A report from the Manhattan Institute this week revealed that “gender-affirming” mastectomies for patients under 18 are more common than previously believed.

While cross-sex genital surgeries are rare in the US for both adults and minors, mastectomies — also known as “top surgery” in the context of transgender medicine — are widely available to minors and are the most common transgender surgery for this population. Around 5,000 to 6,000 girls underwent “gender affirming” double mastectomies in the US from 2017 to 2023, according to the Manhattan Institute, and at least 50 of those patients were younger than 12-and-a-half years old.

While the US medical establishment and trans activists have long argued that cross-sex surgeries for children are exceedingly rare, evidence is emerging of a large and growing surgical industry impacting thousands of children, despite the ongoing lack of authoritative data on precisely how many minors are undergoing the procedures.

The new report demonstrates a higher prevalence of “gender-affirming” mastectomies for minors than previous estimates when broken down by year. One estimate published in the Journal of the American Medical Association found 3,125 “top surgeries” were performed on patients aged 12-18 from 2016 to 2020 — a lower per-year estimate despite including 18-year-olds, which the Manhattan Institute’s data excluded. A 2022 report from Reuters estimated 776 top surgeries on minors from 2019-2021, a significantly lower per-year estimate.

The actual prevalence of these surgeries is likely considerably higher than the latest estimate, since it relies on health insurance data and therefore does not include procedures obtained without using insurance.

The apparent increase in surgeries in recent years may be related to the growing prevalence of transgender identification among youth, along with the growing popularity of the affirmation approach, which takes children’s self-described transgender identity at face value.

Proponents of cross-sex medical interventions downplay the prevalence of these surgeries. The Human Rights Campaign declared last April that “gender affirming surgeries are NOT performed on children”, and the Association of American Medical Colleges wrote, “GAC surgery among youth is rare, experts say.” Marci Bowers, plastic surgeon and president of the World Professional Association for Transgender Health (WPATH), the leasing standard-setting organisation for transgender medical treatments, has made a similar argument. “Surgery really is not done under the age of 18, except in severe cases . . . And even that is rare, I think the estimates are something like 57 surgeries under the age of 18,” Bowers said in 2023.

But their insistence that surgeries for children are rare should not be confused with repudiation of such surgeries. On the contrary, activists strongly oppose restrictions on trans surgeries for kids. When the Biden administration tempered its support for childhood gender transitions this summer by opposing surgeries for minors, there was swift blowback from the trans lobby. State lawmakers called the move a “betrayal” in a letter to Biden, and the HRC said the decision was “flat out wrong”.

The growing body of evidence demonstrating the availability of irreversible cross sex surgeries for minors is only the latest development chipping away at trans activists’ narrative in the US. The American Society of Plastic Surgeons recently became the first major medical organisation in the US to publicly reject the GAC model, acknowledging that  “the existing evidence base is viewed as low quality/low certainty”, the Manhattan Institute reported. Previously, the ASPS lobbied against state restrictions on cross-sex treatments for minors.

“The main justification for “gender-affirming care” for minors in the United States has been that “all major U.S. medical associations” support it,” Manhattan Institute Fellow Leor Sapir wrote in the report. “But the U.S. consensus now appears to have its first big fracture.”

---

is UnHerd’s US correspondent.

laureldugg

---

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.

---

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

miquelvilam

---