"Guns don't kill people'

It would be very hard to go on a mass killing spree with a knife. Guns require no effort. Kids can kill people by accident easily with them.

No shit they do. That's kind of the point of having a gun -- to kill people who are trying to hurt you or take your stuff.

still haven't.

Jesus would probably pack an Uzi.

based sandnigger
based police

...

...

That was an organised terrorist attack carried out by a group of people, not one person. Imagine all attackers with AR-15s.

so this is the power of muslim intellectuals

Some preachers say that if the Lord were alive today, He would tote a high-powered semi-automatic assault rife, while others insist He’d sling an old-fashioned cowboy six-shooter as a symbol of justice. But all agree that when the Second Coming rolls around, Jesus will be loaded for bear.

“Jesus, who said ‘Suffer the little children to come unto me,’ was protective of the weak and defenseless, and He would carry the means to keep them safe from harm,” explains the Rev. Houldercraft of Charleston, S.C, a longtime gun-rights supporter.

“Although kind and gentle, He also accepted that violence was sometimes necessary against evildoers, like when He chased the money changers out of the temple. Today the Messiah would use the modern weapons at His disposal. It’s ridiculous for liberals to argue that He’d go after sinners with a handful of rocks and a sling. Personally, I believe His weapon of choice would be the M1911,” continued the clergyman. “It’s a highly versatile pistol from Colt with plenty of stopping power that’s remarkably reliable even after it falls in mud or sand.”

Imagine all the people with ccw, to stop them. We can play imaginary chess all you want.

biblehub.com/luke/22-36.htm

>what would Jesus pack
Jesus can probably btfo any shitskinned robber since he's the son of God

>imagine all the people with ccw
So the exact same scenario as the Hood? Or the Wild West?

Jesus would pack a 45, just as he told his followers to sell their cloak and buy a sword, the modern sword is our firearms.

>crime rate based on Hollywood movies
Oh man, do some research, homicides was super fucking low in the west.
-sincerely a Californian

Anti 2A thread 13

How are mass shooters stopped currently?

Based women! So fucking sexy!!!

You wouldn't need to stop mass shooters in the first place if they didn't have anything to shoot with.

So imagine the bataclan shooting that happened in the city of Paris where guns are banned? I see.

You are more likely to die in a mass shooting in France, Belgium, Norway and 7 other European countries than you are in the US, statistically speaking.

Most gun murders in the USA are urban criminals with arrest records killing each other. I’m not going to surrender my rights for their safety.

>a Californian
Subhuman scum, get beheaded.
I suppose the Hood doesn't have any gun deaths then.

How are mass shooters stopped?

>Ezra is angry and wants to kill people
>Ezra has a gun, which makes it relatively easy to kill
>the government takes Ezras gun away
>Ezra is still angry and still wants to kill people and explores other options
>the root issue is not addressed

Hey faggot. I'm talking about the wild west you subhuman nigger, imperious cretin! The homicide rate was lower than fucking Chicago.

>people use illegal guns violently so we should make guns more accessible

...

A muzzie talking about killing people //// kek

Heres a treat for you snackbar

Propane bombs, I rather deal with a gun then a bomb

They usually kill themselves. They are also put down by the police.
>Ezra, without a gun, can't kill people in the double digits by squeezing a trigger with minimal effort

>put down by the police
What does that mean?
Can you be more specific?

America and your masters England and Israel have killed people all across the world than Muslims have.

*teleports behind you* en.m.wikipedia.org/wiki/Sagamihara_stabbings

"N-n-nani?"

Armed police, obviously. By shooting.

Again, imagine the same person with a gun.

>What would Jesus pack

The holy spirit, that's what bitch

>what would Jesus pack
Luke 22:36, Jesus tells you to sell your fancy cloak and buy a sword instead, he would definitely be packing heat

>Armed police
with bow and arrows?
>By shooting
shooting crossbows?

Please be specific?

Personally every properly developed country has seen guns as a risk to the public that isn't needed. The ones who stick to archaic rules like Fahrenheit and gun usage dont deserve to be classed as first world or developed.

It's obviously with guns. Trained professionals (although American police isn't all that professional) who are trusted to defend people.

jesus packed a whip and removed kikes.

Oh man look at this, dodge city rate:
165/100000

Chicago
758/100000

Oh man, which has more gun control?

www.chicagotribune.com/news/data/ct-homicide-spikes-comparison-htmlstory.html

cjrc.osu.edu/research/interdisciplinary/hvd/homicide-rates-american-west

Sick my fucking dick

So to further prevent mass shootings we should train everyday gun owners to be professional shooters? So they can act as a sort of trusted militia to defend the people from violent criminals?

I like that idea a lot, based mudslime

What would Jesus pack? Jesus instructed people who did not own swords to sell their cloak and buy one. You guys are right, the Left can't meme.

>What would Jesus pack?
An EBT card

Yes, they're called police. Not some retard who walks into the AR-15 section of Walmart.

still nothing compared to communist democide

Theres a webm of like 10 brit police dealing with one guy with a knife. If they had armed police it would take one to drop him.
No wonder they have butterknife licenses

Haha goat fucker, you're just mad we outgun the shit out of you sandmonkeys.

I'm not done with you, you fucking subhuman knave!
See

That retard who walks into the AR-15 section of Walmart should be trained to be a professional shooter, yes.
I agree.

British police don't have guns, just normal people in ugly high-vis jackets.

>what would jesus pack
Jesus would pack a .45 loaded up with hollows, and he would smite those who sowed inequity and evil with furious vengeance and anger. For he is my brothers keeper, and the shepherd of the weak and defenseless.

We will take over Europe. I am not even trolling, I am 100%. Your women are very kind towards us and your governments protect us. Saint Peter's Basilica will have a crescent over it in a century, and there will be Muslims with brown, red and yellow beards all across Europe.
Should undergo training, should be handpicked.

>Europe
you'l flee the west once it stops with gibs due to general retardation caused by your filthy gene pool

then, you'll meet your death in the eastern parts of the continent, you know the one with deep historic negative experiences with little asian sandnigger hordes

>handpicked
Nope, all the everyday people already buying guns. They should all undergo training and be made into professional shooters like the police, who stop mass shootings.

That's a really good idea.

lmao Jesus told his followers to carry swords for protection

Piece of shit. Won't even finish out discussion, fucking leave. You coward! Nay! You are a fucking caitiff!

this

You've all grown soft with decadence. Watch the Lee Rigby murder video - one Muslim killing a SOLDIER surrounded by crowds of people, nobody doing anything, just standing in fear.
Eastern Europeans are disgusting. We generally have lots of respect for Western Europeans and try to emulate them, like Germany, France and England, but never Poland or whatever inbred backwater that was owned by the Ottomans.
Eastern Europe will have to be taken care of less nicely than the West.

what if you had guns, and people didn't use them to kill people

that would be preferable to a bunch of disarmed savages racking up dozens of kills at a time with kitchen knives
>JUST THINK THEY'D KILL TEN MORE IF THEY HAD A GUN!

maybe we should get focus on the demographics that commit the most crime

If by "proper" you mean giving up our rights and getting fucked in the ass by kebabs, no thanks fog breather.

Okay, and just allow those people to own automatic assault rifles.

Craven!

There's a reason why those states have more gun control, because there is more gun crime. Not hard.

I can agree with this. Well you can own a automatic rifle in America, they are just fucking expensive.

Overturn the automatic weapons ban? Absolutely, the police use some of those to stop mass shootings too.

How can you regulate guns that are illegal and stolen?

>ezra still kills people
>but that's okay! as long as the kill count is below the front page threshhold it's like it never even happened!
>white on white crime becomes the new black on black crime

Less deaths = good.

Well in UK most people are killed by knives, you know why? Because they banned guns. When they banned knives, people started throwing acid at each other. Guns dont kill people, multiculturalism kills people. You dont have a gun problem, you have a nigger problem.

I'm not in Europe faggot, my president is banning you from coming here.

Ok. Then ban swimming pools are cars.

Homicide rate is far lower in the UK as well, no comparison.
Find the source of the illegal guns, seize guns from criminals via raids, etc, annihilate all violent opposition with utmost brutality.

No. Any deaths = bad. Deaths do not become less tragic as they decrease in number. Zero deaths is the only acceptable number of deaths, so the only solution to wrongful death is to peacefully remove the things that cause it.

Let's start with putting the niggers back in africa and the awkward teenage white kids back in church.

>white women

Of course.

The person who pulls the trigger is the one who kills. This is why people get convicted for murder and guns do not you stupid mountainfag.

again, you're mistaking the divided, politically correct western cucks with ethnically homogenous nations who are taught since their childhood what genitally mutilated inbred mohamedan death cultist are like and they should be removed with extreme prejudice
looking forward to seeing you through my scope, sandnigger

We're coming for you too.
They aren't weapons. A car isn't built with the sole intention of killing things. Sure, you can kill people with cars, but it's a lot less practical, a lot less effective, and a lot less common when considering intent.
Wearing seatbelts actually helps. How many American retards die in their cars for not wearing their seatbelt?

You're not gonna take care of shit. You think because you have high birth rates you're gonna out breed everyone and takeover politically. What's actually gonna happen is Euros are gonna get tired of your shit and kick you out. Like I said earlier, we outgun the shit out you sand monkeys.

Hahshahaha. Here, socialmedicine.info/index.php/socialmedicine/article/view/852/1649
So what. Like to door to door and try to take gubd away? That works fucking great, where have I seen that happen? Oh yeah, the middle east, and that work out so fucking well.

>NUKES DON'T KILL PEOPLE, PEOPLE KILL PEOPLE. WE SHOULD LET ISRAEL & NORTH KOREA KEEP THEIR NUKES.

See how stupid that sounds?

What about overall crime in the uk?

Idiotic logic. If one death is bad, then more of it is even worse.
>awkward teenage white kids back in church
More like the mosque.
Slavs can't fight. Easily defeated by Germany, only saved by numbers. Ottomans cut like butter straight through you.

It would be far lower, if they deported all pakis and niggers...

Exactly, laws don't prevent deaths.

You lost to us in the battle of Vienna. Ottoman Empire was shit, we won wars with you while we were having wars with Russia and Sweden at the same time. Sandniggers can't fight, all you can do now is to steal a truck or blow yourself up like a fucking coward. Hit a gym suicidal faggot who worships the moon demon. You do not only have smallest dicks (maybe only Asians from Korea have smaller) but also have lowest IQ among brown people. Go back to your shithole and stay away from traditional countries such as Poland. Your place is in Germany with pagans, gays, transgenders and other immoral and degenerate shit.

yeah comparing guns with nuclear weapons and individuals to a whole state is definitely reasonable

I love Facebook,

I think sure let the fucking norms. Have nukes. As soon as they shoot it, we remove them from existence, and they know it

says the eternal slave
your piece of shit subhuman ancestors never had any semblance of civilization and know nothing but regression since their unfortunate start
the slave is you, even your desert death cult is all about being a slave
again, looking forward to offing you

>implying we shouldn't let israel and north korea keep their nukes

Still lower than in America.
Okay, enjoy living next to warzones.
>You think because you have high birth rates you're gonna out breed everyone and takeover politically
Yes.

Go ahead try to take their nukes dude, then you'll see why this whole discussion will just lead to 100-200 million dead Americans. Not to mention your example which might kill billions!

Missing the point, it went up after him control you mongoloid
theguardian.com/uk-news/2017/jul/20/official-figures-show-biggest-rise-crime-in-a-decade

This is not 1500 you stupid rat

It might happen, anything's possible, but you'll be in a pine box before a global caliphate is established.

Do you think Arnold Schwarzenegger is Jesus considering he can kill 5000 with just 5 magazines and 2 grenades?

We have nogs, so we need guns.

>I understand why Amerinfidels cling onto their guns: it's their only ounce of culture. American culture is a void beyond Walmart, McDonalds and, of course, muh AR-15.
How about 95% of all movies or TV ever produced?
Americans have more impact on world culture through that alone

>yes

Your subsequent generations are all a bunch of drunk and drug fueled degenerates that only pay their parent's religion lip service in front of them to avoid being beaten.

Look up the Islamic Golden Age.
We civilised Spain too.
And we kept Istanbul (Contantinwho?).
Almost every Muslim country was once Christian until it was conquered.

Everywhere your people move to will be a warzone stupid paki.

If any man does not own a sword, he is to sell his cloak and buy one.

Guns are the swords of the modern era. Jesus would pack an AR15, and it would shoot bullets made of pure divinity that would send anyone hit by them directly to heaven.

>what would Jesus pack
I’d bet a Remington 870. Jesus seems like a shotgun guy.

Nope. Sharia law is becoming more prominent. We have welcomed loads of European brothers and sisters.

Thoughts & prayers were enough for that an other terrorist attacks. But no the recent shooting. Really makes me think.

>What would jesus pack
A flaming laser sword - how the fuck isnt this basic knowledge

I'm going to shove bacon in your halal face.

that was someone else's doing, you retard
your golden age begins with ARAMCO and other sandnigger oil-related enterprise, one that shall end soon
thank god for the kikes having their clay in your desert so they have no choice but to play you like a fiddle

I knew I forgot to filter one of the meme flags. Thanks for reminding me kanacke.

You're very ignorant about your history. Istanbul is a Turkic corruption of Constantinople. Also most of the countries conquered by Islam did not have Christian majorities.

Your people are incredibly weak. They take welfare payments because they are too lazy to work. Why would you expect them to fight?

Because all these countries that have higher firearm murder rate have such lax laws.

I can't think of anything the Slavs have done for themselves. Ever.

I don't think a fat ginger neckbeard attention-seeker is necessarily the sign that Western society is collapsing.

We need guns because we have a government
Don't be a cuck

Largest country in this world is slavic.

i.4cdn.org/wsg/1518852687000.webm

Florida Faggots Took a Page right out of MOTHER FUCKIN GW BUSH's handbook. THEY LITERALLY SAID, "YOUR EITHER WITH US ON GUN CONTROL (repubs and gun owners) OR YOUR AGAINST US"
>>How can you be against a poor young kid Senpai???

how would you? all you ever learn is to how to be a slave to your desert cult, and nice cannon fodder to kikes
you're doing great with that, it's your biggest achievement aside from inbreeding your stock down to sub-50 IQ

Your five Christian cities are ours now. All but one. Antioch, check, Jerusalem, check, Constantinople, check, Alexandria, check, now we just have the Vatican to deal with. Will be real easy, considering this is the type of person who dwells in the Vatican nowadays.
Because it has always happened.

YOUWOULDKNOWBEST muzz

Again imagine them with a bomb. No warning. No chance.

Example of how we will take over.
I took a pretty big turd this morning.

What would jesus pack? legions of angels plus he gets resurrected when killed ... its no argument

>At 2:10 a.m. Tuesday morning, 26-year-old Satoshi Uematsu broke through a window of a facility for the disabled in Sagamihara, Japan, and went on a stabbing rampage that killed 19 of the 150 patients in the facility, wounding 25 others. Among those killed were 10 women and nine men, ranging from 19 to 70 years old, according to the Associated Press.
>Less than an hour later, Uematsu turned himself into police.

Holy shit, you can massacre 19 people in Japan and get bored after an hour since the cops won't blow you away and end up turning yourself in

Jesus would pack a jerichi 941 obviously

So we should make bombs illegal.

That's your biggest achievement? I am not shocked considering you have a sub 50 IQ.

No, it just means we need to remove Israel and NKorea.

>It would be very hard to go on a mass killing spree with a knife.
Imagine being such a pathetic individual that you can't get a double digit kill count with a knife.

>biblehub.com/luke/22-36.htm

They needed swords for scripture fulfillment , they had gone without for 3 years preaching

>35Then Jesus asked them, “When I sent you out without purse or bag or sandals, did you lack anything?” “Nothing,” they answered. 36“Now, however, He told them, “the one with a purse should take it, and likewise a bag; and the one without a sword should sell his cloak and buy one. 37For I tell you that this Scripture must be fulfilled in Me: ‘And He was numbered with the transgressors.’ For what is written about Me is reaching its fulfillment.”…

London.

...

>races other than white
>people
lel

...

These people don't consider your kind white. They view you as dirt. They just call you white when it suits them, then disown you when your awful civilisation is discussed.

Where Hitler and the SS once marched.

We should cut out the middleman; just make murder illegal.

...

...

...

Napoleon status = buttblasted

ethnically homogenous societies don't think in terms of western cucks' concept of whiteness but only about their in-group vs all others
aliens' opinions are irrelevant in this regard
the apparent cocksucking towards EU is only for economic gain; once that goes away, so shall succ

...

The Frenchman cowering in fear.

...

...

...

...

Do you think the middle ages had shill bitches like this pushing for sword control.

...

...

...

...

...

> Removing Best Korea
That's literally kimpossible

>Guns make it easier to kill much more people with less effort at a higher rate.

Like a van or a box truck?

...

Guess we need to figure out how to charge guns with murder...hur der now we blame the weapon so the Jews can start to sue manufacturers...oy vey.

LEFTIST LOGIC HERE WE GO :

- YOU CAN'T BAN MUSLIMS BECAUSE OF TERROR ATTACK
- BUT YOU CAN BAN ALL GUN OWNER BECAUSE OF A FEW RETARD

YES YES YES

...

Litterally the entire world tries to emulate American culture...get off my dick faggot. Go fuck a goat.

When we have taken over Western Europe peacefully, we will invade the East.

These scores PogChamp

I'm gonna show you a way to kill 300 peoples without gun and very easy, just with gas.

Go to any concert hall, or movie.
Lock all the exist.
Set the room on fire = 500 DEAD
en.wikipedia.org/wiki/Cinema_Rex_fire

that's where you're wrong kiddo
not everyone strives to be a rootless consumer of the lowest common denominator
language and ethnic identity goes a long way towards making that impossible
cool, I got a magazine full of jacketed lead just for you, nigger

>Sage this faggotry

Gunshots are loud maybe people would have ran and cleared the area causing less death...how about we live in reality and you play what about isms with your faggot friends.

Kebab btfo

Russia will be taken over as well. Russia struggled to defeat the Chechens, and are still on the edge of their seats.

>"What would Jesus pack"

Why are these soccer mums making me picture Jesus's cock?

I don't give a fuck about russia
last time I checked caucasus sandniggers are still under russian rule and their uppity subhumans get removed regularly
also don't forget the chinks, they'll genocide you as soon as they feel like it

>You are more likely to die in a mass shooting in France, Belgium, Norway and 7 other European countries than you are in the US, statistically speaking.
Source?

>What would jesus pack?
His bags because we are deporting shitskins.

quality thread

>maybe we should get focus on the demographics that commit the most crime
Not an argument

>"Niggers don't kill people'
>Ummm... yes they do.

>/leftypol/ BTFO!!!!!

>What would Jesus pack?

Probably a sten gun, or an akm.
>"I have not come to bring peace, but the Kalashnikov automatic gun."

Sorry, but I'm a little tired of the constant mass shootings here in the US. If we need to repeal the second amendment, then fine. Gun fags can fuck right off. Turn over your pop guns, or police can hunt you down.

In practice yes

>We civilised Spain too
Yeah, no

Yes, we did. Before the Moors, you were primitive shit-flingers.

All you have to do is consider France has a smaller population then remember the Bataclan shooting and Charlie Hebdo happened there among others, and NOT EVEN COUNTING THE NICE TRUCK MASSACRE you’re still more likely to be a killed victim of a mass shooting in France than in The USA. This article and the attached site have all kinds of accurate per capita stats on it.

crimeresearch.org/2017/02/france-suffered-more-casualties-murders-and-injuries-from-mass-public-shootings-in-2015-than-the-us-has-suffered-during-obamas-entire-presidency-508-to-424-2/

No you didn't
Iberians had already established small cities and a trade network in the pensinsula
Then came the Romans who perfected it, and made societies flourish around their bases
Then came the goths who fell in line to what romns had already established
Then came the moors, who desu created arose more vilalges and brought nice stuff, such as perfected irragation methods which were needed in the central parts of Spain.

But to claim you civilized the wntire pensinsula is bullshit

You realize that even if you "take over Europe" the US would just come push your shit in, right? It's not like the takeover would be peaceful, and with the average muslim IQ being lower than room temp, it'll devolve into one big rape and murder fest instead of you peacefully taking over their government, and then we'll fucking annihilate you.

>1 post by this ID
>Cred Forums BTFO!!!!!!
IGNORE AND HIDE SHILL THREADS
THEY BELONG AT THE BOTTOM END OF THE CATALOG
Anything else is futile, if they see shill threads with 300 replies, that's all they need to know that Cred Forums is ripe for more shilling.
Don't forget that many shill threads are unoriginal and you can determine if that's the case by searching through text portions like archive.4plebs.org/pol/search/text/insert text here/type/op/ or by image like archive.4plebs.org/pol/search/image/Jv2XBb0uxcavBrh9wgsWbA/type/op/

Surgeon 16 quanti
fi
ed a shift in the general age group of patients:
“
When I
fi
rst started my practice, I would estimate that 85% of
patients were older than 25. Now, I would say that only 40% of
my patients are older than 25 in the last nine years.
”
In addition,
although there was no unanimous recall of the youngest patient
ever reported in the media to undergo the procedure, a few
participants believed that they were responsible for having
operated on
“
the youngest,
”
with surgeon 16 stating that
“
.
the
patient was a 15-year-old who was just on the cusp of
turning 16.
”
Anatomic and Physiologic Issues
There was little concern over the younger adolescent and her
ability to physically withstand the invasive procedure compared
with a middle-age or elderly patient; however, almost all surgeons
remarked on the penoscrotal hypoplasia or limited penile shaft
size that would ensue after the use of puberty-suppressing
gonadotropin-releasing hormone analogues, sometimes for as
long as 3 years. Two surgeons who reported operating on minors
commented,
“
.
they are coming in after being put on blockers,
so they have 11-year-old genitalia
”
(surgeon 9) and
“
.
you are
really doing vaginoplasty on a micropenis
”
(surgeon 16). Most
participants emphasized that the surgical techniques were the
same for all patients no matter the age; of those who had per-
formed the procedure on several minors, the use of
fl
ank skin
grafts most commonly resolved the problem of inadequate tissue
availability. In other reported measures, surgeon 2 implanted a
scrotal tissue expander that required periodic infusion during 2
months, and surgeon 14 used donor tissue matrix (LifeCell,
Branchburg, NJ, USA), deeming it
“
nicely successful
”
and
thereby avoiding patient exposure to external
fl
ank scarring. The
alternative procedure of using sigmoid- or ileum-derived grafts to
create the neovagina was seen as a last resort

by a few participants
who stated diversion colitis, excessive secretion, persistent odors,
and potential leakage of stool into the peritoneum as some of the
concomitant morbidities
Psychological and Contextual Concerns
An overwhelming majority of surgeons cited psychological
maturity as the main criterion for adolescent patient selection,
stating
“
Age is arbitrary. The true measures of how well a patient
will do are based on maturity, discipline and support
”
(surgeon
11). Most participants emphasized that mental maturity was
related to the ability to understand the stressors of undergoing
surgery and expectations of postoperative self-care, particularly
the commitment to a consistent dilatation schedule to maintain
patency of the neovagina:
The biggest concern is, will they be mature enough to be
able to take care of themselves after surgery. Not just having
the surgery done. Will they do what they need to do after
surgery maintain the vaginal depth involved? In actuality,
I don
’
t think it is age dependent, it is the maturity of the

patient. An 18-year-old goes off to college and leaves the
parents. They leave that protective environment and
everything becomes less important to them in terms of the
dilatation and care. Some of my biggest struggles have not
been with the 16-year-old group because they are still at the
parents
’
house
—
it is the 18-year-olds who disappear and go
to college within a few months after their surgery. Those are
the patients who are most likely to lapse in their aftercare.
(Surgeon 9)
The con
fl
uence of undergoing vaginoplasty and leaving home
to become a college student in the same year was seen by many as
problematic:
Oftentimes, a child in the United States comes in after or
during their senior year in high school; they want surgery
over the summer and they want to go off to a dormitory in
September, in their
fi
rst year of college, which is a disaster.
And that is a more important situation than just the age of
the patient. What is going on socially with the patient is
more important than the age. (Surgeon 16)

I have found that it is very dif
fi
cult when the patients have
to transition once they are in college.
.
Plus with their
busy schedules and their busy lifestyles, it is very dif
fi
cult
for them to adhere to their dilation schedule. So the reason
why I decided to operate on people younger than 18, is that
I would prefer that they have their gender reassignment
surgery done while they are still at home and their parents
can help them adhere to their schedule until a signi
fi
cant
period of time has passed so they will not compromise their
results. I base it on very strong family support, very strong
letters from their psychologist and their behavioral health
therapist and that is really how I make the decision. You
also need to take into account the maturity of the individual
and whether they are at a point where they are mature
enough to understand the seriousness of the surgery and the
seriousness of adhering to all of the post-op instructions so
that they maximize their results. (Surgeon 15)
Some surgeons viewed timing the procedure before college
attendance as a harm reduction measure:
Younger patients who have the support of their families,
support of their parents, and can have the operation while
they are still at home, as opposed to being alone at school
or at work, anecdotally tend to do much better than
someone who is alone and doesn
’
t have appropriate
support. (Surgeon 5)

Participants also pointed to the importance of a safe and
af
fi
rmative environment in which to recuperate (ie, being cared
for by supportive parents at home who monitor the recovery
process):
The added issue with the under 18 patient is parental
involvement, and I personally would want to have the
parents on board. Particularly if the child is still living at
home with the parents. The place people go back to after
surgery is critically important for the result. And that
’
snot
just for GCS
—
if someone is going back to a hostile place
and the place is not supportive of the surgery, it is often
likely that the person has a less than optimal result.
(Surgeon 18)
Opinions were sometimes divided as to the adolescent
undergoing the procedure for mainly social or sexual purposes:
The bene
fi
t is not because they want to have sex, but
because they can fully socially transition with their peers
before they go off to college
—
assuming they want to go to
college. (Surgeon 14)
I personally know of two young women who are trying to
transition. They are seeing mental health providers and
endocrinologists. They are 16 and there is a real struggle
there because there is a sense of urgency on their part and
they are being held back. I get that, they need to go through
some steps. But I know that they do not want to do a full
transition later in their life; they want to do this so that they
can be intimate in college. (Surgeon 17)

In addition, a few participants urged caution, suggesting that
some adolescents engage in gender exploration as part of a
developmental phase and as part of the current zeitgeist:
I think it goes along the lines of a young person
’
smind
still being in the developmental stage. Things may happen
and they may reorient their thinking, not just whether
they are trans or not, but they may reorient their thinking
about which surgery will serve their transgender needs. It
is not a binary or tertiary model where they are just gay,
straight, bisexual, or trans; there are a whole host of colors
in-between. Many trans patients do not want GCS
—
it
couldbethatat15theydo,andat25theydonot.
(Surgeon 18)
Depending on how old they are, there are a lot of classes
that adolescents, even preadolescents in elementary schools,
are getting these days. And they are trying to
fi
gure out if
they are doing it because it is a new norm, versus what they
really want. I have seen some of my patients
’
children go
through phases of in and out, of thinking transgender. So
that would be my concern
—
is it because it is popular now?
(Surgeon 19

While participants had a clear understanding of the legal
constraints in obtaining informed consent speci
fi
cally from the
adolescent, there were a few different approaches to securing
consent from the family unit. Parents or legal guardians were
invariably signators; however, Surgeon 2 also added the
requirement of the young patient writing an essay about the
reasons for wanting to undergo the procedure and
“
describe what
her feelings are in her identity as a person.
”
Surgeon 16 explicitly
required the parents to become active participants in the post-
operative dilatation process, or else the patient would not be
deemed
“
a good candidate for surgery.
”
Other participants
requested multiple or longer of
fi
ce visits when going over the
various written consent forms, ranging from 5 to 40 pages, and
always in the presence of parents or legal guardians. The parents
’
marital status was often a concern, because most surgeons were
aware of divorce creating a change in guardianship or custody of
the minor. Comparatively few participants addressed the issue of
postsurgical infertility in the interviews; among those who
reported having discussions with the patient and her family, there
was the recognition that the topic had been explored beforehand
with other practitioners or
“
not often something that is at the
forefront of people
”
(Surgeon 4)

All participants adhered strictly to the SOC by requiring
separate evaluation letters from
two mental health professionals
clearing the minor for surge
ry. Many emphasized that a
recommendation from an unfamiliar psychotherapist was not
acceptable; in addition, a third letter from an independent
psychiatrist or the patient
’
s pediatric endocrinologist was
occasionally required to bolster the surgeon
’
scon
fi
dence that
the minor had been thoroughly ve
tted. The professional quality
of each letter also was very impo
rtant and should demonstrate
the writer
’
squali
fi
cations as an expert in transgender issues.
Surgeon 12 clari
fi
ed:
We ask for two letters. One of them has to be from
someone who has an established relationship with the
patient. I don
’
t remember exactly what the wording is, but
they can
’
t just go to one session and say,
“
Hey, I
’
m trans-
gender, I want surgery.
”
We do read the letters and we also
do con
fi
rm that the letters are real. You can imagine
(laughs). We call the therapist
’
sof
fi
ce and make sure that
our patient is a patient of theirs. We just get con
fi
rmation
that the letters are real and that it
’
s not something they just
typed up on their own, you know. The letter has a certain
verbiage and anybody who is experienced with treating

trust in the diagnostic expertise of mental health providers.
Surgeon 3 concurred:
I rely on them entirely. I need to make sure that the patients
have realistic expectations, that they are not
.
I need to
judge their maturity level and that they can handle pretty
signi
fi
cant stress of any surgical procedure. But I don
’
t
pretend to be a psychologist or have any expertise in the
diagnosis of gender dysphoria, that
’
s a decision that needs
experts.
However, a few pointed out that they were sometimes just as
attuned to potential concerns as mental health professionals and
would assume some responsibility for evaluating the patient
’
s
psychological condition:
I scrutinize the letters that the mental health providers
forward to me. If they are negative, I rely a lot on them
because that has a lot of value. But since they are almost
never negative, I may rely a lot less on them! Then I rely on
my own experience. I cover everything that I believe should
have been covered in the letter, and then I go through that
list of capacity, development, all those issues in my check-
off list. I do this because any other way is a disservice to
the patient; I
’
m responsible for all that. (Surgeon 20)
Despite the legal impossibility to obtain informed consent
from the underage patient, the vast majority of participants were
not concerned with malpractice lawsuits from parents or even
from the patients as adults in the future. Engaging in best
practices, maintaining open communication with the patient and
her parents, and above all providing good results were seen as
protective measures against any legal action. Nevertheless,
opinions were evenly split as to the surgeon
’
s assumption of
physical risk to the adolescent patient. Some asserted that this
was uniquely the surgeon
’
s domain:

It should be the surgeon, not the hormone prescriber.
There is a lot of misinformation that the hormone pre-
scribers give, in my opinion. They have no business talking
about surgical issues, unless they have training. We could
train the hormone providers, but too often they have never
set foot in an operating room, and say things from a surgical
standpoint that in my opinion simply is not true. And
I don
’
t think that the hormone providers understand that
when there is a micropenis, it
’
s a different surgery. When
you all you have is a hammer, everything looks like a nail!
(Surgeon 16)
Others advocated for a dispersion of responsibility:
I think it should be everybody. And I think it should be me,
the endocrinologist, the mental health provider. It has to be
multidisciplinary to make sure they are sexually mature in
terms of development, and that from an endocrine
standpoint they are able to be on the hormones successfully
and manage them appropriately. One of the concerns for
me would be if they haven
’
t been on the hormones long
enough or they haven
’
t had adequate endocrine care
—
how
will that change the tissue postoperatively? I know it
’
sa
concern for top surgery and it would also be for bottom
surgery. It has to be both. (Surgeon 17)