Age Context in High-Engagement X Posts About Gender-Affirming Surgery: A Content Analysis

Gender-affirming surgery (GAS) is an expanding component of craniofacial practice, and patients may encounter social media content that shapes expectations before consultation. Much of the public debate surrounding gender-affirming surgery centers on care for minors, a context that is ethically and clinically distinct from adult procedures. When online posts fail to specify patient age, adult patients may interpret criticism directed at a separate clinical context as relevant to their own care. We conducted a descriptive cross-sectional content analysis of 600 high-engagement, top-ranked posts on X (formerly Twitter) collected in November 2023. Posts were classified for age-group focus, tone (supportive, critical, or neutral), author type, content type, and engagement metrics. Most posts (60.5%) did not specify patient age, whereas 38% referenced minors and fewer than 2% referenced adults. Overall tone was predominantly critical (56.8%; 95% CI, 52.8%-60.7%). Posts referencing minors were 3.45 times more likely to be critical than posts without a minor reference (odds ratio, 3.45; 95% CI, 2.40-4.94; P<0.001). Adult-focused posts were rare and comparatively balanced in tone. Health care professionals accounted for fewer than 3% of authors, and educational posts comprised only 6% of content while receiving the lowest mean engagement of any content type. Age ambiguity was common in online discourse about gender-affirming surgery. For craniofacial surgeons, recognizing that negative sentiment is concentrated in posts referencing minors, whereas age-specified adult content is comparatively more balanced, may help clinicians contextualize social media narratives encountered by patients during discussions of gender-affirming surgery.