Publisher Health

Michael, 17, arrived in the sleek white waiting room of his plastic surgeon’s office in Miami for a moment he had long anticipated: removing the bandages to see his newly flat chest.

After years of squeezing into compression undershirts to conceal his breasts, the teenager was overcome with relief that morning last December. Wearing an unbuttoned shirt, he posed for photos with his mother and the surgeon, Dr. Sidhbh Gallagher, happy to share his bare chest with the doctor’s large following on social media.

“It just felt right — like I’d never had breasts in the first place,” Michael said. “It was a ‘Yes, finally’ kind of moment.”

Michael is part of a very small but growing group of transgender adolescents who have had top surgery, or breast removal, to better align their bodies with their experience of gender. Most of these teenagers have also taken testosterone and changed their name, pronouns or clothing style.

Few groups of young people have received as much attention. Republican elected officials across the United States are seeking to ban all so-called gender-affirming care for minors, turning an intensely personal medical decision into a political maelstrom with significant consequences for transgender adolescents and their families.

Gender-related surgeries, in particular, have been thrust into the spotlight. Arizona and Alabama passed laws this year making it illegal for doctors to perform gender-related surgeries on transgender patients under 18. Conservative commentators with large followings on social media have recently targeted children’s hospitals that offer gender surgeries, leading to online harassment and bomb threats.

Genital surgeries in adolescents are exceedingly rare, surgeons said, but top surgeries are becoming more common. And while major medical groups have condemned the bans on gender-related care for adolescents, the surgeries have presented challenges for them.

Much research has shown that as adults, transgender men generally benefit from top surgery: It relieves body-related distress, increases sexual satisfaction and improves overall quality of life. A few small studies of transgender adolescents suggest similar benefits in the short term.

But some clinicians have pointed to the rising demand and the turmoil of adolescent development as reasons for doctors to slow down before offering irreversible procedures. Although medical experts believe the likelihood to be small, some patients come to regret their surgeries.

The World Professional Association for Transgender Health, an international group of gender experts who write best practices for the field, had been planning for months to set new age minimums for most gender-related surgeries, including endorsing top surgery for adolescents age 15 and up. Although the guidelines are not binding, they provide a standard for doctors across the world. But this month, the group abruptly withdrew the proposals, a shift reflecting both political pressures and a lack of consensus in the medical community.

There are no official statistics on how many minors receive top surgeries each year in the United States. The New York Times surveyed leading pediatric gender clinics across the country: Eleven clinics said they carried out a total of 203 procedures on minors in 2021, and many reported long waiting lists. Another nine clinics declined to respond, and six said that they referred patients to surgeons in private practice.

Dr. Gallagher, whose unusual embrace of platforms like TikTok has made her one of the most visible gender-affirming surgeons in the country, said she performed 13 top surgeries on minors last year, up from a handful a few years ago. One hospital, Kaiser Permanente Oakland, carried out 70 top surgeries in 2019 on teenagers aged 13 to 18, up from five in 2013, according to researchers who led a recent study.

“I can’t honestly think of another field where the volume has exploded like that,” said Dr. Karen Yokoo, a plastic surgeon at the hospital.

Experts said that adolescent top surgeries were less frequent than cosmetic breast procedures performed on teenagers who were not transgender. Around 3,200 girls aged 13 to 19 received cosmetic breast implants in 2020, according to surveys of members of the American Society of Plastic Surgeons, and another 4,700 teenagers had breast reductions.

An evolving field

In the past decade, the number of people who identify as transgender has grown significantly, especially among young Americans. Around 700,000 people under 25 identified as transgender in 2020, according to the Williams Institute, a research center at the University of California, Los Angeles, nearly double the estimate in 2017.

Gender clinics in Western Europe, Canada and the United States have reported that a majority of their adolescent patients were seeking to transition from female to male.

Because breasts are highly visible, they can make transitioning difficult and cause intense distress for these teenagers, fueling the demand for top surgeries. Small studies have shown that many transgender adolescents report significant discomfort related to their breasts, including difficulty showering, sleeping and dating. As the population of these adolescents has grown, top surgery has been offered at younger ages.

Another notable change: More nonbinary teenagers are seeking top surgeries, said Dr. Angela Goepferd, the medical director of the Gender Health Program at the Children’s Minnesota hospital, who is nonbinary. (The program does not perform operations but refers patients to independent surgeons.) These adolescents may want flatter chests but not other masculine features brought on by testosterone, like a deeper voice or facial hair.

After many months of deliberations over its new guidelines, the World Professional Association for Transgender Health initially decided to endorse top surgeries for adolescents 15 and up, part of a suite of changes that would have made gender treatments available to children at younger ages. But the organization backtracked this month, after some major medical groups it had hoped would support the new guidelines bristled at the new age minimums, according to Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the president of WPATH, who is transgender.

“We needed consensus,” Dr. Bowers said. “I just think we need more strength for our argument and a better political climate, frankly, in order to propose this at a younger age.”

Instead, the guidelines kept the previous recommendations, published a decade ago, allowing surgeries for minors on a case-by-case basis.

Because teenagers in most states must be 18 before they can provide medical consent, surgeons require parental consent and approval letters from mental health care providers. The two- to four-hour procedure costs anywhere from $9,000 to $17,000, depending on facility and anesthesia fees. The procedure is often not covered by insurance until patients turn 18.

As demand has grown, Dr. Gallagher, the surgeon in Miami, has built a thriving top surgery specialty. The doctor frequently posts photos, FAQs and memes on Facebook, Instagram and TikTok, proudly flouting professional mores in favor of connecting with hundreds of thousands of followers.

Her feeds often fill with photos tagged #NipRevealFriday, highlighting patients like Michael whose bandages were just removed. On her office windowsill sits a framed nameplate with one of her best-known catchphrases on TikTok: “Yeet the Teet,” slang for removing breasts.

Dr. Gallagher said she performed top surgeries on about 40 patients a month, and roughly one or two of them are under 18. Younger patients are usually at least 15, though she has operated on one 13-year-old and one 14-year-old, she said, both of whom had extreme distress about their chests.

The surgeon said that most of her patients, teenagers and adults alike, found her on TikTok. Her online presence has drawn sharp criticism from right-wing media, as well as from some parents and doctors who say she uses the platform to market to children.

“She goes to the beat of her own drum,” Dr. Bowers said. “For a lot of us, that’s troubling.”

Dr. Gallagher said she doubted she had the influence her critics ascribe to her. “Most of the time I’m just trying to deliver educational content,” she said.

‘Comfortable in my own skin’

When Michael first saw Dr. Gallagher’s TikTok page last summer, he was immediately intrigued. (Michael and others in this article asked to be identified by first or middle names because they were concerned about their privacy.) He liked the photos of her patients, observing that their scars had healed well, and liked that she seemed to be an ally of the transgender community.

Michael’s mother, Annie, had gradually come around to the idea of surgery after years of watching him suffer, she said.

Since hitting puberty at age 10, Michael said he felt a gnawing discomfort about his breasts. By the time he was 12, he wore hooded sweatshirts every day in their Miami suburb.

In eighth grade, after he had several severe panic attacks at school, Michael said he started seeing a therapist, who encouraged him to talk about his body issues. He experimented with small ways to appear more masculine, such as tucking his long curly hair into a beanie and wearing boys’ clothes.

“It was the first thing I ever did to try and make myself more comfortable in my own skin,” Michael said.

He came out to his parents as a transgender boy when he was 14. A year later, at the start of the pandemic, he started weekly testosterone injections while doing remote school. He got into strength-training and his voice dropped, a second puberty he relished but was grateful to undergo privately.

Michael started in-person school feeling “10 times happier,” he said, but his chest still tormented him. Testosterone and exercise had shrunk his breast tissue, making it easier to conceal with a binder. But the garment could restrict his breathing and give him panic attacks. He began seeing a psychiatrist, who prescribed antidepressants.

When Michael was 17, Annie said, she decided that waiting another year for surgery would put him in too much pain. Because her insurance covered the procedure only for adults, she took out a loan to help pay for it.

Michael’s psychiatrist initially wrote a letter signing off on the surgery. But he later revoked it, putting the surgery in limbo, Annie said. After Michael started a higher dose of antidepressants, the psychiatrist endorsed the surgery as planned.

Now, nine months after the operation, Michael is in his senior year of high school. He said he is focused on the parts of his life that have little to do with his gender: doing theater tech at school, seeing friends, painting and applying to college.

He also feels less pressure to prove his masculinity than before, he said. He’s growing out his hair and uses he, she and they pronouns. In June, he took his girlfriend to the prom, wearing a brown suit and a pearl necklace.

Weighing the risks

In 2018, doctors at the pediatric gender clinic at Children’s Hospital Los Angeles published a study of 136 transgender patients ages 13 to 25, half of whom had undergone top surgery. Adolescents who had not undergone the procedure reported significantly more distress because of their chests.

Roughly one-third of those who underwent surgery reported ongoing loss of nipple sensation. Only one patient expressed occasional feelings of regret, when imagining wanting to breastfeed a future child.

“There’s very few things in the world that have a zero percent regret rate. And chest surgery, clinically, I’ve experienced that,” said Dr. Johanna Olson-Kennedy, the lead author of the study and medical director of the clinic in Los Angeles, which began offering surgeries in 2019.

But the study had caveats: Most patients were surveyed less than two years after their surgeries, and nearly 30 percent could not be contacted or declined to participate.

Few researchers have looked at so-called detransitioners, people who have discontinued or reversed gender treatments. In July, a study of 28 such adults described a wide array of experiences, with some feeling intense regret and others having a more fluid gender identity.

Because so few studies have looked at detransitioning, many doctors are asking young patients and their parents to provide consent without acknowledging the unknowns, said Kinnon MacKinnon of York University in Toronto, the researcher who led the study, who is transgender.

“I know personally many, many, many trans men that have benefited and are happy with their medical transition and their top surgery. I would put myself in that category,” Dr. MacKinnon said. “But just as a researcher, I do feel like there are questions that are deserving of answers and have implications for clinical care.”

Jamie, a 24-year-old college student in Maryland, was raised as a girl and began identifying as a transgender boy in the eighth grade. After being sexually assaulted and dropping out in her junior year of high school, she said she started taking testosterone. Three months later, just after she turned 18, she underwent top surgery at a private practice in Massachusetts.

For the next few years, Jamie said, she thrived. Testosterone made her feel energetic, and her anxiety dissipated. She went back to school and got certified as an emergency medical technician.

But when she was 21, her father, who was dying of Alzheimer’s, no longer recognized her. She fixated on her wide hips, which she worried stood out next to her facial hair and deep voice. After a date where she had sex with a straight man, she said, she realized she had made a mistake.

“I realized I lost something about myself that I could have loved, I could have enjoyed, I could have used to feed children,” Jamie said. She said she grieved for months and contemplated suicide.

This spring, after a year of fighting her insurance company to cover the procedure, she had surgery to reconstruct her breasts. She never told her original surgeon that she had changed her mind, partly because she also blamed herself. Sometimes, she said, “I still don’t like being a woman.”

Many surgeons say that they rarely hear about patients with regret. But it’s unclear how many, like Jamie, never inform them.

Dr. Gallagher of Miami said that she follows up with patients for up to a year. “I can say this honestly: I don’t know of a single case of regret,” Dr. Gallagher said in May, adding that regret was much more common with cosmetic procedures.

But one of her former top surgery patients, Grace Lidinsky-Smith, has been vocal about her detransition on social media and in news reports.

“I slowly came to terms with the fact that it had been a mistake borne out of a mental health crisis,” Ms. Lidinsky-Smith, 28, said in an interview.

She had top surgery when she was 23. About 16 months later, Ms. Lidinsky-Smith said she called and emailed her medical providers, including Dr. Gallagher’s office, to tell them she had detransitioned.

When asked about Ms. Lidinsky-Smith’s case, Dr. Gallagher amended her stance, recalling that years ago, a former patient had left a voice mail message saying they regretted their surgery.

“At the time, we wondered, ‘Is it a hoax?’” Dr. Gallagher said.

Chilling effect

Republican politicians in states across the country are pushing to ban all gender-affirming care for adolescents, focusing much of their rhetoric on surgeries.

In Florida, where the medical board is considering such a ban for minors, Gov. Ron DeSantis has argued that surgeons should be sued for “disfiguring” children. In Texas, where parents of transgender children have been investigated for child abuse, Gov. Greg Abbott has called genital surgeries in adolescents “genital mutilation.”

Dr. Bowers, the president of WPATH, said that politicians should not be involved in personal medical decisions. “They just don’t understand this care, so they just want to shut it down,” Dr. Bowers said. “That is a very dangerous precedent.”

Although most of the new state actions against gender care for minors are tied up in litigation, they have had a chilling effect.

Earlier this year, a Dallas children’s hospital shut down the only pediatric gender clinic in Texas, citing political pressure from the governor’s office. This month, a woman was arrested on charges of making a false bomb threat to Boston Children’s Hospital after it was targeted online for its pediatric gender program. Dr. Gallagher also received threats online and said she might hire security guards for her office.

Other clinics have dropped scheduled procedures. William, 14, who has identified as a boy since he was a young child, was supposed to see a plastic surgeon in Plano, Texas, for top surgery in May. But the surgeon canceled the appointment in March because the medical center’s malpractice insurer stopped covering top surgeries for minors.

In August, William and his family flew to California, paying $10,000 more to get the procedure out of state.

Two weeks later, William started ninth grade as just another boy in school. He looks forward to swimming with his shirt off and going to class without wearing a binder.

“It’s like something was unburied,” William said. “My chest was just covering what was always there.”