. who penned a piece “How Young is Too Young” in the Journal of Sexual Medicine in 2014. In it, Milrod argues for new guidelines that would allow underage surgeries on a “case-by-case basis.

Professionals across disciplines treating female-affirmed adolescents can utilize the proposed ethical guidelines to facilitate decision making on a case-by-case basis to protect both patients and practitioners. These guidelines may also be used in support of more open discussions and disclosures of surgical results that could further the advancement of treatment in this emerging population.

“This emerging population”—male minors seeking genital surgeries.

Gary Alter is not the only one who has performed vaginoplasty on underage males. This 2015 New York Times piece features another surgeon, Dr. Christine McGinn (a late transitioning, former military MD):

Several doctors said they had performed surgery on minors. Kat’s surgeon, Dr. Christine McGinn, estimated that she had done more than 30 operations on children under 18, about half of them vaginoplasties for biological boys becoming girls, and the other half double mastectomies for girls becoming boys.

.. Kat’s parents trusted her not only as a specialist, but also as a role model: She had been a dashing male doctor in the Navy, before becoming a beautiful female doctor in civilian life.

When questioning the ethics involved in performing risky, irreversible, sterilizing surgeries on people too young to give informed consent, it’s easy to point the finger only at the surgeons. But as is made abundantly clear in the Milrod-Karasic article, it is psychotherapists like Christine Milrod who are heavily relied upon by the surgeons to make the correct referrals. No minor simply walks into a surgeon’s office to ask for SRS without first being referred by a gender therapist.

Nearly all participants reported an overwhelming reliance on mental health practitioners to assess the minor’s psychological readiness for surgery. Statements including “completely” (Surgeon 9) or “extremely” (Surgeon 10) were used to emphasize trust in the diagnostic expertise of mental health providers.

Surgeon 3 concurred: “I rely on them entirely. I need to make sure that the patients have realistic expectations, that they are not. I need to judge their maturity level and that they can handle pretty significant stress of any surgical procedure. But I don’t pretend to be a psychologist or have any expertise in the diagnosis of gender dysphoria, that’s a decision that needs experts.

Surgeons operate; psychologists assess maturity and readiness. But even with the blessing and recommendations of a gender therapist, some of the surveyed surgeons clearly have some understanding of the immaturity of a 15-year-old brain. Here’s what Surgeon 18 had to say:

In addition, a few participants urged caution, suggesting that some adolescents engage in gender exploration as part of a developmental phase and as part of the current zeitgeist: “I think it goes along the lines of a young person’s mind still being in the developmental stage. Things may happen and they may reorient their thinking, not just whether they are trans or not, but they may reorient their thinking about which surgery will serve their transgender needs. It is not a binary or tertiary model where they are just gay, straight, bisexual, or trans; there are a whole host of colors in-between. Many trans patients do not want GCS—it could be that at 15 they do, and at 25 they do not.”

Surgeon 19 even alludes to social contagion and the fact that kids are being taught indoctrinated about trans issues in school as a factor in some of them thinking they’re trans:

Depending on how old they are, there are a lot of classes that adolescents, even preadolescents in elementary schools, are getting these days. And they are trying to figure out if they are doing it because it is a new norm, versus what they really want. I have seen some … children go through phases of in and out, of thinking transgender. So that would be my concern—is it because it is popular now?

Karasic and Milrod note that a third of the surveyed surgeons believe the current WPATH recommendation for no surgeries under 18 should stand (only a third?) But the main thrust of this article seems to be that minors should be allowed genital surgery on a “case by case” basis; as if some 15 year olds can be 100% sure they are doing the right thing, while others might not. (How to tell?)  Milrod and Karasic say the surveyed surgeons are not worried about a potentially misdiagnosed client who might regret what they’ve done later on:

Despite the legal impossibility to obtain informed consent from the underage patient, the vast majority of participants were not concerned with malpractice lawsuits from parents or even from the patients as adults in the future. Engaging in best practices, maintaining open communication with the patient and her parents, and above all providing good results were seen as protective measures against any legal action.

Do Milrod, Karasic, and the confident surgeons quoted in the article believe some younger adolescents develop their frontal lobes faster than others? Do they think that just because a 15-year-old says “I’m 100% sure this is what I want” (what adolescent doesn’t say such a thing?), they can be trusted to know how they’ll feel in perpetuity? No one in the “gender care” field seems to be calling for MRI screening of frontal lobe density, weight, or size as a possible screening tool to differentiate the “true trans” teens (who really ought to have their testicles removed and their penises inverted) from the others who might change their minds.

Despite a lack of concern about misdiagnosis, many of the surgeons voiced concern about a severe lack of expertise in the field. Here’s Surgeon 14:

I believe that anyone who is performing vulvoplasty should have a fellowship training that is at least one year. It is going to be a rough period figuring that out, but I think we will get there eventually. I have seen horrific unethical practices by surgeons who lie about their experience and horrific results surgically as a result of that. We are using transgender people as guinea pigs and the medical profession allows this to happen. WPATH has the ability to have some teeth and regulate this more. But we don’t.

Then there’s the heady opportunity to ride the bucking bronco of this new medical trend:

The term Wild West also was used by a few highly experienced surgeons who were alarmed at the absence of surgical standards and the ease of entering the subspecialty without any documented training. To remedy the potential influx of “a bunch of solo practitioners, basically cowboys or cowgirls who kind of build their little house, advertise, and suck people in” (surgeon 13), several participants called on the WPATH to assume a larger role in demanding more stringent professional requirements and contribute toward sponsoring fellowships and surgical trainings across the country.

It’s hard to argue with a call for more training and expertise if these surgeries are going to be performed. But the underlying ethical question remains unanswered: Should minors be operated on? Especially when (as Surgeon 14 goes on to say) a new crop of poorly trained entrepreneurial surgeons is keen to profit on the trans trend:

…And now all of a sudden because it’s in the media, and really, the biggest reason for why everyone is doing it now, is the money is flowing. Because now insurance is paying. And now all these institutions have to have a program yesterday. And they are not doing it correctly, in my opinion. Seeing a week’s worth of surgery—maybe for a mastectomy, or maybe for an orchiectomy, or some of these other surgeries that are closely related, but this surgery is very advanced. The complications have severe consequences on patients’ lives and you can’t learn it in a week. And that is what’s happening; someone is going to see someone with a reputable name; they learn for a week, and they start doing them. And that is completely unethical!

 So we’ve established that there is a dearth of skilled surgeons, and that the penile inversion procedure is problematic for males (like Jazz) who have stunted genitalia resulting from years on GnRh agonists (puberty blocking hormones). But there is an alternate procedure that can be done: crafting a neovagina out of intestinal tissue. It turns out that this procedure is done in Europe far more than in the USA (where, according to the Milrod-Karasic article, there is a strong bias toward “one-stage penile inversion”).

In particular, plastic surgeons were biased toward penile inversion augmented by scrotal grafts, sometimes adding flank grafts, tissue expanders, or donor matrix tissue,27e29 and decisively rejecting intestinal vaginoplasty that would require no such additional measures and eliminate the need for lifelong dilatation.

Indeed, several Dutch studies can be found in the literature that discuss advantages of intestinal vaginoplasty for patients who have been on puberty blockers for many years. Arresting puberty seems to have spawned a whole new specialty for Dutch surgeons. In this 2016 article, Primary Total Laparoscopic Sigmoid Vaginoplasty in Transgender Women with Penoscrotal Hypoplasia,” the, authors report generally good outcomes, apart from the fact that 1 of 42 subjects died from septic shock and multiorgan failure, and 17.1 percent suffered “long-term complications that needed a secondary correction.”

No doubt, Dutch surgeons are benefiting from the fact that pubertal blockade for gender dysphoric youth was pioneered in the Netherlands–a breakthrough heralded by the first US doctor to use it, Norman Spack, whose infamous statement about his enthusiasm for the practice was captured in the aforementioned New York Times article:

Dr. Spack recalled being at a meeting in Europe about 15 years ago, when he learned that the Dutch were using puberty blockers in transgender early adolescents.

“I was salivating,” he recalled. “I said we had to do this.”

So, what does all this mean for Jazz? Clearly, the chemical stunting of Jazz’s genitalia–aka “penoscrotal hypoplasia”—is what prompted one of his/her doctors to say in the “I Am Jazz” trailer that “you can’t have the surgery you want.” But the intestinal method is available, at least in Europe. Then again as recently as 2015, Jazz seemed sort of ok with his/her birth genitals:

Surgery is a very big deal as it can be dangerous and very painful. While speaking with her doctor about the possibility of getting surgery someday, Jazz admitted that she has gotten used to her body just the way it is. She said she doesn’t feel awkward when looking down and seeing and seeing what’s there, but says, “Hey, thingaminga, how are you?”

In the promo for the new season, Jazz says “I’ve always dreamed of getting this procedure.” But this is only the trailer, so we don’t know what happens next until the season premiere in June. Maybe Jazz’s surgeon will go ahead with the modified penile inversion, involving donor skin grafts from Jazz’s own body, scrotal expanders, and all the rest. For the “cowboy and cowgirl” entrepreneurs who have hung out their shingle to “suck people in,” Jazz’s immature genitalia may be just another surgical challenge to overcome in the exciting new frontier of medical experimentation on teens frozen—like ancient insects in amber– in prepubescence; teens who, more likely than not, would have grown up to be gay in the bygone days before Big Medicine and Big Pharma stepped in to medicalize adolescent identity crises–as even the DSM-5 attests:

But let’s not forget what several surgeons in the Milrod-Karasic article said: That they trust “completely” or “extremely” that gender therapists like Diane Ehrensaft, Christine Milrod, and all the other “affirmative” therapists will recommend surgery only for the correctly diagnosed youth in their care. So anyone questioning the increase in medical transition of minors should, above all, scrutinize the practices of these gender therapists.  Just how careful are they not to make a mistake? As Christine Milrod herself describes in her own “How Young is Too Young” piece,

[there is] “a genuine expression of fear among clinicians in making the wrong diagnosis, based on the fact that young people often experiment with gender role behavior as a consequence of normative identity development, and perhaps more so when the adolescent is gender variant”

OK, but given that “informed consent” is the current trend in practice, whereby adolescents who say they are trans are taken at their word while “gatekeeping” is derided, how easy will it be for US gender therapists to avoid making a wrong diagnosis—or any diagnosis at all?

Instead of grappling with these vexing issues, our media, academia, entertainment industry, and politicians remain in thrall to a medical fad which has resulted in a child celebrity whose most private struggles have been leveraged into a marketing bonanza.