Mastektomie unter 26: Hohe Sicherheit nur für körperliche Komplikationen

Mastektomie für Personen mit Geschlechtsdysphorie jünger als 26 Jahre: Ein systematisches Review und eine Meta-Analyse

Systematische Übersichten & Evidenzberichte Operationen

Authors: Anna Miroshnychenko, Yetiani M. Roldan, Sara Ibrahim, Chan Kulatunga-Moruzi, Kristen Dahlin, Steven Montante, Rachel Couban, Gordon Guyatt, Romina Brignardello-Petersen
Journal: Plastic and Reconstructive Surgery
Year: 2024
Source: doi.org/10.1097/prs.0000000000011734

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

Die Übersicht fand 39 Studien, durchsucht bis Juni 2023: Nur 3 verglichen Gruppen und 2 maßen Personen vor und nach der Operation; die anderen 34 beschrieben nur operierte Patienten.
Evidenz hoher Qualität gab es nur aus Studien zu chirurgischen Komplikationen: keine Todesfälle (5 Studien), etwa 20 von 1.000 verloren Brustwarze oder Hauttransplantat durch Gewebetod (13 Studien), etwa 10 von 1.000 verloren einen Hautlappen (3 Studien) und etwa 50 von 1.000 hatten dicke Narbenbildung (12 Studien).
Zwei Studien, die die Operation mit Brustbinden verglichen, lieferten sehr schwache Evidenz zu brustbezogenem Geschlechtsleidensdruck und zur Zufriedenheit mit Körper und Brust.
Eine Studie, die Operation mit Nicht-Operation verglich, lieferte sehr schwache Evidenz zu Leidensdruck und Suizidversuchen sowie schwache Evidenz, dass Menschen nach der Operation etwa halb so wahrscheinlich sich selbst verletzten (ohne Suizidabsicht).
Lebensqualität, Depression, Tod durch Suizid, Zufriedenheit mit der Brust und Reue wurden alle als sehr schwache Evidenz eingestuft, überwiegend weil es keine Vergleichsgruppe gab.
Geplante Prüfungen, ob sich die Ergebnisse nach anderen psychischen Erkrankungen, Alter bei Beginn des Leidensdrucks oder sexueller Orientierung unterschieden, konnten nicht durchgeführt werden, und Suizidgedanken, Sexualfunktion und spätere Operationen wurden nicht erfasst.
Die Autoren fordern Studien, die Patienten über die Zeit verfolgen, und, wenn ethisch vertretbar, randomisierte Studien, um Patienten, Chirurgen, Leitlinienautoren und politische Entscheidungsträger zu informieren.

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.

Methodological limitations

Weak underlying studies: 34 of 39 studies only described operated patients, with no comparison group. So the review cannot estimate how surgery affects mental health, as the authors admit.
Strong evidence only for complications: The 'high-quality' findings are about short-term surgical complications. The authors say these studies are of limited quality and may not apply to the wider group of people with gender distress.
Funder involvement: The review was done under an agreement with SEGM, which urges caution in youth gender medicine. SEGM members helped design the research question, though the McMaster team says it alone did the analysis and drew the conclusions.
Weak evidence is not proof of no benefit: Weak evidence of mental health benefit means the benefit is uncertain, not absent. Critics argue this difference can be lost when the review is used in policy debates.
Surgeons challenged its framing: Armstrong, Morrison, Lee and Kuzon (Plast Reconstr Surg 2026;157:144e-145e) argued that randomised trials and comparisons with people who do not want surgery are unsuitable, that suicide is the wrong measure for a body-image operation, and that the review rated supportive recent studies too low. Kulatunga-Moruzi and Montante replied (Plast Reconstr Surg 2026;157:145e-147e) that the review takes no position on whether surgery should be offered.
Many patients older than the target age: Studies counted if the average age was under 26 (under 30 for complications). Ratings were lowered when fewer than 60% of people were in range, so many patients were older than the group of interest.
English-language studies only: Studies in other languages were left out, as the authors admit, though they do not expect this to change the conclusions.
No group-by-group checks: There was too little data to test whether results differ by other mental health conditions, when distress began, clinic versus community groups, or sexual orientation.
Some results not looked at: Suicidal thoughts, sexual function, repeat surgery, emotional and eating disorders, relationships and daily functioning were left out to keep the work manageable. No data were found on breathlessness, back pain, psychiatric hospital stays or drug and alcohol use.
A guessed number: Before-and-after changes relied on an assumed figure, because the studies did not report it. The authors checked that higher and lower guesses gave similar results.
Too short to see regret: Few studies followed people long enough to capture regret or detransition, so that evidence was rated very weak.
Search is out of date: The search ended in June 2023, so later studies are not included.

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Summary

Key findings

Abstract

Conclusion