The most effective way to reduce the need for gender affirming surgery is to give trans young people the right puberty at the right time. Social transition, puberty blockers and then matching hormones prevent the changes that surgery later has to undo. Only genital surgery would remain, for those who want it.
Why would anyone want to minimise gender affirming surgery?
Nobody I have ever listened to wants more surgery than they need. Surgery is expensive, it takes a long time to reach, it leaves scars and it carries the risk of infection and outcomes that are not what you hoped for. For many trans people it is also worth every bit of that, because it changes how they live in their own body. Both of those things are true, and the second does not cancel the first.
So the question is not whether surgery should exist. It should, and it should be safe and available. The question is how many people have to go through it only because the wrong puberty was allowed to happen to them first.
What does the wrong puberty actually leave behind?
Think about a trans boy who is not given puberty blockers. His breasts grow. Years later, when he can afford it or is finally able to get it, he will want them removed. That means surgery, scarring and recovery for something that did not have to be built in the first place. If he had been given blockers, the breasts would not have grown, and then testosterone would have given him the chest he was always going to want.
Now think about a trans girl who is not given blockers. Her face develops into a shape shaped by testosterone. In the future she will want that changed, and if she can afford facial feminisation surgery she will go and have it. It is expensive, it scars, and it has a real risk of not turning out well. If she had been given blockers at the right time, she would not need it.
The same goes for the voice breaking, for height, for the width of the shoulders and the size of the hands. People who have been through the wrong puberty are often read as trans for the rest of their lives, in a hundred small ways that have nothing to do with how they dress or how they live. Most men do not want to be five foot three, and most women do not want to be six foot two. Nobody should have to be identifiable as trans just because their puberty was held back by a system that told them to wait.
Is gender affirming surgery preventable?
Apart from genital surgery, gender affirming surgery is preventable, and that follows directly from how puberty works. If we stop the wrong puberty and then give the right one, we have stopped the need for top surgery because breasts have not developed where a chest should be. We have stopped the need for facial feminisation because testosterone has not shaped a skeleton that was never going to match who she is.
What would be left is genital surgery, and not everybody wants that, which is absolutely fine. For those who do, it should be available, safe and evidence-based, using the best techniques we can offer. It is not the easiest surgery in the world, so choosing your surgeon carefully matters. The aim is not only a result that looks right or functions, it is a result that lets you give and receive sexual pleasure, because that is what it is all about.
What does the right puberty at the right time look like?
The dream, as I see it, is that children are allowed to identify as and when they are ready. If that is in the years before puberty, that is wonderful. They get to express their gender and socially transition with the safety and support of family, school and friends, so that by the time puberty starts they have already lived in their gender role and are comfortable in it.
Then, when puberty begins, we stop the wrong one from progressing. At the right time we give them the right one, and that might be at the same moment blockers begin. It means switching off the hormones that do not fit and giving the ones that match their gender identity. The result is the most natural puberty they could possibly have, going through it at the same time as their peers rather than years behind them.
Puberty blockers are medications that pause puberty. They have been used for decades, including in the care of children whose puberty starts very early. International guidelines support gender affirming care, and the recognised professional bodies in this field have published standards of care.
What happens when puberty blockers are taken away?
This is where I get angry. In the UK the sale and supply of puberty blockers on private prescription to trans young people has been banned, and other countries have followed. Prescriptions through public services are almost impossible to obtain, because the services and the expertise are simply not there. The Cass Review is the document that led to those restrictions, and it has been widely discredited, with many gender experts publishing detailed rebuttals.
Say what the ban actually does. It means a trans boy's breasts grow and a trans girl's voice breaks. It means we are leading these young people towards top surgery with its scars, its infections and its possible poor outcomes, and towards facial surgery with its cost and its risks. We are not preventing surgery by restricting blockers. We are engineering the need for it.
The people who campaign against top surgery will gather the worst photographs they can find of poor outcomes and scars, and put them online as proof of harm. Those same people are blocking the one thing that would prevent many of those operations from being needed. And the cost is paid by the young person, who has no say in any of it.
What about the fear that someone will change their mind?
Nobody wants a person to go through hormones, have their voice break, grow a beard, have their breasts removed, and then at twenty-five decide that it was all a mistake. Not the trans community, not their family, and least of all that person. Detransition happens, and people who go through it deserve respect, not mockery and not to be used as a weapon.
But look at what is being asked of everyone else. To prevent that one outcome, all the other trans young people are made to go through a puberty that does not fit. That brings the known difficulties with psychological, social and mental health, and the known risk of self-harm and suicide. We are making many people suffer in case one person made a mistake. How many people are we willing to hurt so that one person is never allowed to make what might turn out to be the worst decision of their life?
It is also worth asking what regret is made of. Is it that they were not trans, or is it that living life as a trans person is just too hard? When a family does not accept you, when someone you love will not accept you, when you cannot get a job, a person can reach the point of saying they cannot do it any longer. That is not the same as discovering that you were never trans. We have to be careful to tell the two apart.
None of this happens overnight. Nobody goes to the doctor on Monday and has everything done by Tuesday. People knew they were trans years before they reached a doctor. Getting a first appointment takes time, hormones take time, puberty takes time, and surgery happens a long time after that. The whole path is slow already, and slowing it further has costs that land on the young person.
What if I am an adult who needs surgery now?
Nothing here says your surgery is a mistake or a failure of the system. If you went through the puberty that did not fit, because blockers were never offered or were never within reach, then surgery is a sensible way of putting that right. It should be safe, done by a surgeon you have chosen with care, and funded or affordable in a way that does not take years of your life to arrange.
The point of talking about prevention is that the next generation might not have to carry the same cost. It is not a judgement on anyone who has.
Where can I get practical medical help?
If you want to explore the medical side, GenderGP, the service I founded, can help with access to affirming care, including hormones, blockers, prescribing and monitoring. If you would rather talk it through first, Sammy is here to think it over with you, whether you are a young person, a parent or an adult weighing up surgery.
Most of all, look after yourself.
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