Summary
This review gathered 39 studies on breast removal surgery for young people with gender distress and rated how trustworthy the evidence was. Nearly all only followed operated patients, with no comparison group. Only short-term surgical complications were rated high-quality evidence, and they were uncommon: no deaths, about 2% to 3% loss of the nipple or skin graft through tissue death, and about 5% thick scarring. For the results that matter most, such as gender distress, mental health, suicide attempts, quality of life and regret, the evidence was weak or very weak. One study did suggest people were about half as likely to self-harm after surgery. The authors call for better studies. The review shows the evidence is weak; it does not show that surgery fails to help. It was funded by SEGM, a group that urges caution, and surgeons have challenged its framing in published letters.
Key findings
- وجدت المراجعة 39 دراسة، بُحث فيها حتى يونيو 2023: قارنت 3 فقط بين مجموعات وقاست 2 الأشخاص قبل الجراحة وبعدها؛ ووصفت الـ 34 الأخرى المرضى المُجرى لهم الجراحة فقط.
- جاءت الأدلة عالية الجودة من دراسات المضاعفات الجراحية فقط: لا وفيات (5 دراسات)، ونحو 20 من كل 1,000 فقدوا الحلمة أو الطعم الجلدي بسبب موت النسيج (13 دراسة)، ونحو 10 من كل 1,000 فقدوا شريحة جلدية (3 دراسات)، ونحو 50 من كل 1,000 أصيبوا بندوب سميكة (12 دراسة).
- قدمت دراستان تقارنان الجراحة بربط الصدر أدلة ضعيفة جداً عن الكرب الجندري المتعلق بالصدر وعن الرضا عن الجسم والصدر.
- قدمت دراسة واحدة تقارن الجراحة بعدم إجرائها أدلة ضعيفة جداً عن الكرب ومحاولات الانتحار، وأدلة ضعيفة على أن الأشخاص كانوا أقل عرضة بنحو النصف لإيذاء النفس (دون نية الانتحار) بعد الجراحة.
- صُنّفت جودة الحياة والاكتئاب والموت انتحاراً والرضا عن الصدر والندم جميعها على أنها أدلة ضعيفة جداً، في الغالب لعدم وجود مجموعة مقارنة.
- تعذّر إجراء الفحوص المخططة لمعرفة هل اختلفت النتائج حسب الحالات النفسية الأخرى أو العمر عند بدء الكرب أو التوجه الجنسي، ولم تُقيَّم الأفكار الانتحارية والوظيفة الجنسية والعمليات اللاحقة.
- يدعو المؤلفون إلى دراسات تتابع المرضى عبر الزمن، وإلى تجارب عشوائية إن كان ذلك أخلاقياً، لإفادة المرضى والجراحين وكتّاب الإرشادات وصانعي السياسات.
Abstract
BACKGROUND: Gender dysphoria (GD) refers to psychological distress associated with the incongruence between one's sex and one's gender. In response to GD, birth-registered female patients may choose to undergo mastectomy. In this systematic review, the authors summarize and assess the certainty of the evidence about the effects of mastectomy. METHODS: We searched MEDLINE, Embase, PsycINFO, Social Sciences Abstracts, LGBTQ+ Source, and Sociological Abstracts through June 20, 2023. We included studies comparing mastectomy to no mastectomy in birth-registered patients younger than 26 years with GD. Outcomes of interest included psychological and psychiatric outcomes, and physical complications. Pairs of reviewers independently screened articles, abstracted data, and assessed risk of bias of the included studies. We performed meta-analysis and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: We included 39 studies. Observational studies (n = 2) comparing mastectomy to chest binding provided very low-certainty evidence for the outcome of GD. One observational study comparing mastectomy to no mastectomy provided very low-certainty evidence for the outcomes of global functioning and suicide attempts, and low-certainty evidence for the outcome nonsuicidal self-injury (adjusted OR, 0.47; 95% CI, 0.22 to 0.97). Before-and-after (n = 2) studies provided very low-certainty evidence for all outcomes. Evidence from case series (n = 34) studies ranged from high to very low certainty. CONCLUSIONS: Case series studies demonstrated high-certainty evidence for the outcomes of death, necrosis, and excessive scarring; however, these are limited in methodologic quality. In comparative and before-and-after studies, the evidence ranged from low to very low certainty.
Conclusion
The best available evidence reporting the effects of mastectomy in individuals with GD ranged from high to very low certainty. High certainty evidence in this SR was derived from case series studies only. High-certainty evidence from prospective cohort studies and, if ethical, randomized controlled trials, are needed to describe the short- and long-term effects of mastectomy in individuals with GD on mental health outcomes. Higher certainty evidence would be useful to individuals with GD considering chest masculinization; clinicians and surgeons involved in their care; guideline developers; and policy makers and stakeholders who make decisions about treatment related to GD.