How to Break a Medical Consensus

A political scientist couldn’t get a medical association to say what he wanted. So he co-wrote a government report—and now they’re citing it.

On Tuesday, Leor Sapir—a political scientist at the Manhattan Institute, a conservative think tank—published in the Institute’s policy magazine, City Journal, that the American Society of Plastic Surgeons (ASPS), the country’s largest organization of board-certified plastic surgeons, had just recommended delaying all gender-affirming surgeries on minors until age 19. Gender-affirming surgeries—procedures such as chest reconstruction that treat gender dysphoria, the clinical distress some young people experience when their gender identity does not match the sex they were assigned at birth—have become one of the most politically contested areas of medicine in the country. Sapir was pleased to note that the ASPS statement cited “the HHS report (of which I was a coauthor),” referring to a Department of Health and Human Services review of pediatric gender medicine that he helped write for the Trump administration.

Sapir is not a doctor. He does not treat patients and has no clinical experience with gender dysphoria. But over the past eighteen months, he has become one of the most consequential figures in the political fight over this care—not by producing new medical evidence, but by co-authoring a government report that gave federal regulators the justification to threaten the financial survival of any hospital that disagreed.

He has been working this seam for more than a year. In August 2024, Sapir wrote in the same publication that ASPS had become “the first major medical association to challenge the consensus” on gender-affirming care, citing a statement the organization gave him calling the evidence “low quality/low certainty.” It was a stretch. After Erin Reed, a journalist who covers transgender policy, asked ASPS about Sapir’s characterization, the organization published a statement affirming that they “support transgender patients’ constitutional protections” and “oppose any attempts at legal encroachment into the practice of medicine.”

That was before the election. After Trump took office, the political landscape shifted dramatically—and what Sapir couldn’t achieve through persuasion, the new federal apparatus would make far more likely.

After Trump took office, Sapir was tapped to co-author the administration’s official report on pediatric gender dysphoria, alongside a founder of the Society for Evidence-Based Gender Medicine (SEGM), an advocacy group critical of gender-affirming care whose work has been cited in support of state bans. In December, the Centers for Medicare and Medicaid Services (CMS)—the federal agency that administers health insurance for roughly 150 million Americans—proposed rules threatening to cut all Medicare and Medicaid funding from any hospital that provides gender-affirming care to anyone under 19. That funding represents up to 45% of hospital revenue nationwide. The rules cited Sapir’s report.

Eighteen state attorneys general sued. Some hospitals didn’t wait for the courts. They started stopping the care before the rules were even finalized.

Which brings us back to Tuesday. Seven weeks after the CMS rules were proposed, ASPS released its new statement recommending that all gender-affirming surgeries be delayed until age 19, citing both the HHS report Sapir co-authored and the Cass Review, an assessment of pediatric gender medicine commissioned by England’s National Health Service that recommended more caution and has become a touchstone for opponents of this care internationally. The language about “constitutional protections”—the language from 2024, when ASPS was pushing back on Sapir’s framing—is gone. The opposition to “legal encroachment” is gone.

What didn’t change is the evidence. ASPS still calls it “low quality/low certainty”—the same technical designation they used in 2024. This is a standard classification in evidence-based medicine that reflects the absence of randomized controlled trials, not a judgment that the care is harmful. It is true of most surgery. It is true, specifically, of the 5,300 breast reductions and 2,700 breast augmentations ASPS members perform on patients 19 and under every year—procedures no one has proposed banning, for which ASPS has never demanded stronger evidence, and which are subject to exactly the same evidentiary limitations ASPS now cites to justify delay. The standard didn’t change. The politics did.

STAT News, a health-care industry publication, asked past ASPS president Scot Glasberg if the Trump administration played a role in the reversal. He said no, the timing was “happenstance.” Asked if ASPS had met with the administration, he “couldn’t discuss any private meetings.”

HHS had a press release ready the same day, with statements from HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz praising ASPS for “protecting children from harmful sex-rejecting procedures.” The ASPS statement was approved internally on January 23 but not released until February 3—the same day HHS published its response. For a reversal that Glasberg called “happenstance,” the federal government was remarkably well prepared to capitalize on it.

None of this is coincidence, but it also isn’t surprising. ASPS was always the softest target. Its political action committee gave 56% to Republicans last cycle. A study in JAMA, one of the country’s most prestigious medical journals, found plastic surgeons gave $600,000 to Republicans and $140,000 to Democrats in 2020, among the widest partisan gaps the researchers identified in surgery. In October 2025, C. Bob Basu, a Houston plastic surgeon, became ASPS president. Federal Election Commission records show Basu has made eight contributions to Ted Cruz for Senate and four to the Trump National Committee.

But the point was never ASPS itself. Until Tuesday, every major American medical association supported gender-affirming care for minors who met clinical criteria. The American Academy of Pediatrics (AAP), which represents 67,000 pediatricians. The American Medical Association (AMA), the largest association of physicians in the country. The Endocrine Society. The American Psychological Association. That unanimity is what Sapir needed to break. Not because ASPS is influential on this issue—it isn’t—but because now he can point to a major medical society and write “no consensus” in City Journal.

In an interview, Sapir rejected the idea that federal pressure influenced the reversal. “I don’t see why the CMS stuff would directly weigh on the ASPS,” he said, describing both the funding threat and the new medical position as “outgrowths of the same international move toward deprioritizing medical interventions in youth.”

He acknowledged that ASPS kept its new position on age-minimum laws “vague on purpose.” And he was frank about the underlying logic: “The argument for bans has always been: if they can’t or won’t self-regulate, government has to step in.”

ASPS self-regulated.

The ASPS statement will be cited in court filings, state legislation, and cable news for years. It will be presented as proof that doctors are independently “waking up” to the dangers of gender-affirming care. What it will not mention is the federal funding threat that preceded it, the HHS report it relied on, or the political scientist who helped write that report and is now celebrating the result.

The American Academy of Pediatrics is still holding its position in support of gender-affirming care. So is the AMA. The CMS rules are still pending. The machinery that broke ASPS is still running. ASPS’s August 2024 statement is still on their website.

ASPS did not respond to a request for comment.