The Cowardice Of American Medicine On Trans Youth Care

After capitulation by hospitals across the country, the ASPS and AMA have both thrown trans kids under the bus on surgical care.

Ted Eytan

The first year of the Trump administration has offered a master class in how powerful institutions capitulate to right-wing pressure rather than defend the marginalized people who depend on them. That pattern has played out across American life—from newsrooms to elite universities to television networks—but few sectors have folded as quickly or as completely as medical institutions facing federal threats over transgender care. Now, after a bruising week of far-right pressure and coordinated messaging, one of the most consequential shoes has dropped. The American Society of Plastic Surgeons, led by a president who has donated heavily to the Trump campaign and to Ted Cruz, has issued a statement opposing gender-affirming surgeries for patients up to age 19—a move subsequently pseudo-endorsed by the American Medical Association and further bolstered by a lawsuit led by a detransitioner and backed by the current president-elect of the World Professional Association for Transgender Health.

This week, the American Society of Plastic Surgeons released a statement concluding that “ASPS recommends that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.” Notably, 19 years of age is explicitly the age mentioned in Trump’s executive order, including a whole extra year of adulthood for no discernable reason. In justifying that position, the statement cites the Cass Review, which was advised on by members of anti-LGBTQ+ hate groups and has been rejected by multiple major medical organizations worldwide. Shortly after the ASPS announcement, the American Medical Association issued a statement concurring in part, writing, “In the absence of clear evidence, the A.M.A. agrees with A.S.P.S. that surgical interventions in minors should be generally deferred to adulthood.” Taken together, the statements represent a significant departure from prior approaches to transgender youth surgical care. It is notable, mildly so at least, that the AMA’s use of the word “generally” leaves open the possibility that specific clinical indications—such as chest masculinization surgeries for some transgender youth with exceptional dysphoria—may still be permitted.

It is no surprise that the American Society of Plastic Surgeons was among the first major medical organizations to fall. Plastic surgeons, as a group, have long donated far more heavily to Republicans than to Democrats, with contributions over the past two decades favoring Republicans by two to one. The society’s president, Bob Basu, is himself a significant Republican donor, having given repeatedly to Ted Cruz and Donald Trump. In that sense, ASPS was always a prime pressure point for the far right’s campaign against transgender health care. What is more alarming is the broader capitulation now unfolding across American medical institutions—the speed with which they are yielding to political threats, and the silence or acquiescence of bodies tasked with protecting transgender care in the face of mounting political intimidation.

President of ASPS donations

In that sense, it is impossible to view this capitulation and cowardice in isolation. It sits alongside the dozens of hospitals that have curtailed or closed transgender youth care under threats from the Trump administration—often in direct violation of state law—while state attorneys general decline to enforce those protections against compliant hospitals. Over the past year alone, more than 20 hospitals have formally shut down all transgender youth care, with many more doing so quietly. In numerous cases, those decisions run afoul of state statutes that explicitly or implicitly protect gender-affirming care. And while there has been a notable exception—CA AG Rob Bonta’s lawsuit in California seeking to restore care after a hospital abandoned its obligations—what has defined this moment more broadly is institutional retreat: a pervasive unwillingness to fight for LGBTQ+ youth in the face of political threats from the far right and President Trump.

Even organizations tasked with protecting transgender people have abdicated that responsibility. Institutions such as Fenway Health in Massachusetts have dropped transgender youth health care, despite having been founded explicitly to protect vulnerable communities from politically withheld medical care. And it is impossible to ignore the elephant in the room that preceded the ASPS announcement: the recent New York lawsuit over gender-affirming masculinizing chest surgery, in which Dr. Loren Schechter, president-elect of the World Professional Association for Transgender Health, testified on behalf of a detransitioner who regretted gender-affirming care and ultimately won a large monetary award. And while to Dr. Schechter’s credit, that case may have featured legitimate malpractice not present in virtually any other case involving a detransitioner, it was shortsighted not to anticipate that such testimony—offered in a blue state—would play into the kind of coordinated blitz now unfolding, as anti-trans forces seize on the outcome they had been waiting to exploit.

Instead, it is difficult to view the actions of the American Medical Association and the American Society of Plastic Surgeons as anything other than cowardice. These organizations were neutral to, and at times even supportive of, transgender health care when the political winds favored doing so. It is easy to take principled stances when there is little cost. Now, as hospitals face discrimination lawsuits from transgender patients whose care has been dropped in blue states and as federal threats escalate, the timing of these statements makes their purpose clear: to shield hospitals in blue states from discrimination claims by preemptively narrowing standards of care. Little has changed about the underlying medical evidence. What has changed is the political environment. These decisions come not after new science, but after institutional capitulation and sustained pressure from the Trump administration. They are not medical judgments. They are political ones.

And it is important to recognize that this kind of preemptive cowardice is not theoretically confined to surgical care for transgender youth. The same tactics can be deployed against all transgender health care, including care for adults. Many of the same actors pushing these moves have made clear that this is only the beginning. And once this model is normalized, there is little reason to believe it will stop with transgender care. Any form of medical treatment that becomes politically inconvenient—PrEP, birth control, vaccines, antidepressants, and more—can be subjected to the same pressure campaigns and legal intimidation. These actions must be understood for what they are: a blueprint for eliminating any care that those in power disagree with.

And it is impossible to ignore the blatant hypocrisy embedded in the American Society of Plastic Surgeons position statement. Procedures such as rhinoplasty, gynecomastia surgery, and other aesthetic interventions remain entirely acceptable within ASPS standards. And while ASPS does not formally “recommend” breast augmentation surgery for cisgender patients under 18, many plastic surgeons continue to perform those procedures without any apparent enforcement effort from the organization. It is only when care involves transgender patients that the guns come out.

With all of this said, it is clear that transgender people are among those most impacted by institutional capitulation to the far-right project of eliminating the people it deems most disposable. But this, too, is not new. For decades, medical institutions forced transgender women to socially transition for years before granting access to hormones—a cruel and dangerous gatekeeping regime that pushed people into public exposure long before they could achieve any measure of safety. Institutions such as Johns Hopkins Hospital abruptly shut down transgender health care after declaring transgender people mentally ill in the 1970s. And for generations, trans people have been driven into black- and gray-market care, not by choice, but by medical systems that viewed them as expendable or worse.

And so, as pressure from the far right continues to intensify and hospitals and institutions choose cowardice, trans people and the providers who serve us are once again being pushed to the margins. The ASPS statement will make care harder to access for some transgender youth and may be further weaponized to target adults as well. But history makes one thing clear: care does not disappear—it moves. Even as major hospitals retreat, independent providers continue to step in. Organizations like the Trans Youth Emergency Project have already been routing patients to clinics willing to provide care, often quietly and through word of mouth. Informal and gray-market pathways persist, not because they are ideal, but because political cowardice leaves people with no other choice.

At the same time, blue states remain one of the few institutional counterweights left, passing and updating shield laws to protect providers from abusive lawsuits, malpractice threats, and the weaponization of captured professional bodies like ASPS. Those protections will need to keep evolving as attacks do, and those of my many readers with such connections should strategize on how to lobby in the face of these recent strategies. What this moment makes unmistakably clear is that the American medical establishment, as an institution, cannot be relied upon to defend transgender care… it never could be. That work will continue to fall to individual providers, independent clinics, state lawmakers, and communities willing to act creatively and defiantly. As it has always been, transgender people will survive not because institutions protect us, but because we build parallel systems of care under a political regime increasingly committed to our erasure.