How Harvard Teed Up the False Claim That the 'Vast Majority of Minors Getting Gender-Affirming Surgeries Are Cis Kids'

An opaquely written Harvard study and linked press release prompted false reporting that gynecomastia surgeries for boys are vastly more common than gender-affirming surgeries for trans kids.

This erroneous headline appeared in the LGBTQ news site Them on June 28.

Readers of the LGBTQ media outlet Them could be excused for harboring the false belief that out of all surgeries that affirm the gender of minors in the U.S., the vast majority are gynecomastia operations on cisgender (non-transgender) boys to remove breast growth. (The idea is that by surgically removing a physical characteristic that makes boys appear more feminine, the operation affirms their male identity.) A Them article published June 28 falsely claims that for minors, gender-affirming surgeries among these cis boys dwarf such operations among transgender people under age 18.

The reporter from Them apparently followed the combined lead of an opaquely written research letter and a misleading and opaquely written associated press release.

In its headline, the press release, issued by Harvard’s public health school, proclaims, “Gender-affirming surgeries rarely performed on transgender youth”—an almost certainly false claim given the limitations of the research letter’s data set, as well as the findings of other researchers (more on those a bit later on).

The Harvard press release’s erroneous headline

The research letter was published in JAMA Network Open on June 27 and written by a team out of Harvard, Boston Children’s and Brown University. It sought to compare how common gender-affirming surgeries were based on whether individuals were adults or minors and whether they were what’s known as transgender and gender diverse (TGD) or were cisgender. They examined what the Harvard-issued press release characterized as a “nationally representative pool of medical insurance claims” from 2019.

This pool included data on 47.4 million adults age 18 and older and 22.8 million minors. This is a fraction of the overall U.S. population of either group. U.S. medical databases are always limited and never able to capture the full incidence of any medical procedure, because they never cover all Americans. For this study, the authors also couldn’t capture surgical procedures paid for out of pocket. So the true figures are likely much higher (a more recent investigation found much higher figures; more on this later).

Looking at data on trans and gender diverse people, the study found evidence of 2,664 gender-affirming surgeries in adults and 85 such surgeries among minors in 2019. A total of 59.7% (1,591 of 2,664) of the surgeries in TGD adults and 96.4% (82 of 85) of the surgeries in TGD minors were chest-related procedures. The investigators did not break this down according to whether these were double mastectomies (known as “top surgery,” conducted on trans males), breast augmentations (for trans females), or other procedures. But at least in minors, such surgeries are overwhelmingly mastectomies, according to other research I’ll go into later on.

Here’s where the Harvard research letter gets opaque: Without specifying that they are going on to discuss a category of surgeries that are distinct from chest-related gender-affirming surgeries, the authors then write:

“Of the 636 breast reductions among cisgender male and TGD adults, 507 (80%) were performed on cisgender males. Of the 151 breast reductions among cisgender male minors and TGD minors, 146 (97%) were performed on cisgender male minors.”

I was baffled as to why the researchers broke down their numbers this way. Why make an apparent differentiation between top surgery and breast reductions? So I emailed the authors and heard back from Dannie Dai, a research data analyst in the department of health policy and management at Harvard’s public health school. Dai said that in order to make an even comparison between trans and cisgender individuals’ surgeries, they “needed to select a gender-affirming surgery that is commonly covered by insurance for minors and adults of cisgender and TGD identity. The only gender-affirming surgery that met this criteria was breast reduction surgery.”

This begs the question of why the study authors made this comparison in the first place when they knew that it would leave out the vast majority of gender-affirming surgeries among trans minors. Plus, they might’ve imagined that their findings would be misinterpreted.

A breast reduction surgery is sometimes sought by natal females who identify as nonbinary and who wish to reduce the size of but not completely eliminate their breasts. Such surgery is thus distinct from a double mastectomy. Despite this crucial distinction, neither the research letter nor the Harvard press release clarified the matter. Here’s how the press release describes the figures:

“For teens ages 15 to 17 and adults ages 18 and older, the rate of undergoing gender-affirming surgery with a TGD-related diagnosis was 2.1 per 100,000 and 5.3 per 100,000, respectively. A majority of these surgeries were chest surgeries. When considering use of gender-affirming breast reductions among cisgender males and TGD people, the study found that cisgender males accounted for the vast majority of breast reductions, with 80% of surgeries among adults performed on cisgender men and 97% of surgeries among minors performed on cisgender male teens.”

Notice how the release makes no clear indication that midway through this passage, it is switching to discussing a different category of surgery. Readers are likely to presume that chest surgeries and breast reductions are synonyms. And the passage also makes no mention of the specific sums of the different types of surgeries.

Plus, neither the press release nor the research letter state the major limitation—one that calls into question whether the investigators’ tallies of surgeries are anywhere close to the true national figures—that the medical-claims database on which the investigation relied only covered a fraction of the U.S. population.

Let’s dispel the myth propagated by both the press release and the Them article that the “vast majority” of gender-affirming surgeries in minors are conducted on cisgender boys. (Note that the press release in question is dated July 8, and thus was published after the Them article. I haven’t been able to find a version of the release published prior to the article; perhaps the press-release copy that prompted the article went out only via email. It’s possible the Them article was written based on a somewhat different press release than what is currently on the Harvard web site; but the article makes clear it drew a quote from Dai from a press release.)

Let’s combine the 82 chest-related gender-affirming surgeries conducted on TGD minors in 2019 with the 5 breast-reduction surgeries and compare that sum with the 146 gynecomastia surgeries conducted in cisgender boys. Out of 233 total surgeries, that would break down to 87, or 37%, among TGD minors, and the remaining 62% would be among cisgender boys.

I would hardly characterize a figure under two-thirds as the “vast majority”.

But such a comparison between the TGD and cisgender kids is still misleading, because trans kids make up small minority—perhaps 1.4%—of all minors. If adjusted for differences in the estimated sizes of the TGD vs. cisgender minor populations, the surgical rate in trans kids would dramatically dwarf that of the cisgender kids.

Big Names Push the Same Misinformation

A couple of the most prominent voices who speak about trans kids on X fell right into the same misapprehension about the surgery data as the Them journalist.

Michael Hobbes, a cranky Seattleite (I am a cranky former Seattleite, so I can can judge) who boasts a lucrative career as a debunking podcaster, meaning he profits handsomely off of correcting other people’s supposed errors despite often pushing misinformation himself, falsely claimed that “only 5 trans kids received mastectomies in 2019.”

Dr. Jack Turban, a child psychiatrist at the University of California, San Francisco, who has made himself into the face of pediatric gender medicine, either overlooked or ignored the 82 chest-related gender-affirming surgeries in trans kids and zeroed in on the misleading claim about 97% of chest-reduction surgeries being in cisgender boys.

I recently wrote about Turban’s new book on trans kids:

Part of the problem with Turban and Hobbes making the false or misleading claims about gender-affirming surgeries in minors might be in how they comprehended the following paragraph (presuming they read it in its entirety):

The word “respectively” in the highlighted sentence indicates that of all the surgeries in TGD people, 2,664 were in adults and 85 were in minors. I can see how someone not reading carefully would miss this distinction.

How Many Gender-Affirming Surgeries Have There Actually Been in Minors?

Leor Sapir, a fellow at the conservative think tank the Manhattan Institute, published a non-peer-reviewed analysis in the City Journal on Aug. 12 that appears to get closer to the true number of trans minors getting gender-affirming surgeries. Sapir reported:

“A new analysis by the Manhattan Institute, using a more up-to-date all-payer national insurance database from 2017 to 2023, found evidence of 5,288 to 6,294 “gender-affirming” double mastectomies for girls under age 18. This includes 50 to 179 girls who were 12.5 or younger at the time of their procedure.”

Sapir’s conservative estimate for the number of such surgeries conducted in 2019 among minors with gender dysphoria is about 9-fold higher than the figure the Harvard team reported:

Sapir added these caveats: “2023 data are incomplete, making it premature to conclude that a dip occurred that year, relative to previous years. Second, even the liberal estimates are an undercount, as the data are limited by two constraints: the procedures had to be covered by insurance, and patients had to have a preexisting diagnosis of gender dysphoria.”

Sapir’s chart calls into question the Harvard press release’s claim that these surgeries are “rarely” performed on minors. That release quotes Dai arguing that legislation that bans gender-affirming surgery in minors—26 states have passed such laws since 2021—is “rooted in bias and stigma against TGD identities and seeks to address a perceived problem that does not actually exist.”

Putting aside whether such surgeries are a problem or a solution, it’s quite clear that a substantial number are performed annually. And multiple analyses have indicated such surgeries were quickly becoming more common during the years leading up to state bans starting to kick in.

A study published in Sept. 2023 in the journal Cureus analyzed data from the American College of Surgeons National Surgical Quality Improvement Program Pediatric database, covering 2018 to 2021 and looking at Americans under age 18. The authors found a swift growth curve in the annual number of gender-affirming surgeries for trans minors. Almost all the procedures were chest masculinization surgeries (CMS). Keep in mind this study relied on an even more limited set of data than the Harvard group did, so the actual numbers are especially small.

Another study, published July 16 in the Annals of Plastic Surgery, looked at trends in top surgery in people with gender dysphoria from 2013 to 2022. It did not break down the annual number of surgeries by age group. But it did find that over that decade, the average age upon having a double mastectomy declined from 36 to 29 years old.

Between the first two-year period of the decade that was analyzed and the last, there was a 38-fold growth in the number of surgeries:

Another study, published in JAMA Network Open in Aug. 2023, examined gender-affirming surgery rates from 2016 to 2020. The youngest age bracket it examined ran from age 12 to 18. Because this included 18 year olds, the study could not provide precise information on surgeries among minors in particular. I asked an author of the paper, Dr. Jason Wright, an associate professor of gynecologic oncology at Columbia, whether he could provide the relevant figures for just 12 to 17 year olds. He said no. “All of the analysis we did was based on the age groups that we specified, we haven’t done analyses with other age groups,” he said.

All that said, these charts demonstrate dramatic recent growth in gender-affirming surgeries among adolescents and young adults:

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I am an independent journalist, specializing in science and health care coverage. I contribute to The New York Times, The Guardian, NBC News and The New York Sun.  I have also written for the Washington Post, The Atlantic and The Nation.  Follow me on Twitter: @benryanwriter. Visit my website: benryan.net