The Biden administration has made an apparent shift in its view on gender-affirming surgeries for transgender and non-binary youth, alarming doctors as well as 2SLGBTQ+ rights groups that are already fighting a barrage of anti-trans legislation across the country.

In recent media statements, the White House expressed its opposition to such surgeries for minors — which are rare — despite having expressed support for protecting access to gender-affirming care for minors and preventing discrimination in health care. 

"These are deeply personal decisions and we believe these surgeries should be limited to adults," a White House spokesperson said in a statement this week to The 19th, a website reporting on gender politics and policy. 

That followed an earlier statement to The New York Times in response to its reporting that administration health officials had pushed to have age limits for gender-affirming surgeries removed from guidance on transgender health care provided to medical professionals around the world. 

Advocates fear the remarks will fuel anti-transgender movements and conservative legislators seeking to restrict access to all forms of gender-affirming care for young transgender and non-binary people, despite various medical associations insisting such care is vital. 

A one-size-fits-all approach to the issue isn't helpful to patients who are better off with the case-by-case care decided upon with their families and medical professionals, according to Dr. Meredithe McNamara, an assistant professor at the Yale School of Medicine and an adolescent medicine physician.

"It's really hard to tell somebody that … you may need, desire and otherwise qualify for this care, but written on a piece of paper it says that you're not old enough yet." 

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Justifying medical care harmful, doctor says

The New York Times report that spurred the White House comments was published last week. It detailed how Department of Health and Human Services assistant secretary Dr. Rachel Levine urged the World Professional Association for Transgender Health (WPATH) to remove surgery age limits from the standards of care guidance it publishes and distributes to health-care providers around the world.

Levine — the highest-ranking openly transgender U.S. government official — was concerned the inclusion of age limits for certain surgeries could have negative consequences when it comes to anti-transgender legislation and access to care, according to the Times. 

McNamara says doctors haven't had to justify any forms of medical care to government bodies in the past, and that it's harmful to have to do so in these cases.

"It scares our patients. It dissuades them from coming in to get care."

CBC News reached out to the White House and the Department of Health and Human Services, but did not hear back.  

In recent years, the U.S. has seen a swell of proposed legislation targeting transgender rights and gender-affirming care for minors.

The American Civil Liberties Union has tracked 527 anti-2SLGBTQ+ bills introduced so far in 2023. Of those, 78 pertain to health-care restrictions. Many are facing court challenges. 

The Supreme Court will also take up the issue in its next session, weighing whether or not bans on access to puberty blockers and hormone therapy for transgender and non-binary youth are constitutional.

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Surgeries for trans youth not common

Gender-affirming surgical procedures can include facial feminization/masculinization, the removal of breast tissue, breast enhancements and genital transformation and reconstruction surgeries. 

These procedures aren't a first course of action, McNamara says, and are by no means necessary or desired by all patients — whether they're in adolescence or adulthood — nor are they easily accessible to most people. 

Social transition and non-surgical medical treatments, such as the prescription of puberty blocking medication or hormone treatments, may be as far as some want to go when it comes to their transition, she explained.

McNamara told CBC News that providing access to reversible non-surgical treatments such as puberty blockers, will often limit a patient's need or desire for surgery later in life. She says those treatments are being singled out, banned and criminalized.

Proponents of restricting gender-affirming care for young people argue that there is not enough research on the outcomes and risks of such treatments and claim that medications like puberty blockers and hormone therapy are irreversible. They also say that adolescents are making decisions about surgeries without knowing the consequences.

There is limited reliable data on how many people under the age of 18 have undergone gender-affirming surgeries. 

According to the Cleveland Clinic, between 25 to 35 per cent of transgender and non-binary people in the U.S. opt for gender-affirming surgeries. 

A 2023 study led by Columbia University found that out of more than 48,000 patients who underwent gender-affirming surgeries between 2016 and 2020, 7.7 per cent (3,678) were aged 12 to 18 years, with breast or chest surgeries accounting for the overwhelming majority of the procedures.

That's a tiny fraction of the some 1.6 million transgender people ages 13 and up in the U.S., according to an estimate from the Williams Institute at the University of California-Los Angeles School of Law.

McNamara says that among the thousands of adolescent patients she treats, very few are transgender and even fewer — enough to count on her hands — have expressed an interest in having gender-affirming pharmaceutical therapies, let alone surgery. 

She says that throughout her career, she's only heard of one person under the age of 18 seeking any sort of surgery and it was someone dealing with "extreme dysphoria related to chest discomfort" and rib fractures following years of binding their breasts. 

According to McNamara, far more gender-affirming procedures are performed on cisgender children, such as the removal of excessive male breast tissue due to a condition called gynecomastia.

She also notes cosmetic surgeries that have nothing to do with gender-affirming care for trans youth are far more common and have no government-imposed age limits.

"The number of pre-operative clearances that I have done for breast augmentation, for Brazilian butt lifts in adolescents, far outnumbers even the mention of gender-affirming surgeries for transgender people in my practice."

2SLGBTQ+ groups critical of White House statement

McNamara is concerned that disinformation about gender identity and gender-affirming care laid the groundwork for the Biden administration's stance on gender-affirming surgeries for minors.

CBC News reached out to several U.S. transgender and 2SLGBTQ+ advocacy organizations, but did not receive responses. 

However, a number of groups have criticized the White House statement as both harmful and ill-informed. 

Advocates for Trans Equality executive director Rodrigo Heng-Lehtinen said in a statement that trans youth and their families rely on their doctors and medical research to make the right decisions about health care, and the government should stay out of it. 

"Sadly, the Biden Administration has chosen to put politics over science, and that mistake backs up the bullies, reinforces misinformation from extremists, and puts lives in jeopardy," the statement read. 

"It's wrong on the science and wrong on the substance," said Kelley Robinson, the president of the Human Rights Campaign, on the group's website, which also noted the White House statement isn't consistent with the administration's previous commitments to protect transgender health care. 

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