Michael 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 flatchest.
The teenager was overcome with relief that morning after years of hiding his breasts. He posed for a picture with his mother and the doctor, who had a large following on social media.
It was like I had never had breasts before. It was a sort of moment.
Michael is one of a small but growing group of adolescents who have had breast removal to align their bodies with their gender identity. Most of these teenagers have taken testosterone and changed their names.
The groups of young people have gotten the most attention. Republican elected officials across the United States are seeking to ban all so-called gender-affirming care for minor children, turning an intensely personal medical decision into a political maelstrom.
The spotlight has been put on gender-related surgeries. Arizona and Alabama made it illegal for doctors to perform gender related surgeries on children. Children's hospitals that offer gender surgeries have recently been targeted by conservative commentators with large followings on social media, leading to online harassment and bomb threats.
Top surgeries are becoming more common, but genital surgeries in adolescents are extremely rare. Major medical groups have condemned the bans on gender related care for adolescents, but the surgeries have presented challenges for them.
As an adult, trans men generally benefit from top surgery because it relieves body- related distress, increases sexual satisfaction and improves overall quality of life. There are a few small studies suggesting the same benefits.
Some clinicians say the rising demand and the turmoil of adolescent development are reasons for doctors to slow down. Some patients come to regret their surgeries because medical experts don't think it's likely.
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. The guidelines provide a standard for doctors. The group withdrew the proposals due to political pressures and a lack of consensus in the medical community.
There is no official data on how many minor surgeries are done in the US. According to a survey by the New York Times, eleven clinics carried out a total of 203 procedures on minor children in the next two years. Six clinics said that they referred patients to private practices.
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 minor last year. Researchers who led a recent study said that the number of surgeries carried out on teenagers rose from five to 70.
A plastic surgeon at the hospital said she couldn't think of another field where the volume has exploded like that.
Teenagers who are not trans are less likely to have top surgeries than are teens who are. According to surveys of members of the American Society of Plastic Surgeons, around 3,200 girls between the ages of 13 and 19 received breast augmentations in 2020.
The number of people who identify as trans has grown in the past ten years. According to the Williams Institute, a research center at the University of California, Los Angeles, the number of people under the age of 25 who identify as trans is expected to double in 2020.
Most of the adolescents in Western Europe, Canada and the United States want to transition from female to male, according to gender clinics.
Because breasts are highly visible, they can make transitioning difficult and cause intense distress for teenagers. There are small studies that show that many trans adolescents have issues with their breasts. Top surgery has been available at younger ages as the population of these adolescents has grown.
The medical director of the gender health program at the Children's Minnesota hospital, who is non-binary, said that more nonbinary teenagers are seeking top surgeries. Patients are referred to independent surgeons by the program. These adolescents don't want masculine features brought on by testosterone such as a deeper voice or facial hair.
Top surgeries for adolescents 15 and up were part of a suite of changes that would have made gender treatments available to children at younger ages. The organization backpedaled this month after some major medical groups objected to the new age minimums.
The doctor said that they needed consensus. In order to propose this at a younger age, we need more strength and a better political climate.
The previous guidelines allowed surgeries for minor children on a case-by-case basis.
Most states require teenagers to be 18 before they can provide medical consent. A two- to four-hour procedure can cost anywhere from $9,000 to $17,000. Insurance won't cover the procedure until the patient is 18.
A top surgery specialty has been built by the surgeon in Miami. The doctor frequently posts photos, FAQ and meme on Facebook,Instagram and TikTok in order to connect with hundreds of thousands of followers.
Patients like Michael who had their bandages removed are highlighted in her feeds. One of her best-known phrases on TikTok is "Yeet the Teet", which means "remove breasts".
Roughly one or two of the 40 patients she performs top surgeries on a monthly basis are under the age of 18. She has operated on at least one 13-year-old and one 14-year-old, both of whom had severe chest pains.
The surgeon said that most of her patients came to her on TikTok. Right-wing media has criticized her online presence, as well as some parents and doctors who say she uses the platform to market to children.
She plays her own drum. That is troubling for many of us.
She didn't think she had the influence her critics thought she had. She said she tries to deliver educational content most of the time.
He was immediately interested when he first saw the page. Michael and other people in the article wanted to be identified by their first or middle names because they were worried about their privacy. He liked the photos of her patients, observing that their scars had healed, and that she seemed to be an ally of the trans community.
After years of watching her son suffer, Annie decided to have surgery.
Michael said he felt a gnawing pain about his breasts since he hit puberty. He wore sweatshirts every day when he was a child.
A therapist encouraged Michael to talk about his body issues after he had a lot of panic attacks. He tucked his long curly hair into a beanie and wore boys clothes to look more masculine.
It was the first time Michael tried to make himself more comfortable in his own skin.
When he was 14, he came out to his parents as a male. He started weekly testosterone injections at the beginning of the Pandemic. His voice dropped as he got into strength-training and he was grateful to have undergone a second puberty.
He said that he felt 10 times happier when he was in school. He was able to hide his breast tissue with a binder. The garment could cause him to have a panic attack. He saw a doctor who prescribed drugs.
Annie decided that Michael should have surgery when he was 17 so that he wouldn't suffer as much. She took out a loan to help pay for the procedure that her insurance wouldn't cover.
The letter was written by Michael's doctor. The surgery was put in limbo after he revoked it. The surgery was approved after Michael began a higher dose of antidepressants.
Michael is in his senior year of high school. He said he is focused on the parts of his life that are not related to his gender, such as doing theater tech at school, seeing friends, painting and applying to college.
He said that he felt less pressure to prove his manhood. He is growing his hair out and using pronouns. He took his girlfriend to the prom in a brown suit and a pearl necklace.
Half of the 136 patients who were studied had undergone top surgery, according to the report. The adolescents who didn't have the procedure reported more distress because of their chests.
More than one-third of those who had surgery lost their nipple sensation over time. One patient expressed occasional feelings of regret when they imagined breastfeeding a child.
Only a few things in the world have a zero percent regret rate. The lead author of the study said that she had experienced chest surgery.
Most patients were surveyed less than two years after their surgeries, and nearly 30 percent could not be contacted.
People who have stopped or reversed gender treatments have been the focus of little research. A study of 28 such adults described a wide range of experiences, with some feeling intense regret and others having a more fluid gender identity.
The researcher who led the study, Kinnon MacKinnon of York University in Toronto, said that doctors are asking young patients and their parents to give consent without acknowledging the unknowns.
Many trans men have benefited from their medical transitions and are happy with their surgeries. The doctor said he would put himself in that category. There are questions that are deserving of answers and have implications for clinical care.
Jamie was raised as a girl and began to identify as a boy in the eighth grade. She said she started taking testosterone after she was raped and dropped out of high school. She had surgery at a private practice in Massachusetts three months after turning 18.
She thrived for the next few years. Testosterone made her happy. She went back to school to become an EMT.
She was 21 when her father died of Alzheimer's. She fixated on her wide hips, which she worried was next to her voice and facial hair. She realized she had made a mistake after having sex with a straight man.
Jamie said that he lost something about himself that he could have liked. She contemplated suicide after a long period of grief.
She had surgery to reconstruct her breasts after a year of fighting with her insurance company. She didn't tell her original surgeon that she had changed her mind. She doesn't like being a woman sometimes.
Patients with regret are rarely heard about by surgeons. Jamie never tells them.
She follows up with patients for at least a year. The doctor said that he didn't know of a single case of regret.
One of her former patients has spoken out about her transition on social media.
She said in an interview that she came to terms with the fact that she had made a mistake.
She had surgery at a young age. Ms. Lidinsky- Smith told her medical providers about her detransition after 16 months.
In the past, a former patient had left a voice mail message saying they regretted their surgery.
We were wondering if it was a hoax at the time. The doctor said that.
Republican politicians in states across the country want to ban all gender-affirming care for adolescents.
In Florida, the medical board is considering banning the use of scalpels for children under the age of 18. The governor of Texas called genital surgeries in adolescents a form of child abuse.
Politicians shouldn't be involved in personal medical decisions, according to the president of WPATH. They want to shut it down because they don't understand it. It's a very dangerous precedent.
The new state actions against gender care for minor have had a chilling effect.
The only children's gender clinic in Texas was shut down due to political pressure. A woman was charged with making a false bomb threat to Boston Children's Hospital after it was targeted online for its gender program. The doctor said she might hire security for her office.
Clinics have stopped scheduling procedures. William, who has identified as a boy since he was a young child, was supposed to see a plastic surgeon in Plano, Texas, in May. The doctor canceled the appointment because the malpractice insurer stopped covering top surgeries for minor children.
William and his family flew to California in August to have the procedure done.
William began ninth grade as a boy. He is looking forward to swimming with his shirt off and going to class.
William said it was like something was missing. What was always there was covered by my chest.
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