2016 Study: ‘Wild West’ Trans Surgery Regulated by ‘Subjective Criteria,’ ‘Personal Conviction,’ 55% Operate on Minors

Gender reassignment surgeries are the “Wild West,” according to practitioners interviewed for a study from 2016 titled, “Age Is Just a Number.” The study conducted lengthy interviews with 20 Americans who performed “vaginoplasty,” an operation that amputates healthy male genitalia and refashions it into a dysfunctional imitation of female genitalia. Some of the surgeons “were alarmed at the absence of surgical standards and the ease of entering the subspecialty without any documented training.” Of those surveyed, 11 out of 20 surgeons (55%) had performed a vaginoplasty on one to 20 minors aged 15 to 17 — and this was seven years ago.

The researchers, Christine Milrod and Dan Karasic, noted that surgeons who perform “irreversible” vaginoplasties on boys under the age of 18 “thereby contravene or sidestep” the Standards of Care (SOC) published by the World Professional Association for Transgender Health (WPATH), at least as they stood in 2016. WPATH is a transgender advocacy organization. Its SOC for gender reassignment procedures, along with that of the Endocrine Society that largely copies it, informs the practice of most U.S. medical providers. In recent debates over SAFE Acts and similar state laws, health care providers have often defended their actions by claiming to follow the WPATH SOC.

However, “a plurality of participants perceived the SOC as purposely ‘vague’ and more as ‘inherently flexible guidelines’” regarding the minimum age requirement, said Milrod and Karasic. Without firm guidance, these surgeons decide whether to perform a vaginoplasty on a minor teen boy based on “subjective criteria,” such as “evaluations by other professionals, careful patient selection, and the personal conviction that proceeding with surgery is the right decision.”

“The problem is that it [the WPATH SOC] is up to interpretation, and that’s where the dangers lie,” said one urologist they interviewed. Some respondents complained that WPATH “lacked interest in promoting surgical standards” while others “favor[ed] the SOC as sufficiently vague.”

Compounding the confusion from this “inherently flexible” SOC was a lack of published data on the topic. “In all age groups,” gender reassignment surgery “had been a very small part of surgical medicine until very recently,” practitioners informed the researchers, and “data on large volumes of procedures were not yet available.” For surgery on minors, this scarcity of data became nonexistence. “The available research literature contains no data on vaginoplasty in transgender minors,” reported Milrod and Karasic, and every surgeon they interviewed who had performed vaginoplasties on minors had “refrained from publishing any peer-reviewed outcome data.”

The researchers dug deeper into the motivations behind discarding the SOC age guidelines. “Among nearly all surgeons, the term maturity rather than specific chronological age defined the desired mental readiness criterion for undergoing vaginoplasty and participating in crucial postsurgical dilatation,” they found. “Age is arbitrary. The true measures of how well a patient will do are based on maturity, discipline and support,” said one surgeon. “I will see a 16-or 17-year-old that I will agree to do surgery on, and then there could be another one I won’t agree to, based on sexual and physical maturity,” said another.

But some study participants had an unusual definition of maturity. “The biggest concern is, will they be mature enough to be able to take care of themselves after surgery?” said one surgeon. “Some of my biggest struggles have not been with the 16-year-old group because they are still at the parents’ house — it is the 18-year-olds who disappear and go to college within a few months after their surgery. Those are the patients who are most likely to lapse in their aftercare.” (A vaginoplasty requires invasive, painful, and time-consuming post-operative intervention to prevent the biological male’s body from re-sealing the artificially created hole, as its genetic programming dictates.) To this surgeon, “maturity” simply means someone will follow through on “aftercare,” which he says depends more on their surroundings than their actual maturity level; the same individual who is “mature” enough while under his parent’s roof at age 16 would not be mature enough at age 18 when he leaves home for college.

The researchers noted the ethical “dilemma” produced by the nebulous definition of maturity. “Even if the surgeon deems the teenager to be mature and expressing a definite intent to undergo the procedure, there simply might not be sufficient recognition of its finality,” they said. This dilemma caused particular concern because the surgeons did not seem to have a clinician’s normal fear of “making the wrong diagnosis,” and “mostly denied concerns about lawsuits or fears of postsurgical regret among their adolescent patients.”

Other surgeons agreed that “the confluence of undergoing vaginoplasty and leaving home to become a college student in the same year” was “problematic.” One argued, “what is going on socially with the patient is more important than the age.” Another said that the difficulty of getting college students to “adhere to their dilation schedule” with “their busy lifestyles” is “the reason why I decided to operate on people younger than 18.”

Some surgeons preferred to perform vaginoplasties while an adolescent remained at home as a way to mitigate legal liability. “Engaging in best practices, maintaining open communication with the patient and [his] parents, and above all providing good results were seen as protective measures against any legal action,” the researchers noted. One surgeon spoke for several “younger patients who have the support of their families, support of their parents, and can have the operation while they are still at home … anecdotally tend to do much better.”

However, “the vast majority of participants were not concerned with malpractice lawsuits from parents or even from the patients as adults in the future,” reported Milrod and Karasic. As a result, “nearly all participants reported an overwhelming reliance on mental health practitioners to assess the minor’s psychological readiness for surgery.”

However, some surgeons articulated a broader vision of their responsibility of the minor’s psychological readiness. “It should be the surgeon, not the hormone prescriber. There is a lot of misinformation that the hormone prescribers give, in my opinion. They have no business talking about surgical issues, unless they have training,” stated one. “I scrutinize the letters that the mental health providers forward to me,” said another. “Then I rely on my own experience. I cover everything that I believe should have been covered in the letter, and then I go through that list of capacity, development, all those issues in my checkoff list. I do this because any other way is a disservice to the patient; I’m responsible for all that.” The researchers noted that was the minority view.

One surgeon feared that minors might only have a temporary desire for an irreversible surgery, or might be influenced by classroom education and peer pressure. “Many trans patients do not want GCS — it could be that at 15 they do, and at 25 they do not,” said one. “It goes along the lines of a young person’s mind still being in the developmental stage. … They may reorient their thinking about which surgery will serve their transgender needs.”

Another surgeon feared that minors seeking surgery might be influenced by classroom education and peer pressure. “There are a lot of classes that adolescents, even preadolescents in elementary schools, are getting these days,” he said (in 2016). “They are doing it because it is a new norm, versus what they really want. I have seen some of my patients’ children go through phases of in and out, of thinking transgender. So that would be my concern — is it because it is popular now?”

In the 2016 study, all the surgeons who performed vaginoplasties on minors obtained parental consent, but they adopted “a few different approaches to securing consent,” the researchers noted. Consent forms ranged in length from five to 40 pages, and some surgeons added additional requirements. One “explicitly required the parents to become active participants in the postoperative dilatation process,” while another required the minor to write an essay about his reasons for wanting surgery. “Comparatively few participants addressed the issue of postsurgical infertility,” said Milrod and Karasic, either because “the topic had been explored beforehand with other practitioners” or simply because it was “not often something that is at the forefront of people[’s minds].”

In many contexts, medical consent forms are standardized by law. In 2023, Arkansas passed a law stipulating the text of informed consent documentation that gender reassignment providers must provide (their SAFE Act is suspended due to a legal challenge). However, these researchers found no standardization.

Every surgeon who decided to perform a gender reassignment surgery on a minor did so without the guidance of a standard of care or any other physician. In fact, Milrod and Karasic stated, “there are no guidelines in the WPATH SOC that support the surgeon in the decision to perform vaginoplasty on transgender women younger than 18 years.”

Adding to the difficulty was the growing number of patients on puberty blockers. “Almost all surgeons remarked on” how puberty blockers made their job harder. As part of blocking puberty, the hormones prevented the male genitalia from developing enough tissue for the plastic surgeons to sculpt into the opposite form. This forced them to pull skin grafts from the patient’s arm, which causes unsightly scarring, or take tissue from other systems, such as the colon, which could cause other harmful side effects.

The researchers added, “most participants had noticed a definite increase in the number of minors requesting information about the procedure on their own or being referred for vaginoplasty by their mental health providers.” If not minors, the patients are still very young adults. One surgeon estimated that 85% of his gender reassignment patients were over 25 years old when he began his practice, but “only 40% of my patients are older than 25 in the last nine years [2007-2016].”

This increase in demand had sparked an increase in surgeons willing to perform vaginoplasties. “The biggest reason for why everyone is doing it now is, the money is flowing,” said one surgeon. “Now insurance is paying. And now all these institutions have to have a program yesterday.”

The same surgeon lamented that many of his newer colleagues were “not doing it correctly, in my opinion.” He explained, “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; … they learn for a week, and they start doing them. And that is completely unethical!”

“I have seen horrific unethical practices by surgeons who lie about their experience and horrific results surgically as a result of that,” continued the surgeon. “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.”

Another surgeon complained about “a bunch of solo practitioners, basically cowboys or cowgirls who kind of build their little house, advertise, and suck people in” — evoking the “Wild West” metaphor. Several of the surgeons urged WPATH to adopt “more stringent professional requirements,” although at least one thought this should come with lowering the minimum age. In the latest edition of the WPATH SOC, they did modify the guidance — by eliminating minimum age requirements.

“As the field matures, it is certain that the WPATH will play a more prominent role,” predicted the researchers, and “the rate of such procedures will likely continue to increase.”

Seven years later, the rate of gender reassignment surgeries on minors has certainly increased. But attempts to regulate and standardize the practices have stalled out, at least in medical associations.

Many state legislators have introduced bills to address the problem, although they often face hyper-partisan backlash, even when they also receive bipartisan support. Any effort to curtail the “Wild West” of gender reassignment procedures on minors — whether it bans the procedures or merely regulates them — has been lumped into a single category of “attacks on LGBTQ healthcare.”

Among the arguments opponents of state legislative efforts to prevent gender reassignment procedures hurl at the bills, they sometimes claim that gender reassignment surgeries are never performed on minors. According to this 2016 study, 55% of surgeons they interviewed had performed gender reassignment surgeries on minors, and one surgeon had performed as many as 20 of them.