https://jamanetwork.com/journals/jamapediatrics/fullarticle/2796426?guestAccessKey=c50d5d6e-7fa1-4ed8-8b5d-f4da9753364d&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=092622

Mona Ascha, MD¹; Daniel C. Sasson, BA¹; Rachita Sood, MD¹; et alJeremy W. Cornelius, MA²; Jacob M. Schauer, PhD³; Adariane Runge, MS⁴; Abigail L. Muldoon, MA⁴; Noopur Gangopadhyay, MD⁵; Lisa Simons, MD^4,6; Diane Chen, PhD^4,5,6,7; Julia F. Corcoran, MD, MHPE⁸; Sumanas W. Jordan, MD, PhD¹

Key Points

Question  Does gender-affirming top surgery improve chest dysphoria, gender congruence, and body image in transmasculine and nonbinary adolescents and young adults?

Findings  This nonrandomized, multicenter, prospective, control-matched study [of 36 surg.patients] showed that top surgery was associated with statistically significant improvement in chest dysphoria, gender congruence, and body image at 3 months postsurgery. Surgical complications were minimal.

Meaning  This study suggests that gender-affirming top surgery is associated with improved chest dysphoria, gender congruence, and body image in this age group.

Abstract

Importance  Transgender and nonbinary (TGNB) adolescents and young adults (AYA) designated female at birth (DFAB) experience chest dysphoria, which is associated with depression and anxiety. Top surgery may be performed to treat chest dysphoria.

Objective  To determine whether top surgery improves chest dysphoria, gender congruence, and body image in TGNB DFAB AYA.

Design, Setting, and Participants  This is a nonrandomized prospective cohort study of patients who underwent top surgery between December 2019 and April 2021 and a matched control group who did not receive surgery. Patients completed outcomes measures preoperatively and 3 months postoperatively. This study took place across 3 institutions in a single, large metropolitan city. Patients aged 13 to 24 years who presented for gender-affirming top surgery were recruited into the treatment arm. Patients in the treatment arm were matched with individuals in the control arm based on age and duration of testosterone therapy.

Exposures  Patients in the surgical cohort underwent gender-affirming mastectomy; surgical technique was at the discretion of the surgeon.

Main Outcomes and Measures  Patient-reported outcomes were collected at enrollment and 3 months postoperatively or 3 months postbaseline for the control cohort. The primary outcome was the Chest Dysphoria Measure (CDM). Secondary outcomes included the Transgender Congruence Scale (TCS) and Body Image Scale (BIS). Baseline demographic and surgical variables were collected, and descriptive statistics were calculated. Inverse probability of treatment weighting (IPTW) was used to estimate the association of top surgery with outcomes. Probability of treatment was estimated using gradient-boosted machines with the following covariates: baseline outcome score, age, gender identity, race, ethnicity, insurance type, body mass index, testosterone use duration, chest binding, and parental support.

Results  Overall, 81 patients were enrolled (mean [SD] age, 18.6 [2.7] years); 11 were lost to follow-up. Thirty-six surgical patients and 34 matched control patients completed the outcomes measures. Weighted absolute standardized mean differences were acceptable between groups with respect to body mass index, but were not comparable with respect to the remaining demographic variables baseline outcome measures. Surgical complications were minimal. IPTW analyses suggest an association between surgery and substantial improvements in CDM (–25.58 points; 95% CI, –29.18 to –21.98), TCS (7.78 points; 95% CI, 6.06-9.50), and BIS (–7.20 points; 95% CI, –11.68 to –2.72) scores.

Conclusions and Relevance  Top surgery in TGNB DFAB AYA is associated with low complication rates. Top surgery is associated with improved chest dysphoria, gender congruence, and body image satisfaction in this age group.

Introduction

Recent studies estimate that up to 9% of adolescents and young adults (AYA) identify as transgender or nonbinary (TGNB).¹ Many TGNB youth designated female at birth (DFAB) experience chest dysphoria, defined as distress related to the development of breasts.² Chest dysphoria can lead to negative physical and emotional consequences, such as lack of participation in exercise and sports, chest-binding practices that can be physically harmful when not performed safely, psychosocial distress, functional limitations, and suicidal ideation.^2-4 A retrospective review by our group of 156 TGNB DFAB AYA aged 12 to 18 years found that chest dysphoria was associated with greater anxiety and depression independent of gender dysphoria, degree of appearance congruence, and social transition status.⁵ TGNB youth may perform chest binding to relieve gender dysphoria, improve social acceptance, and reduce misgendering.³ However, chest binding may cause skin irritation, musculoskeletal pain, and shortness of breath.⁶ Prior research has shown that most TGNB youth who perform chest binding desire definitive top surgery.³

Top surgery (ie, mastectomy or reduction) is a common gender-affirming surgery sought by TGNB DFAB individuals and has been shown to improve chest dysphoria and quality of life in adults.^7-9 Top surgery among TGNB DFAB patients increased 15% in 2020 compared with 2019.¹⁰ While outcomes of top surgery in adults are well reported, outcomes in youth are not well described.^11-13 A qualitative study of 30 TGNB DFAB AYA reported that patients who underwent top surgery experienced near or total resolution of chest dysphoria, lack of surgical regret, and improved quality of life and functioning.⁴ The Chest Dysphoria Measure (CDM) was recently introduced to assess chest dysphoria in TGNB patients, and youth who had not received top surgery had CDM scores nearly 10 times higher than those who did receive top surgery.² Despite these promising findings, these studies are limited by their retrospective design. There is a need for robust prospective studies in TGNB youth to guide evidence-based practices, especially with increasing proposed legislation to criminalize gender-affirming health care for minors.

The present study evaluates the association of top surgery with chest dysphoria, gender congruence, and body image in TGNB DFAB AYA. We hypothesize that top surgery will significantly improve chest dysphoria compared with patients who do not undergo top surgery. To our knowledge, this is the first and only prospective matched cohort study evaluating top surgery in youth to date.

Methods

Study Sample and Design

This is a multicenter, prospective, matched cohort study, in which TGNB DFAB AYA were recruited between December 2019 and April 2021 to 1 of 2 study arms: patients undergoing surgical mastectomy (treatment group) or patients not undergoing surgical mastectomy (control group). There was no attempt to randomize patients. Patients in the treatment group were recruited from Northwestern Memorial Hospital, The University of Illinois at Chicago, or Ann & Robert H. Lurie Children’s Hospital of Chicago at their preoperative consults for top surgery. Inclusion criteria for treatment patients were 13 to 24 years of age at the time of surgery, transmasculine or nonbinary gender identity, DFAB, and English speaking. Gender-affirming hormone therapy was not a requirement in order to recruit patients who may not be interested in hormones but were interested in top surgery.¹⁴ Control patients were recruited from Ann & Robert H. Lurie Children’s Hospital of Chicago’s Gender and Sex Development Program. Inclusion criteria for control patients were 13 to 24 years of age, presenting for gender-affirming care, transmasculine or nonbinary gender identity, DFAB, and English speaking.

Multicenter institutional review board approval was obtained. Oral and written informed consent were obtained from patients older than 18 years, and from parents when patients were younger than 18 years. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines were followed.

Intervention and Matching

All patients in the treatment arm were assessed for surgical readiness according to World Professional Association for Transgender Health guidelines Standards of Care version 7.¹⁵ Health care professionals tailored surgical techniques to each individual’s presentation and preferences. Preoperative and postoperative care protocols varied by institution, and no attempt to standardize surgical technique or protocol was made. Patients in the control group did not receive surgical intervention for chest dysphoria during the study period. Control patients who underwent top surgery during the study period were removed from the study. Two control patients were matched to each treatment patient; the 2:1 matching rate was chosen to account for expected control patient attrition, with a goal of a final 1:1 matching rate for analysis. Patients were matched by age (±1 year) and duration of testosterone therapy (±1 year) at the time of surgery.

Study Variables and Baseline Measures

Demographic variables, date of testosterone therapy initiation, and surgical details were collected via patient medical record review. Race and ethnicity information was obtained from the patient medical record; categories for these variables are provided by the electronic medical record. Age, gender identity, sex designated at birth, and chest binding practices at initial presentation were collected with a survey distributed through Research Electronic Data Capture hosted at Northwestern University.

Parental Support of Gender Variance—Child/Youth

The Parental Support of Gender Variance (PSGV-CY) is a 21-item questionnaire assessing the respondent’s perception of their relationship with their parents and perceived support for their gender identity.¹⁶ Items are scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), with higher scores indicating greater parental support. The PSGV-CY score was only measured at baseline assessment.

Patient-Reported Outcomes

Patient-reported outcomes were obtained via Research Electronic Data Capture preoperatively as a baseline and 3 months postoperatively for surgery patients or postbaseline for control patients. The 3-month time frame was chosen as a period beyond immediate postsurgical pain and euphoria, while remaining in proximity to the study intervention.

Chest Dysphoria

The primary outcome measure of this study is the CDM. The CDM is a 17-item questionnaire that measures aspects of chest dysphoria.² It is the only validated instrument published to date that measures chest dysphoria in TGNB AYA patients. Questions assess physical functioning, hygiene, exercise, intimate partnerships, and disruption of plans. Items are rated on a 4-point scale (0 = never, 3 = all the time) and summed, with higher scores indicating greater chest dysphoria (range, 0-51). This measure has high internal consistency (Cronbach α = 0.79 for postsurgical patients, and α = 0.89 for nonsurgical patients).²

Gender Congruence

The Transgender Congruence Scale (TCS) is a 12-item questionnaire that evaluates congruence between gender identity and life experience. The TCS comprises 2 subscales, appearance congruence (TCS-AC) and gender identity acceptance (TCS-GIA). The 9-item TCS-AC measures the degree to which respondents feel their external appearance represents their gender identity. The 3-item TCS-GIA measures the degree to which patients accept their self-identified gender identity rather than the gender identity designated by society. Items are rated on a 5-point scale (1 = strongly disagree, 5 = strongly agree) and summed, with higher scores representing favorable gender congruence. The TCS has strong internal consistency (Cronbach α = 0.94 for TCS-AC, α = 0.77 for TCS-GIA, and α = 0.92 for TCS).¹⁷

Body Image

The Body Image Scale (BIS) is a 30-item questionnaire that assesses satisfaction with various body parts, rated on a 5-point scale (1 = very satisfied, 5 = very dissatisfied) and summed.^18,19 The BIS includes primary sex characteristics, secondary sex characteristics, and neutral (nonsex-related) body parts.^18,20 The BIS includes subscales based on 6 primary, 14 secondary, and 10 neutral characteristics. The BIS has moderate internal consistency (Cronbach α = 0.65 for primary characteristics, α = 0.84 for secondary characteristics, and α = 0.81 for neutral characteristics).²⁰

Data Collection and Analysis

Primary (CDM) and secondary (TCS, BIS) outcomes were analyzed with inverse probability treatment weighting (IPTW) propensity score analysis with linear regression adjustments. As robustness checks, we also estimated association of top surgery with outcomes via nearest-neighbor and poststratification matching, linear regression analysis with covariate adjustment, sensitivity analyses, and analysis of gain scores (secondary analyses).

The IPTW propensity score analysis was performed to improve balance of covariates between surgery groups and control groups on baseline measures.²¹ The propensity score analysis first involved estimating the probability of receiving surgery using a gradient boosted machine as a function of the following covariates: race, ethnicity, baseline outcome scores for outcomes of interest, age, insurance type, body mass index, testosterone use duration, chest binding, and parental support of gender variance score. Probability of treatment was computed based on propensity scores, and IPTW analyses used weights inversely proportional to the probability of treatment. Balance was checked among covariates with unweighted absolute standardized mean differences (SMDs) and weighted absolute SMDs after matching. To minimize the association of remaining imbalance between the surgery and control groups after weighting, our final IPTW analysis used (weighted) linear adjustments for covariates that did not exhibit satisfactory balance after weighting. Prior to IPTW analysis, we excluded control patients with low chest dysphoria (CDM score <19), high transgender congruence (TCS score >50), and low body image dissatisfaction (BIS score <50) to better ensure that the surgery and control groups were comparable. The final cohort for IPTW analysis included 25 control patients and 35 surgical patients. Methods describing the secondary analyses are available in the online supplement (eMethods in the Supplement).

Subgroup analysis was conducted for patients younger than 18 years. This was done because the age of 18 is often used as an arbitrary cutoff for insurance companies for reimbursing care. The same covariates were used in these models, except for age. IPTW propensity score analysis was recalculated for the subgroup and outliers were removed in a similar fashion. The final cohort for IPTW subgroup analysis included 9 control patients and 15 surgical patients. All analyses were performed using R (The R Project) version 4.0.1 and Rstudio (The R Project) version 1.3.959.²²

Results

Table 1 compares baseline characteristics between surgery and control groups (mean [SD] age, 18.6 [2.7] years), with unweighted absolute SMDs and weighted absolute SMDs after propensity score matching. There were 36 patients in the surgery group and 34 patients in the control group. The planned 2:1 matching rate resulted in the anticipated 1:1 final matched rate; recruitment of control patients was difficult given the limited number of available patients and lack of testosterone-matched and age-matched controls for some surgical patients. Eleven patients were lost to follow-up (6 surgical patients and 5 control patients). Drop-out patients had significantly greater median (IQR) baseline CDM (52.0 [46.0-53.0] vs 29.0 [23.0-35.8]) and BIS (103.0 [91.5-109] vs 87.0 [75.3-96.8]) compared with retained patients. Reasons for dropping out of the study are unknown. After propensity score matching, most absolute SMDs improved with weighting, but did not achieve desired balance of less than 0.1 for all covariates.

Average age was comparable in the treatment and control groups. Most patients in both groups identified as transmasculine, were White, were not Hispanic/Latinx, and were never smokers (Table 1). Testosterone use in months was comparable in both groups; eFigure 1 in the Supplement illustrates testosterone use vs age for the surgical and control groups. Two patients in the control group and 1 patient in the surgical group were not taking testosterone. Seventeen surgical patients reported performing chest binding, while 9 control patients reported binding. Complete case analysis was performed comparing demographic variables between complete and incomplete patient medical records. There were no statistically significant findings between complete and incomplete cases.

The most common surgical technique was double incision mastectomy with nipple areolar complex grafting (n = 24 [67%]), followed by nipple-sparing mastectomy (n = 10 [28%]), and periareolar mastectomy (n = 2 [ 6%]). The resection weight was calculated as the average value of both breasts. Median (IQR) resection weight in grams was 329.5 (111.9-552.8). Seven patients (19%) received concomitant liposuction and 29 patients (81%) received drains. Median (IQR) drain duration was 8.3 (7.0-9.0) days. Complications were minimal, with 1 hematoma (3%), 2 seromas (6%), and 1 instance of nipple loss (3%). There were no incidences of infection or delayed wound healing.

Chest Dysphoria

An exploratory data analysis was performed. Covariates including age, body mass index, and testosterone use in months appeared normally distributed. Table 2 outlines IPTW analysis results for the primary and secondary outcomes of interest. Summary statistics for 3-month outcomes scores in each group are also reported. eFigure 2 in the Supplement illustrates boxplot distribution of propensity scores for each group. eFigure 3 in the Supplement illustrates mean and standard deviation of propensity scores across quintiles for each group. The IPTW model estimated a 25.58 (95% CI, –29.18 to –21.98) point decrease in CDM for the surgery group relative to the control group. The Figure illustrates 3-month CDM as a function of baseline CDM. Three-month CDM scores for all surgery patients were low, regardless of baseline CDM score. The mean (SD) difference between baseline and 3-month scores in the treatment group was –28.12 (8.32). In contrast, among control patients, CDM scores did not appear to change significantly at 3 months. The mean (SD) difference between baseline and 3-month scores in the control group was –0.52 (6.29). Table 3 outlines subgroup analysis of outcomes among patients under 18 years. The IPTW model estimated a 25.48 (95% CI, –32.85 to –18.11) point decrease in CDM for the surgery group relative to the control group.

Gender Congruence

The IPTW model estimated a 7.78 (95% CI, 6.06-9.50) point increase in TCS for the surgery group relative to the control group (Table 2). Results for the TCS-AC subscore were similar (Table 2).

Table 3 reports results for the cohort of individuals younger than 18 years. The IPTW model estimated a 5.36 (95% CI, 0.47- 10.24) point increase in TCS for the surgery group relative to the control group. Results for the TCS-AC subscore were similar (Table 3).

Body Image Dissatisfaction

The IPTW model estimated a 7.20 (95% CI, –11.68 to –2.72) point decrease in BIS for the surgery group relative to the control group (Table 2), indicating reduced body dissatisfaction. Results for the BIS secondary subscore did not demonstrate a significant association between surgery and score improvement (Table 2).

Table 3 reports results for the younger than 18 years cohort. The IPTW model estimated a 7.83 (95% CI, –13.98 to –1.67) point decrease in BIS for the surgery group relative to the control group. Results for the BIS secondary subscore did not demonstrate a significant association between surgery and score improvement (Table 3).

Secondary Analyses

Results for the secondary analyses are available in the eResults in the Supplement. eTables 1 through 3 in the Supplement present these results, which are similar to those of the IPTW analysis.

Discussion

To our knowledge, we present the first and largest prospective matched study evaluating quantitative outcomes of top surgery among TGNB DFAB AYA. We found that top surgery was associated with significant improvement in chest dysphoria (measured by the CDM) 3 months postoperatively; patients receiving surgery exhibited substantial decreases in CDM from presurgery to postsurgery and their reductions in CDM were significantly greater than those for patients who did not undergo top surgery. Top surgery also led to significant improvements in gender congruence (TCS) and body image satisfaction (BIS) at 3 months postoperatively. Surgical complications were minimal and comparable with those in adult patients.^23-28

Chest dysphoria can be treated with top surgery, and patients with minimal or no chest dysphoria may not require or desire top surgery. We removed participants with baseline CDM scores of less than 19 from the control group prior to conducting our primary analysis; this was the lowest CDM score in the surgery group. We acknowledge that several control patients with low CDM scores have not sought top surgery because of minimal chest dysphoria. Surgeons should consider treating patients with a diagnosis of gender dysphoria and who experience the negative mental and physical health effects of chest dysphoria.

TGNB youth frequently encounter systemic barriers to care. Obtaining insurance coverage for top surgery is a common problem; while World Professional Association for Transgender Health Standards of Care version 7 do not recommend a specific age for top surgery, many insurance plans deny coverage for patients younger than 18 years.²⁹ Medicolegal barriers exist as many states have ratified legislation prohibiting, and even criminalizing, medical and surgical therapy in TGNB minors.^30,31 This can lead to delays in care and health care avoidance, which result in worsening mental health burden.³² The American Academy of Pediatrics and the Pediatric Endocrine Society have issued statements in support of providing gender-affirming medical and surgical care to TGNB minors, contending that it is effective, safe, the standard of care, and should be covered by insurers.^33-35 In this study, patients younger than 18 years demonstrated parallel trends of improved CDM, TCS, and BIS compared with the entire cohort, demonstrating the robustness of our findings in this age subgroup. Findings from this study can help dispel misconceptions that gender-affirming treatment is experimental and support evidence-based practices of top surgery. Our retrospective review demonstrated associations between chest dysphoria and anxiety and depression; top surgery can improve chest dysphoria, thereby leading to improvements in quality of life.⁵ Our results also corroborate studies that gender-affirming therapy improves mental health and quality of life among TGNB youth.

Limitations

Our study is not without limitations. Analyses omit 11 patients whose outcomes were not measured due to attrition. Furthermore, we acknowledge that patients in the treatment group who were able to access surgery may have greater socioeconomic status and parental support, possibly introducing sampling bias. Patients in the control group may have desired top surgery but were unable obtain it due to both medical and nonmedical barriers; this could not be controlled during analysis. We were unable to achieve a high degree of balance on baseline measures between surgery and control groups, even after propensity score adjustments. Weighted SMDs exceeded 0.1 for many covariates, rendering analyses susceptible to confounding. As a sensitivity analysis, we computed E-values in the Supplement to quantify the potential effect of confounding; reported E-values suggest an extremely high degree of confounding would need to be present to negate estimated treatment effects. We acknowledge that there may be differences between groups and intrinsic differences in the gender experience that are unmeasurable. In the future, control patients should be better matched to treatment patients, with matching using several demographic variables and baseline outcome measures. This will permit estimation of a causal effect on subsequent analyses. Some insurance plans require testosterone therapy for 1 year prior to surgery; this may negatively affect nonbinary patients who do not undergo testosterone therapy and may have limited inclusion of this patient population in our cohort.² Nonbinary patients continue to be underrepresented in the literature; subgroup analysis of nonbinary patients was not possible due to small sample size and future studies should focus on this population. One-year follow up data are currently being collected to determine the long-term effect of top surgery on chest dysphoria, gender congruence, and body image satisfaction.

Conclusions

To our knowledge, we present the first prospective study evaluating the association of top surgery with chest dysphoria and gender congruence in TGNB DFAB AYA. Top surgery in this age group is associated with improved chest dysphoria, gender congruence, and body image satisfaction.

Article Information

Accepted for Publication: June 8, 2022.

Published Online: September 26, 2022. doi:10.1001/jamapediatrics.2022.3424

Corresponding Author: Sumanas W. Jordan, MD, PhD, Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, 675 North St Clair St, Galter Ste 19-250, Chicago, IL 60611 (sumanas.jordan@nm.org).

Author Contributions: Drs Ascha and Jordan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ascha, Sasson, Sood, Runge, Simons, Chen, Corcoran, Jordan.

Acquisition, analysis, or interpretation of data: Ascha, Sasson, Sood, Cornelius, Schauer, Runge, Muldoon, Gangopadhyay, Chen, Corcoran, Jordan.

Drafting of the manuscript: Ascha, Sasson, Cornelius, Schauer, Runge, Muldoon, Simons, Jordan.

Critical revision of the manuscript for important intellectual content: Ascha, Sasson, Sood, Muldoon, Gangopadhyay, Simons, Chen, Corcoran, Jordan.

Statistical analysis: Ascha, Sasson, Schauer, Jordan.

Obtained funding: Sood, Jordan.

Administrative, technical, or material support: Ascha, Sasson, Sood, Cornelius, Runge, Muldoon, Gangopadhyay, Chen, Jordan.

Supervision: Ascha, Gangopadhyay, Chen, Jordan.

Other – Data collection: Runge.

Conflict of Interest Disclosures: Dr Simons reported consultant fees from CVS Caremark for reviewing medication protocols for gender dysphoria, outside the submitted work. Dr Chen reported grants from the National Institutes of Health (R01 HD097122, R01 MH123746, and R01 HD082554), outside the submitted work. Dr Jordan reported grants from the Plastic Surgery Foundation during the conduct of the study. No other disclosures were reported.

Funding/Support: Northwestern University Clinical and Translational Sciences Institute is funded in part by a Clinical and Translational Science Award grant from the National Institutes of Health (UL1TR001422) that contributed to collection, management, analysis, and interpretation of the data. This study was also funded by the Plastic Surgery Foundation and American Association of Pediatric Plastic Surgery Combined Research grant that contributed to collection, management, analysis, and interpretation of the data.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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24. Cuccolo  NG, Kang  CO, Boskey  ER,  et al.  Masculinizing chest reconstruction in transgender and nonbinary individuals: an analysis of epidemiology, surgical technique, and postoperative outcomes.   Aesthetic Plast Surg. 2019;43(6):1575-1585. doi:10.1007/s00266-019-01479-2PubMedGoogle ScholarCrossref

25. Agarwal  CA, Scheefer  MF, Wright  LN, Walzer  NK, Rivera  A.  Quality of life improvement after chest wall masculinization in female-to-male transgender patients: a prospective study using the BREAST-Q and Body Uneasiness Test.   J Plast Reconstr Aesthet Surg. 2018;71(5):651-657. doi:10.1016/j.bjps.2018.01.003PubMedGoogle ScholarCrossref

26. van de Grift  TC, Elfering  L, Bouman  M-B, Buncamper  ME, Mullender  MG.  Surgical indications and outcomes of mastectomy in transmen: a prospective study of technical and self-reported measures.   Plast Reconstr Surg. 2017;140(3):415e-424e. doi:10.1097/PRS.0000000000003607PubMedGoogle ScholarCrossref

27. van de Grift  TC, Kreukels  BPC, Elfering  L,  et al.  Body image in transmen: multidimensional measurement and the effects of mastectomy.   J Sex Med. 2016;13(11):1778-1786. doi:10.1016/j.jsxm.2016.09.003PubMedGoogle ScholarCrossref

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30. Lyman  B; Montgomery Advertiser.  Alabama Senate approves bill banning transgender youth treatments amid protests at state Capitol.  Accessed August 24, 2022. https://www.montgomeryadvertiser.com/story/news/2021/03/02/alabama-senate-approves-bill-banning-transgender-youth-treatments/6867380002/

31. Freedom for All Americans.  Legislative tracker: anti-transgender Medical Care bans.  Accessed August 24, 2022. https://freedomforallamericans.org/legislative-tracker/medical-care-bans/

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35. Turban  JL, Kraschel  KL, Cohen  IG.  Legislation to criminalize gender-affirming medical care for transgender youth.   JAMA. 2021;325(22):2251-2252. doi:10.1001/jama.2021.7764
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CHICAGO, Illinois  – Medical professionals and social scientists criticized a new study that claimed to find benefits to double mastectomies on young females who suffer from gender confusion. 

The study, titled “Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults,” and published in the American Medical Association’s journal JAMA Pediatrics claimed “gender-affirming top surgery is associated with improved chest dysphoria, gender congruence, and body image in this age group.” 

The study looked at females ages 13 to 24 who either had a “surgical mastectomy” or who only took testosterone as the control group.  

The supposed benefits led the authors to conclude there should be no age minimum for removing healthy breasts from girls. “In our practice, there is no predetermined timeline for gender-affirming medical or surgical treatment,” they wrote. “[P]atients are assessed individually by a multidisciplinary team for readiness. There is no evidence to support delaying surgery for eligible patients based on age.” 

Despite fawning media coverage, according to Catholic University of America professor Michael New, the study is flawed,  

The short follow-up time also concerned Professor New. 

“Indeed, it is very important that research on individuals undergoing top surgery track long term outcomes, since top surgery, like other types of transgender surgery, is irreversible,” he noted. 

Political scientist Leor Sapir at the Manhattan Institute had similar concerns. Sapir, who studies and writes about transgenderism, stated, it is “only a slight exaggeration to say that the study basically asked people who just got surgery whether they were happy with the results of that surgery.” 

“The two biggest problems with the study are the short follow-up time (a mere 3 months!) and the narrowly defined outcome that was measured (‘chest dysphoria’ and related body image),” Sapir noted in his comments sent to LifeSiteNews. 

He suggested a 10-year follow-up would be a better time frame, based on how long regret can take to set in, or “twenty years later, when some of them might want to have children and breastfeed (assuming they are still fertile).” Double mastectomies eliminate the possibility of breastfeeding.

The executive director of the Association of American Physicians and Surgeons challenged the ethics behind the research. 

“There used to be some ethics in research, which should forbid any project that involves mutilating patients, especially children, especially for a made-up diagnosis,” Dr. Jane Orient noted. She also called the 90-day follow-up used in the study a “ludicrous” standard “for an irreversible, life-altering change.” 

“Ethics and science are dead at JAMA and the AMA. They are captured by a radical, extreme ideology that calls ‘misgendering’ a crime, and the destruction of normal body parts as a routine surgical procedure,” she wrote. 

Surgeon Greg Marchand also took issue with the study. “There is no [13-year-old] girl who can make the decision to permanently have her breasts removed,” Dr. Marchand wrote in a news release. “The chance of regret is simply too high. Children who suffer from gender dysphoric disorder should receive support, counselling, and treatment for associated conditions, such as depression and anxiety.” 

https://www.nytimes.com/2022/09/26/health/top-surgery-transgender-teenagers.html

More Trans Teens Are Choosing ‘Top Surgery’

Small studies suggest that breast removal surgery improves transgender teenagers’ well-being, but data is sparse. Some state leaders oppose such

By Azeen Ghorayshi

Published Sept. 26, 2022Updated Oct. 3, 2022

Michael, 17, arrived in the sleek white waiting room of his plastic surgeon’s office in Miami for a moment he had long anticipated: removing the bandages to see his newly flat chest.

After years of squeezing into compression undershirts to conceal his breasts, the teenager was overcome with relief that morning last December. Wearing an unbuttoned shirt, he posed for photos with his mother and the surgeon, Dr. Sidhbh Gallagher, happy to share his bare chest with the doctor’s large following on social media.

“It just felt right — like I’d never had breasts in the first place,” Michael said. “It was a ‘Yes, finally’ kind of moment.”

Michael is part of a very small but growing group of transgender adolescents who have had top surgery, or breast removal, to better align their bodies with their experience of gender. Most of these teenagers have also taken testosterone and changed their name, pronouns or clothing style.

Few groups of young people have received as much attention. Republican elected officials across the United States are seeking to ban all so-called gender-affirming care for minors, turning an intensely personal medical decision into a political maelstrom with significant consequences for transgender adolescents and their families.

Gender-related surgeries, in particular, have been thrust into the spotlight. Arizona and Alabama passed laws this year making it illegal for doctors to perform gender-related surgeries on transgender patients under 18. Conservative commentators with large followings on social media have recently targeted children’s hospitals that offer gender surgeries, leading to online harassment and bomb threats.

Genital surgeries in adolescents are exceedingly rare, surgeons said, but top surgeries are becoming more common. And while major medical groups have condemned the bans on gender-related care for adolescents, the surgeries have presented challenges for them.

 Much research has shown that as adults, transgender men generally benefit from top surgery: It relieves body-related distress, increases sexual satisfaction and improves overall quality of life. A few small studies of transgender adolescents suggest similar benefits in the short term.

But some clinicians have pointed to the rising demand and the turmoil of adolescent development as reasons for doctors to slow down before offering irreversible procedures. Although medical experts believe the likelihood to be small, some patients come to regret their surgeries.

The World Professional Association for Transgender Health, an international group of gender experts who write best practices for the field, had been planning for months to set new age minimums for most gender-related surgeries, including endorsing top surgery for adolescents age 15 and up. Although the guidelines are not binding, they provide a standard for doctors across the world. But this month, the group abruptly withdrew the proposals, a shift reflecting both political pressures and a lack of consensus in the medical community.

There are no official statistics on how many minors receive top surgeries each year in the United States. The New York Times surveyed leading pediatric gender clinics across the country: Eleven clinics said they carried out a total of 203 procedures on minors in 2021, and many reported long waiting lists. Another nine clinics declined to respond, and six said that they referred patients to surgeons in private practice.

Dr. Gallagher, whose unusual embrace of platforms like TikTok has made her one of the most visible gender-affirming surgeons in the country, said she performed 13 top surgeries on minors last year, up from a handful a few years ago. One hospital, Kaiser Permanente Oakland, carried out 70 top surgeries in 2019 on teenagers age 13 to 18, up from five in 2013, according to researchers who led a recent study.

“I can’t honestly think of another field where the volume has exploded like that,” said Dr. Karen Yokoo, a retired plastic surgeon at the hospital.

On Being Transgender in America

·                           ‘Top Surgery’: Small studies suggest that breast removal surgery improves transgender teenagers’ well-being, but data is sparse. Some state leaders oppose such procedures for minors.

·                           In Montana: Transgender people born in the state will no longer be able to change the sex listed on their birth certificate under a new rule that is among the most restrictive in the country.

·                           Generational Shift: The number of young people who identify as transgender in the United States has nearly doubled in recent years, according to a new report.

·                           The Battle Over Gender Therapy: More teenagers than ever are seeking transitions, but the medical community is deeply divided about why — and what to do to help them.

Experts said that adolescent top surgeries were less frequent than cosmetic breast procedures performed on teenagers who were not transgender. Around 3,200 girls age 18 to 19 received cosmetic breast implants in 2020, according to surveys of members of the American Society of Plastic Surgeons, and another 4,700 teenagers age 13 to 19 had breast reductions. (Surveys from other groups have shown that girls under 18 also receive implants, though the ASPS does not recommend breast augmentation for minors.)

In the past decade, the number of people who identify as transgender has grown significantly, especially among young Americans. Around 700,000 people under 25 identified as transgender in 2020, according to the Williams Institute, a research center at the University of California, Los Angeles, nearly double the estimate in 2017.

Gender clinics in Western Europe, Canada and the United States have reported that a majority of their adolescent patients were seeking to transition from female to male.

Because breasts are highly visible, they can make transitioning difficult and cause intense distress for these teenagers, fueling the demand for top surgeries. Small studies have shown that many transgender adolescents report significant discomfort related to their breasts, including difficulty showering, sleeping and dating. As the population of these adolescents has grown, top surgery has been offered at younger ages.

Another notable change: More nonbinary teenagers are seeking top surgeries, said Dr. Angela Goepferd, the medical director of the Gender Health Program at the Children’s Minnesota hospital, who is nonbinary. (The program does not perform operations but refers patients to independent surgeons.) These adolescents may want flatter chests but not other masculine features brought on by testosterone, like a deeper voice or facial hair.

After many months of deliberations over its new guidelines, the World Professional Association for Transgender Health initially decided to endorse top surgeries for adolescents 15 and up, part of a suite of changes that would have made gender treatments available to children at younger ages. But the organization backtracked this month, after some major medical groups it had hoped would support the new guidelines bristled at the new age minimums, according to Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the president of WPATH, who is transgender.

“We needed consensus,” Dr. Bowers said. “I just think we need more strength for our argument and a better political climate, frankly, in order to propose this at a younger age.”

Instead, the guidelines kept the previous recommendations, published a decade ago, allowing surgeries for minors on a case-by-case basis.

Because teenagers in most states must be 18 before they can provide medical consent, surgeons require parental consent and approval letters from mental health care providers. The two- to four-hour procedure costs anywhere from $9,000 to $17,000, depending on facility and anesthesia fees. The procedure is often not covered by insurance until patients turn 18.

As demand has grown, Dr. Gallagher, the surgeon in Miami, has built a thriving top surgery specialty. The doctor frequently posts photos, FAQs and memes on Facebook, Instagram and TikTok, proudly flouting professional mores in favor of connecting with hundreds of thousands of followers.

Her feeds often fill with photos tagged #NipRevealFriday, highlighting patients like Michael whose bandages were just removed. On her office windowsill sits a framed nameplate with one of her best-known catchphrases on TikTok: “Yeet the Teet,” slang for removing breasts.

Dr. Gallagher said she performed top surgeries on about 40 patients a month, and roughly one or two of them are under 18. Younger patients are usually at least 15, though she has operated on one 13-year-old and one 14-year-old, she said, both of whom had extreme distress about their chests.

The surgeon said that most of her patients, teenagers and adults alike, found her on TikTok. Her online presence has drawn sharp criticism from right-wing media, as well as from some parents and doctors who say she uses the platform to market to children.

“She goes to the beat of her own drum,” Dr. Bowers said. “For a lot of us, that’s troubling.”

Dr. Gallagher said she doubted she had the influence her critics ascribe to her. “Most of the time I’m just trying to deliver educational content,” she said.

 ‘Comfortable in my own skin’

Michael and his mother, Annie. He learned more about top surgery through Dr. Gallagher’s TikTok page.Credit...Eva Marie Uzcategui for The New York Times

When Michael first saw Dr. Gallagher’s TikTok page last summer, he was immediately intrigued. (Michael and others in this article asked to be identified by first or middle names because they were concerned about their privacy.) He liked the photos of her patients, observing that their scars had healed well, and liked that she seemed to be an ally of the transgender community.

Michael’s mother, Annie, had gradually come around to the idea of surgery after years of watching him suffer, she said.

Since hitting puberty at age 10, Michael said he felt a gnawing discomfort about his breasts. By the time he was 12, he wore hooded sweatshirts every day in their Miami suburb.

In eighth grade, after he had several severe panic attacks at school, Michael said he started seeing a therapist, who encouraged him to talk about his body issues. He experimented with small ways to appear more masculine, such as tucking his long curly hair into a beanie and wearing boys’ clothes.

“It was the first thing I ever did to try and make myself more comfortable in my own skin,” Michael said.

He came out to his parents as a transgender boy when he was 14. A year later, at the start of the pandemic, he started weekly testosterone injections while doing remote school. He got into strength-training and his voice dropped, a second puberty he relished but was grateful to undergo privately.

Michael started in-person school feeling “10 times happier,” he said, but his chest still tormented him. Testosterone and exercise had shrunk his breast tissue, making it easier to conceal with a binder. But the garment could restrict his breathing and give him panic attacks. He began seeing a psychiatrist, who prescribed antidepressants.

When Michael was 17, Annie said, she decided that waiting another year for surgery would put him in too much pain. Because her insurance covered the procedure only for adults, she took out a loan to help pay for it.

Michael’s psychiatrist initially wrote a letter signing off on the surgery. But he later revoked it, putting the surgery in limbo, Annie said. After Michael started a higher dose of antidepressants, the psychiatrist endorsed the surgery as planned.

Now, nine months after the operation, Michael is in his senior year of high school. He said he is focused on the parts of his life that have little to do with his gender: doing theater tech at school, seeing friends, painting and applying to college.

He also feels less pressure to prove his masculinity than before, he said. He’s growing out his hair and uses he, she and they pronouns. In June, he took his girlfriend to the prom, wearing a brown suit and a pearl necklace.

Weighing the risks

Image

Jamie, a college student in Maryland, began identifying as a transgender boy in the eighth grade, but has since returned to identifying as a woman.Credit...Cheriss May for The New York Times

In 2018, doctors at the pediatric gender clinic at Children’s Hospital Los Angeles published a study of 136 transgender patients ages 13 to 25, half of whom had undergone top surgery. Adolescents who had not undergone the procedure reported significantly more distress because of their chests.

Roughly one-third of those who underwent surgery reported ongoing loss of nipple sensation. Only one patient expressed occasional feelings of regret, when imagining wanting to breastfeed a future child.

“There’s very few things in the world that have a zero percent regret rate. And chest surgery, clinically, I’ve experienced that,” said Dr. Johanna Olson-Kennedy, the lead author of the study and medical director of the clinic in Los Angeles, which began offering surgeries in 2019.

But the study had caveats: Most patients were surveyed less than two years after their surgeries, and nearly 30 percent could not be contacted or declined to participate.

Because so few studies have looked at detransitioning, many doctors are asking young patients and their parents to provide consent without acknowledging the unknowns, said Kinnon MacKinnon of York University in Toronto, the researcher who led the study, who is transgender.

“I know personally many, many, many trans men that have benefited and are happy with their medical transition and their top surgery. I would put myself in that category,” Dr. MacKinnon said. “But just as a researcher, I do feel like there are questions that are deserving of answers and have implications for clinical care.”

Jamie, a 24-year-old college student in Maryland, was raised as a girl and began identifying as a transgender boy in the eighth grade. After being sexually assaulted in her junior year of high school and then dropping out, she said, she started taking testosterone. Three months later, just after she turned 18, she underwent top surgery at a private practice in Massachusetts.

For the next few years, Jamie said, she thrived. Testosterone made her feel energetic, and her anxiety dissipated. She went back to school and got certified as an emergency medical technician.

But when she was 21, her father, who was dying of Alzheimer’s, no longer recognized her. She fixated on her wide hips, which she worried stood out next to her facial hair and deep voice. After a date where she had sex with a straight man, she said, she realized she had made a mistake.

“I realized I lost something about myself that I could have loved, I could have enjoyed, I could have used to feed children,” Jamie said. She said she grieved for months and contemplated suicide.

This spring, after a year of fighting her insurance company to cover the procedure, she had surgery to reconstruct her breasts. She never told her original surgeon that she had changed her mind, partly because she also blamed herself. Sometimes, she said, “I still don’t like being a woman.”

Many surgeons say that they rarely hear about patients with regret. But it’s unclear how many, like Jamie, never inform them.

Dr. Gallagher of Miami said that she follows up with patients for up to a year. “I can say this honestly: I don’t know of a single case of regret,” Dr. Gallagher said in May, adding that regret was much more common with cosmetic procedures.

But one of her former top surgery patients, Grace Lidinsky-Smith, has been vocal about her detransition on social media and in news reports.

 “I slowly came to terms with the fact that it had been a mistake born out of a mental health crisis,” Ms. Lidinsky-Smith, 28, said in an interview.

She had top surgery when she was 23. About 16 months later, Ms. Lidinsky-Smith said she called and emailed her medical providers, including Dr. Gallagher’s office, to tell them she had detransitioned.

When asked about Ms. Lidinsky-Smith’s case, Dr. Gallagher amended her stance, recalling that years ago a former patient left a voice mail message expressing regret over a surgery.

“At the time, we wondered, Is it a hoax?” Dr. Gallagher said.

A clinic for transgender children in Dallas, Texas, stopped accepting new patients for hormone therapy and gender affirming care under pressure from the Gov. Greg Abbott’s office.

Republican politicians in states across the country are pushing to ban all gender-affirming care for adolescents, focusing much of their rhetoric on surgeries.

In Florida, where the medical board is considering such a ban for minors, Gov. Ron DeSantis has argued that surgeons should be sued for “disfiguring” children. In Texas, where parents of transgender children have been investigated for child abuse, Gov. Greg Abbott has called genital surgeries in adolescents “genital mutilation.”

Dr. Bowers, the president of WPATH, said that politicians should not be involved in personal medical decisions. “They just don’t understand this care, so they just want to shut it down,” Dr. Bowers said. “That is a very dangerous precedent.”

Although most of the new state actions against gender care for minors are tied up in litigation, they have had a chilling effect.

Earlier this year, a Dallas children’s hospital shut down the only pediatric gender clinic in Texas, citing political pressure from the governor’s office. This month, a woman was arrested on charges of making a false bomb threat to Boston Children’s Hospital after it was targeted online for its pediatric gender program. Dr. Gallagher has also received threats online and said she might hire security guards for her office.

Other clinics have dropped scheduled procedures. William, 14, who has identified as a boy since he was a young child, was supposed to see a plastic surgeon in Plano, Texas, for top surgery in May. But the surgeon canceled the appointment in March because the medical center’s malpractice insurer stopped covering top surgeries for minors.

In August, William and his family flew to California, paying $10,000 more to get the procedure out of state.

Two weeks later, William started ninth grade as just another boy in school. He looks forward to swimming with his shirt off and going to class without wearing a binder.

“It’s like something was unburied,” William said. “My chest was just covering what was always there.”

Audio produced by Parin Behrooz.

Correction: 

Sept. 26, 2022

An earlier version of this article misstated the timing of Jamie’s departure from high school. She dropped out after her junior year, not during it.

Correction: 

Oct. 1, 2022

An earlier version of this story, relying on information from a spokesperson for the American Society of Plastic Surgeons, misstated the age range that the ASPS used for reporting data on breast implants. Its data included girls 18 to 19, not 13 to 19.

https://journals.lww.com/annalsplasticsurgery/Abstract/2022/05004/Gender_Affirming_Mastectomy_Trends_and_Surgical.4.aspx

Tang, Annie MD^a; Hojilla, J. Carlo PhD^b,c; Jackson, Jordan E. MD^a; Rothenberg, Kara A. MD^a; Gologorsky, Rebecca C. MD^a; Stram, Douglas A. MS^c; Mooney, Colin M. MD^a; Hernandez, Stephanie L. MA, LMFT^d; Yokoo, Karen M. MD^e

ABSTRACT

Background 

There are more than 150,000 transgender adolescents in the United States, yet research on outcomes after gender-affirming mastectomy in this age group is limited. We evaluated gender-affirming mastectomy incidence and postoperative complications, including regret, in adolescents within our integrated health care system.

Methods 

Gender-affirming mastectomies performed from January 1, 2013, to July 31, 2020, in adolescents 12 to 17 years of age at the time of referral were identified. The incidence of gender-affirming mastectomy was calculated by dividing the number of patients undergoing these procedures by the number of adolescents assigned female at birth aged 12 to 17 years within our system at the beginning of each year and amount of follow-up time within that year. Demographic information, clinical characteristics (comorbidities, mental health history, testosterone use), surgical technique, and complications, including mention of regret, of patients who underwent surgery were summarized. Patients with and without complications were compared to evaluate for differences in demographic or clinical characteristics using χ² tests.

Results 

The incidence of gender-affirming mastectomy increased 13-fold (3.7–47.7 per 100,000 person-years) during the study period. Of the 209 patients who underwent surgery, the median age at referral was 16 years (range, 12–17 years) and the most common technique was double incision (85%). For patients with greater than 1-year follow-up (n = 137; 65.6%), at least one complication was found in 7.3% (n = 10), which included hematoma (3.6%), infection (2.9%), hypertrophic scars requiring steroid injection (2.9%), seroma (0.7%), and suture granuloma (0.7%); 10.9% underwent revision (n = 15). There were no statistically significant differences in patient demographics and clinical characteristics between those with and without complications (P > 0.05). Two patients (0.95%) had documented postoperative regret, but neither underwent reversal surgery at follow-up of 3 and 7 years postoperatively.

Conclusions 

Between 2013 and 2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low, and of more than 200 adolescents who underwent surgery, only 2 expressed regret, neither of which underwent a reversal operation. Our study provides useful and positive guidance for adolescent patients, their families, and providers regarding favorable outcomes with gender-affirming mastectomy.

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