The majority of minors seeking Gender-affirming treatment, such as top surgery, are adolescents who were given the gender "female" at birth, which has sparked discussion about the impact of peer groups and social media.

Eight-year-old Samuel Kulovitz thought his life couldn't get much worse a year after relocating to Bridge City, Texas. He spent much of his time in the mobile home belonging to his family and had no acquaintances in the sluggish oil refinery town. He missed playing on the beach with other kids in Florida.

Still, things did grow worse. Attained puberty. Kulovitz, who was given the gender of a woman at birth, remarked that "becoming a young woman frightened me." I couldn't understand why I didn't enjoy it, so I just kept weeping.

Then, at the age of 11, Kulovitz began using social media. He stumbled upon a cosplayer on Tumblr who claimed he discovered he was transgender after experiencing euphoria while portraying the protagonist of an online comic. Kulovitz was spellbound. He told Reuters: "I kept questioning myself, 'Why do you want to appear like him?'" Kulovitz adopted the pronouns "he" and "he" in the online community where he was spending an increasing amount of time, and he enjoyed it.

His mother was accepting and enrolled him in counseling after learning of his transgender identity. At the age of 12, his gender dysphoria, or the distress that results from identifying as a gender other than the one given at birth, was diagnosed.

Kulovitz began taking testosterone two and a half years later. He was ecstatic as his voice lowered, his period ended, and he developed face and chest hair.

His body hurt from wearing a chest binder, and his breasts continued to bother him. Kulovitz added, "I always wished I could get rid of them.

Kulovitz, who was 16 at the time, was scrolling through his phone one day in his junior year of high school when the TikTok account of a Miami surgeon who volunteered to "yeet the teets" of young transgender persons appeared. Dr. Sidhbh Gallagher explained in-depth information about top surgery to remove or modify breasts in videos with hip-hop music playing in the background. She also showed photos of her happy gender-diverse patients, most of whom were young people, with their shirts off to demonstrate the success of the doctor's work. She added in one of the films, "Come to Miami to see myself and the rest of the De Titty Committee.

In June 2021, six months after giving her assent for her son's surgery, Kulovitz was in Miami with his mother, who had also paid $10,000 out of pocket for the procedure. Additionally, he had the letters of recommendation his therapist and doctor had to provide to Gallagher. Kulovitz recalled feeling "euphoric" when he first awoke following the treatment. I at last felt comfortable in my own skin.

Samuel Kulovitz finally shows the scars from his breast ectomy procedure. Following the treatment, he claimed, "I finally felt right in my body." MIKALA COMPTON, REUTERS

a concern about influence

In recent years, thousands of kids who, like Kulovitz, were given the gender of a girl at birth have sought out gender-affirming care. Furthermore, they significantly outnumber those born with a male gender assignment who seek treatment. This is for unknown reasons.

As Reuters reported in October, an increasing proportion of children receiving care at the more than 100 gender clinics in the United States choose to have medical interventions, such as hormone therapy, hormone-blocking medications, and, less frequently, surgery. And they are doing this despite the fact that there is little solid scientific data supporting the long-term efficacy and safety of these treatments for children.

This has caused a rift among gender-care professionals: some advocate caution to ensure that only adolescents who are deemed well-suited to treatment after thorough evaluation receive it, while others think that unnecessary treatment delays prolong a child's suffering and increase their risk of self-harm.

Parallel concerns have been raised by the disproportionate number of youngsters seeking treatment to transition from being feminine to male. Gender-care experts concur that all transgender children should receive supportive and affirming care. Peer groups and online media may be pressuring some of these individuals to pursue medical transition, which could have irreversible adverse effects, at a time in their lives when their identities are frequently in flux, raises the question of whether they may be doing so.

Professor of public health Corey Basch, who studies health communication and teen social media use at William Paterson University in New Jersey, expressed her concern that some teenagers may be prone to generating incorrect self-diagnoses without sufficient input from medical professionals. Teenagers are extremely susceptible to information overload and being forced in one direction, according to Basch. They might not have the critical thinking abilities to consider the source of the advise and if it is sound.

According to the World Professional Association for Transgender Health (WPATH), a 4,000-member organization of medical, legal, academic, and other professionals, adolescents who were assigned female at birth initiate transgender care 2.5 to 7.1 times more frequently than those who were assigned male at birth. According to several American clinics that spoke with Reuters, the ratio was almost 2-to-1 among their patients. Similar occurrences have also been reported in Europe, Canada, and Australia.

These patients don't all get medical care. Adopting a name and pronouns that are in line with their gender identity may be a part of their gender-affirming care. It might incorporate therapy and counseling. However, more people are choosing to take hormones and have top surgery.

In a study released in October by Vanderbilt University School of Medicine researchers, gender-affirming chest operations done on individuals under the age of 18 nationwide from 2016 to 2019 increased by 389%. A weighted estimate based on data from more than 2,000 American medical facilities indicates that there were 1,130 surgeries performed overall over the time period, almost all of which were for chest masculinization. According to U.S. insurance records examined for Reuters by health technology company Komodo Health Inc., at least 776 chest masculinization operations were performed on patients aged 13 to 17 with a gender dysphoria diagnosis during the course of the previous three years. Given that procedures financed out of pocket are not included, this number is likely understated.

The majority of patients who were given a female gender at birth represents a change from the past. Those who were born with a male gender predominantly sought gender treatment for years when relatively few minors did. However, studies and conversations with gender-care specialists show that this started to alter approximately 15 years ago as care became more widely available and the total number of patients began increasing.

For instance, the ratios were reversed at Amsterdam University Medical Center's gender clinic, a pioneer in teenage gender treatment. In a 2015 study that was published in the Journal of Sexual Medicine, the Dutch clinic found that from 1989 to 2005, 59% of its adolescent patients were assigned male at birth. Since 2016, young people who were classified as female at birth have made up roughly 75% of the clinic's patients.

Many different identities

 

Advocates for transgender equality and clinicians who work with kids don't see anything unusual about the development. They assert that despite widespread discrimination and violent threats against transgender children, more kids are now seeking therapy as a result of growing social acceptance of transgender identity. This argument further contends that because society generally views effeminate boys as less acceptable than manly girls, those who are born male may be less inclined to seek treatment, which would decrease their proportion of the patient population.

These kids may identify more widely as gender varied rather than specifically as transgender. This diversity of gender identities is reflected in a growing list of terminology, including agender, nonbinary, gender fluid, polygender, demiboy, and demigirl.

Because the social discussion has been made public, people may feel more liberated and secure to express themselves and adopt a more diverse identity.

Dr. Michelle Forcier, a professor of pediatrics at Brown University's Alpert Medical School who has specialized in the treatment of transgender and gender-diverse patients, said: "There's been an explosion in the gender-expansive model." Because the social discussion has been made public, people may feel more liberated and secure to express themselves and adopt a more diverse identity. "Giving them a list of options that might help them reach their gender goals," she added of these patients, is the moral and ethical thing to do.

However, some parents and other gender-care professionals are dubious. They expressed concern in interviews with Reuters that some teenagers who were born female may be struggling with serious mental health issues in addition to doubts about their gender identity or may be looking to transition as a safety in a society that internalizes misogyny, body hatred, and early sexualization of girls.

Dr. Erica Anderson, a clinical psychologist, a transgender woman, and a former member of the WPATH board of directors, claimed that "girls have a harder struggle with the physical and emotional changes that follow with the onset of puberty." And I believe there is some validity to the claim that men generally enjoy a better quality of life than women.

According to experts, adolescence is a time when all youngsters are on an identity search, trying on different personas, appearances, and hobbies as they move away from their families and look to their peers for approval. In her private practice in Berkeley, California, Anderson treats transgender and gender-questioning youth. She expressed concern that a large number of girls who are dissatisfied with their bodies, finding it difficult to fit in socially, or experiencing mental health issues have decided to undergo medical transitioning as the only option.

Children do try things on, but not all of them stick. They test things out," she remarked. "I don't think we have to take everything a young child says to us at face value," the author says.

The risk, according to Anderson and other medical professionals, is that teens who obtain medical attention do not find relief from their suffering and may come to regret the irreversible effects of hormone medication and top surgery. The treatment recommendations made by WPATH and other medical organizations mainly rely on research from the Netherlands that looked at kids who had chronic gender dysphoria from a young age and who had no major psychiatric conditions prior to getting hormones, surgery, or puberty blockers.

The positive and negative

In talks regarding the gender imbalance among transgender young patients, the effect of peers and social media is prominent.

Young transgender people have avidly embraced social media in recent years to share their tales. Young people receiving gender treatment frequently post information about taking meds and getting surgery with followers on social media sites like TikTok and Instagram, who can number in the tens of thousands. Doctors who interact with potential patients on social media to increase their profile.

Many patients, including Kulovitz, and the medical professionals who care for them assert that social media can help young people who are unsure of their gender identity by providing them with guidance and information, as well as by introducing them to others who share their struggles.

But in addition to those advantages, some eminent physicians assert that social media may cause some young people to confuse mental health issues or apprehension about their identity for gender dysphoria.

WPATH acknowledged for the first time in its updated Standards of Care, which were released in September, that "social influence" may affect a teen's gender identification. According to Dr. Eli Coleman, director of the University of Minnesota Medical School's Institute for Sexual and Gender Health, who oversaw the revision of WPATH's recommendations, the organization advises that youths undergo a thorough evaluation in part so that clinicians "can discern between a person's gender identity that is marked and sustained and an identity that might be socially influenced."

Some patients may think, "'I'm having these same problems, and transitioning to a different gender will help me feel better,'" said Dr. Laura Edwards-Leeper, a clinical psychologist in Oregon who specializes in treating transgender children. Other patients may boast about the enormous improvements in their quality of life after transitioning. The updated WPATH standards of care for adolescents were co-written by her.

Parents of 40 gender-variant children told Reuters they were worried about the fact that their kids didn't come out until puberty, frequently at the same time as their friends and after social media use had increased. Many people's concerns were made worse when medical professionals advocated medical intervention without adequately evaluating whether other possible underlying sources of distress were also present and immediately confirmed their children's transgender identities.

The 12-year-old began experimenting, seemingly overnight, with being a transgender boy, according to Kelly, a 43-year-old parent who asked that her full name not be used to protect the privacy of her family. Kelly told Reuters that her child was heavily into highly sexualized anime and transgender online forums. Kelly stated that the child's therapist had recommended medical intervention; nevertheless, while she supported the child's social transition outside the family, Kelly made it clear that hormone therapy and top surgery would have to wait until the child turned 18.

Kelly's child, now 18, is back to using her female name, dressing in feminine apparel, and using "she" and "her" pronouns after several years of living as a boy and using "he" and "him" pronouns. If we had done as the therapist advised, the mother claimed, "We would have lost our daughter."

There is currently no conclusive evidence linking youth gender identification and social media use. However, gender-care specialists assert that the potential impact of peer groups and social media underscores the need for thorough examinations prior to recommending patients for medical care. The issue, according to these experts, is that some clinics lack the mental health professionals and patience necessary to do these exams to ascertain whether a patient has persistent gender dysphoria and whether medical treatment is best for them.

According to Edwards-Leeper, "many of these adolescents are learning about gender dysphoria for the first time online or via friends," making the need for these assessments "more critical than ever."

Dr. Riittakerttu Kaltiala, chief psychiatrist at the Tampere University Hospital Department of Adolescent Psychiatry, first noticed a change in the demographics of patients seeking medical transition a few years ago. Finland was one of the first countries to embrace gender care for minors. 90% of patients by 2017 were assigned as female at birth, and many did not exhibit signs of gender dysphoria until puberty. They also frequently belonged to similar social groups in school and online. She claimed that patients occasionally shared identical details about their own personal experiences.

Kaltiala wasn't bothered by the possibility that these teenagers were copying one another. She told Reuters: "That is absolutely natural" in adolescence. What bothered her was that many of the teenagers had come to the conclusion that they were transgender rapidly and saw their identity as fixed, trying to speed up the years-long process of identity construction.

She also met a few young patients who regretted making the medical shift. "I was so certain that you could not have altered my mind, they said. I was so sure that this was the right path, but I now believe I was mistaken," Kaltiala said. "I truly take that seriously. Everyone is in a terrible circumstance.

Her worries led a group of mental health specialists overseeing Finland's two adolescent gender clinics to request that the national healthcare council of that nation assess the scientific evidence in favor of juvenile gender care. In their request, they informed the board that, in the absence of sufficient scientific or professional guidance, physicians were under increasing pressure to make increasingly complex medical judgments about the treatment of transgender youths.

In 2020, the council came to the conclusion that "gender reassignment of minors is still an experimental practice, in view of available evidence." The most common form of treatment for most teenagers with gender dysphoria nowadays is psychosocial support. If, during psychotherapy, the patient's gender-related anxiety remains, their personality development appears stable, and no serious mental health conditions would impede treatment, then Finland allows for case-by-case medical measures.

Avoiding the story of a "fad"

The assumption that peer pressure and social media may be factors in the overwhelming number of female-to-male transitions among adolescent patients is rejected by transgender activists and some medical professionals. They assert that it promotes a harmful transphobic myth and that those opposed to gender care use this misleading "fad" story as a weapon to restrict children's access to care.

Dr. Dan Karasic, professor emeritus of psychiatry at the University of California San Francisco and the lead author of the mental health chapter in the new WPATH Standards of Care, said: "One of the false narratives is that young people are being lured in and directed somehow against their will to become transgender, which is not at all.

Those opposed to providing gender care for youngsters, he claimed, mistakenly compare "someone who has a text discussion with someone and is left with some confusion about who they are" with "young patients who are receiving medical therapy for chronic, long-standing gender dysphoria."

Prisha Mosley is one of many who told Reuters that, in hindsight, they believe the medical personnel who assisted them in their transition should have evaluated them more carefully and discouraged them from receiving medical treatments they now regret.

Mosley, who was given the gender of a woman at birth, began to experience anorexia, anxiety, and despair in her early teens. She tried to kill herself by drowning, and a sexual assault only made her trauma worse.

She looked for friends online because she was lonely and depressed and found a group of people on Tumblr who informed her that she was transgender if she disliked her body, felt suicidal, and didn't fit in with her gender. Now 24 years old, Mosley told Reuters, "I wanted to do the procedure that would fix that."

By assuming a male name and pronouns, Mosley underwent social transition. She also came out to her mother through a PowerPoint presentation.

However, that did not make her anxiety go away, nor did counseling or assistance from a pediatric eating disorders expert. She slashed her wrist with a knife in January 2015, according to her medical records from Cone Health in Greensboro, North Carolina.

Mosley said that a therapist gave her a gender dysphoria diagnosis after just one session later that year. By July, Mosley had started testosterone therapy under the supervision of her Cone physician. Her energy and appetite were instantly increased by the hormone. But she didn't get better, and she kept considering suicide.

Doug Allred, a spokesman for Cone Health, declined to comment specifically on Mosley's case. According to him, the health system provides gender-affirming care to patients who have undergone psychological testing and have parental consent. This care is based on established guidelines. He said, "A person's attitude about their gender-affirming care may occasionally alter.

Christine Bourgeois-Mosley, Mosley's mother, admitted that she had a difficult time accepting Mosley's gender for years, but she eventually agreed to gender treatment as a result of her son's recurrent suicide concerns. Both Shana Gordon, Mosley's therapist, and Dr. Martha Perry, her doctor at Cone, reassured the family that it was the right decision, according to both Mosley and her mother. Regarding Mosley's care, Gordon and Perry declined to comment.

Prisha Mosley regrets having undergone medical changes, including top surgery. PAINFUL REVERSAL Before I had ever had the opportunity to experience being a woman, she added, "I determined that I didn't want to be a woman." Dieu-Nalio Chery for Reuters

Mosley underwent breast removal surgery when she became 18 years old. Although her mother objected to the procedure, she still went with Mosley. Was I going to let her leave on her own, or what? stated Bourgeois-Mosley.

According to Mosley, the physical change did not make her sadness any better; she still cut herself. Only after several years of behavioral therapy did her mental health start to get better. She stopped taking testosterone at age 22 and realized she had changed her gender.

Before I had even had the opportunity to experience being a lady, I made the decision that I didn't want to be one, said Mosley, who is currently majoring in psychology at a community college in Michigan. "Now I feel like I'll never really understand,"

Mosley experiences painful vaginal atrophy, a common side effect of testosterone that she claims she didn't fully understand when her doctor warned her about it. This condition is characterized by dryness and inflammation of the vaginal walls. She is undergoing laser hair removal procedures to get rid of the face and body hair that testosterone has caused, and she is hoping to be approved for breast reconstruction.

Mosley expressed regret that her doctors had supported her desire to alter her physical appearance rather than paying more attention to her mental health. She claimed, "I just accepted the cure that was given to me, and I ruined my life.

Surgical Approach

Puberty blockers, hormones, and surgery are the mainstays of medical care for young transgender people. According to clinicians, many teenagers who want to transition arrive after puberty has begun, rendering puberty blockers useless. Testosterone may be used as the first step in treating those born with a female gender. The hormone has the potential to result in vaginal atrophy, elevated blood pressure, an enlarged clitoris, and male-pattern baldness over time. Uncertain are the long-term implications on fertility.

These young patients may decide to have surgery. When they do, top surgery is nearly always included. Phalloplasty, a frequent bottom procedure where a penis is created, is pricy and has a high likelihood of complications. Many hospitals won't operate on patients under the age of 18 for genital procedures.

Comparatively, top surgery is less difficult and hazardous. In addition to the usual post-operative dangers including sluggish wound healing, surgeons also caution patients about scarring, loss of milk, and potential loss of sensation in the nipples. Usually, prices fall between $5,000 and $30,000 or more. For patients with gender dysphoria as young as 13, certain insurance companies will pay the operation.

Opponents of gender care, who are against permitting adolescents to undergo life-altering procedures at such a young age, target top surgery in particular. For treating teenagers, certain children's hospitals and prominent surgeons have received threats and harassment online.

Top surgery is regarded by the gender-care community as a secure and efficient method of easing a significant source of suffering in transgender boys.

Dr. Scott Mosser of the Gender Confirmation Center in San Francisco declared in August that he had halted taking new adolescent patients for gender surgery after receiving a "overwhelming quantity of threatening threats." "We are gravely worried by the extent to which misinformation, bigotry, and fanaticism jeopardize trans, nonbinary, and gender expansive people's access to life-saving care," Mosser said in a statement posted on his website.

Top surgery is regarded by the gender-care community as a secure and efficient method of easing a significant source of suffering in transgender boys. According to the revised WPATH guidelines, testosterone has minimal effect in easing the distress caused by chest dysphoria in individuals who were assigned female at birth and who also have greater levels of anxiety and depression. The group states that top surgery "may be considered in minors when clinically and developmentally suitable" without offering a recommended minimum age.

Around the time of puberty, Floor Hurlbert was a middle schooler in Connecticut and started experiencing significant chest dysphoria. Hurlbert avoided taking showers and removed a full-length mirror from their room because he was embarrassed by how they looked. It was painful and did not make their distress go away to wear a chest binder. Hurlbert remarked, "I knew people were staring at me and seeing me in a way I didn't enjoy.

Hurlbert had no desire to use testosterone. They solely want top surgery, and soon after turning 18, they received it. Hurlbert, now a 19-year-old college student, said, "It was like a significant cause of my mental health concerns were not there anymore." "I could feel good about who I was and how I appeared."

There is a dearth of research on the long-term results for patients who have top surgery when still minors. WPATH includes two recent small studies that "demonstrated good surgical outcomes, satisfaction with findings, and low regret during the study monitoring period" in its guidelines. Patients were followed up on in both studies on average 1.5 years following surgery.

A list of choices

Some surgeons are utilizing internet channels to meet the increased demand for the treatments, despite the controversy surrounding whether social media is pushing teenagers to get expensive surgeries.

Instagram profiles for Top Surgery Specialists of New York City and Los Angeles post pictures of young individuals proudly displaying their scars following top surgery.

The hashtag "#teetusdeletus" is frequently used by Dr. Tony Mangubat, a Seattle plastic surgeon with more than 200,000 followers on TikTok @TikDocTony. He responds to inquiries like, "What age is ideal for top surgery?" in his films. Hey Doc, how old do I have to be to start T, short for testosterone, to which Mangubat responded, "My youngest patient was 15." Mangubat retorted, "You start T, really, when you're ready," and encouraged patients to see their doctors.

Requests for response from Mangubat and Top Surgery Specialists went unanswered.

Kulovitz's top surgery was performed by Gallagher, who frequently uploads selfies of her patients, known as "Gallagher guys," having fun on sunny beaches while baring their chests. She furthermore shares pictures of parents posing next to their kids wearing unbuttoned "nip-reveal shirts" that showcase their red incision scars in the foyer of her Miami office. In the captions of her photos, Gallagher exclaims, "Supportive moms are the best!"

Gallagher explains the possibilities she provides for "designer" chests to her 273,000 TikTok subscribers. To accentuate feminine curves, torso "masculoplasty" is a top surgery option. Gallagher can completely remove the nipples for the nonbinary; as one post's text display stated, "No Nips, No Problem." And for those who identify as gender-fluid, she offers "non-flat" surgery, which leaves enough breast tissue so that patients can have a "perky breast" with cleavage some days and bind their breasts other days.

TikTok declined to comment when contacted. A representative for Instagram's parent company, Meta Platforms Inc., stated that although paying for ads targeted at kids is illegal, doctors posting about medical procedures involving minors would not necessarily be in violation of the platform's guidelines.

Many of Gallagher's young patients who underwent successful surgery, including Kulovitz, told Reuters they were happy with the outcome. Additionally, they expressed their gratitude for Gallagher's public support of their right to a body that is consistent with their gender identification.

Organizations opposed to the care of minors that is gender-affirming have taken notice of Gallagher's marketing strategies. Five of these organizations—parents, doctors, and persons who have undergone a detransition—filed a complaint with the Federal Trade Commission in February requesting that the agency look into Gallagher's interactions with children on social media. In the aggressive marketing and advertising to minors of their plastic surgery services, specifically mastectomies of healthy female breasts, as proven safe, effective, and medically necessary, the complaint claims that Gallagher and her medical practice are "engaged in unfair, false, and deceptive practices." One of the group's participants claimed that when her child, who followed Gallagher on social media, told her that she wanted surgery by the doctor, she was frightened.

Reaching out: Gallagher has 273,000 followers on TikTok, where she routinely shares details about top surgery and the different alternatives she provides to young transgender women in need of "designer" chests.

The Florida Attorney General's Office received a similar complaint from two attorneys earlier this year stating that Gallagher is inappropriately advertising surgery to adolescents on TikTok and Instagram, especially to "youth with mental health concerns."

Nine months after the FTC complaint was submitted, according to Gallagher, "there is, to our knowledge, no investigation by the FTC," and the "clear objective of these opposing groups is to oppress, stifle, and destroy gender-affirming care and those that give it," he said in a statement to Reuters. Her social media platform's purpose, she continued, was to "amplify transgender voices, celebrate transgender lives, and, most critically, to give education that equips our patients to successfully traverse the challenging process of surgical transition."

Requests for comment from the FTC and the Florida attorney general's office went unanswered.

More broadly, Florida is one of many conservative-run states that have aimed to restrict access to treatment because they reject gender-affirming care for kids. Early in November, two Florida medical boards approved draft regulations that would prohibit hormones, gender-affirming operations, and puberty blockers for kids. Children participating in research studies and patients currently undergoing treatment could continue to