At least 5,747 children underwent gender transition surgeries in the US from 2019 to 2023, according to insurance data obtained by the medical watchdog group Do No Harm.

The data relies on insurance claims and therefore excludes surgeries paid for out-of-pocket and those performed at institutions which don’t report claims, meaning it significantly underestimates the prevalence of these surgeries. Nonetheless, it reveals an enormous industry and undermines activists’ claims that such surgeries for minors are exceedingly rare.

Covered surgeries include mastectomies, breast construction, facial surgeries, and genital surgeries. Only two states, Alaska and Wyoming, had zero insurance claims filed for paediatric gender surgeries from 2019 to 2023, and even these states had patients receiving puberty blockers or cross-sex hormones under the age of 18, as did every other US state.

Some states served as hot spots, including California, which had at least 1,359 surgeries. Meanwhile, New York had 616; and Pennsylvania, Oregon and Massachusetts all had more than 300 paediatric gender surgeries during the five year period. Several red states served as the location for surprisingly high numbers of surgeries, such as Texas where there were more than 200, and Florida where there were more than 100.

A 2022 Reuters report, which also relied on insurance data, found that gender-affirming mastectomies and breast construction surgeries performed on children aged 13-17 increased from 238 in 2019 to 282 in 2021. At the same time, there was a steep increase in the prescription of puberty blockers and cross-sex hormones and a surge in gender dysphoria diagnoses, Reuters found. But the new data from Do No Harm reveals that the industry is larger than previously known, and it’s quickly growing despite state-level restrictions. The reported surgeries brought in more than $108 million during the five year period.

The database also tracked insurance claims for puberty blockers and cross-sex hormones. Do No Harm found that more than 8,500 patients underwent hormones or puberty blockers, comprising more than 62,000 total prescriptions and costing more than $11 million. Hormones are relatively affordable and can be easily obtained without insurance, so these findings represent a very conservative estimate.

Paediatric medical transitions have been championed by trans activists as well as the Biden administration — sometimes in concert. Rachel Levine, Assistant Secretary for Health of the Department of Health and Human Services, pressured the World Professional Association for Transgender Health to remove age limits for cross-sex medical treatments, including surgeries, from its guidelines. Most major medical organisations in the US officially endorse these procedures for minors, though doctors remain deeply divided over the issue.

A number of patients who have come to regret gender-related procedures they underwent in adolescence are now suing their providers, which could push malpractice insurers to stop covering the practice. While there are no federal restrictions on child medical transitions, 24 states have laws restricting the procedures. These contentious laws have resulted in legal disputes, one of which is on the Supreme Court’s docket for the current term. Justices are expected to rule in the late spring on whether laws restricting transgender medical procedures for minors violate the Equal Protection Clause of the 14th Amendment.

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is UnHerd’s US correspondent.

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China is trying to catch up with America on artificial intelligence. The Wall Street Journal has reported that Zhipu AI — one of China’s six “AI tiger” LLMs — has released a new model that can rival leading US systems, including Anthropic’s Mythos, in cybersecurity tasks such as pinpointing security bugs. While this marks a milestone in China’s drive to catch up with Western AI capabilities, strong performance on a single benchmark does not mean it has taken the lead. Chinese models still lag behind their Western counterparts in broader capabilities, such as autonomous operation. Skepticism is therefore warranted before resorting to hysterical conclusions, but complacency about the geopolitical implications of China’s AI advances would be an even greater mistake.

On the infrastructure side, Chinese AI is still constrained by access to advanced chips, with American labs way ahead in computing capacity as well as investment. Analysis from earlier this year suggests that Chinese models are likely to be at least a few months behind those in the US. But they are still continuing to make progress, or that the geopolitical importance of AI will be decided only by whose LLM has ventured deeper into the technological frontier. The practical applications of AI, countries’ to capture foreign markets, and the application of AI into the real economy will matter just as much.

Here, China may hold an advantage. As with its dominance across many critical supply chains, Beijing may not need to produce the most advanced AI systems — only those that are affordable and widely deployable. In doing so, it could consolidate global influence by supplying functional, low-cost AI at scale.

Beijing seems to be pursuing exactly that path, developing an AI “open-source” strategy that offers affordable, widely available AI models for companies and individuals to use and modify as they wish. The production of the DeepSeek AI model, which matched the performance of Silicon Valley tools such as ChatGPT at a fraction of the cost for users, created goodwill among Chinese models with developers.

The four most popular models on OpenRouter, an AI hardware platform for developers, are now all Chinese. The goal for China is not only to win the frontier-model race, but to make its systems the default layer of AI adoption across industries and global markets. For most economies, the choice is increasingly between an affordable tool they can deploy now and a more robust one that may be out of reach.

And while the countries adopting Chinese models may be exposed to political pressure and cyber threats from Beijing, safer and more capable alternatives matter little if they are unaffordable. American AI companies are already under pressure to monetize products whose operating costs are rising. If Chinese open-source models become the cheap default for startups, universities, governments and businesses across the developing world, then America’s AI lead will be eroded from below.

Perhaps more concerning for America in the long run is how AI can give Chinese manufacturing even more strength, through the ongoing integration of AI as a general-purpose technology. China’s new Five-Year Plan mentioned AI more than 50 times and includes an “AI+” action plan aimed at spreading AI across the economy.

Beijing has been pioneering automation of its critical infrastructure for years, with promising recent results in increasing warplane production capacity. In that regard, China’s open-model strategy and manufacturing dominance will reinforce each other. Cheap, adaptable models accelerate deployment across the real economy while those deployments generate real-world data and use cases that can feed back into further model improvement.

The United States should not dismiss the importance of its lead in the AI race. That lead worries Beijing, not least because a more automated Chinese economy would also become more vulnerable to AI-generated cyber threats. But nor should Washington assume that China cannot catch up with American capabilities over time.

This AI competition represents part of a broader struggle over tech supply chains and geopolitical influence. Decisions over whether to adopt US or Chinese models could produce a more fragmented global reality, with different regions relying on different cloud providers, chips and security structures. The result will likely be a global economy which is divided into competing spheres, rather than one which produces a single winner.

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Miquel Vila is a political and geopolitical risk consultant focusing on industrial strategy, critical infrastructure and global supply chains.

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