Metaanalyse: 1 % Reue nach Geschlechtsoperation, doch die Studien hatten kurze Nachbeobachtung und hohe Ausfälle

Reue nach geschlechtsbejahender Operation: eine systematische Übersichtsarbeit und Metaanalyse zur Prävalenz

Systematische Übersichten & Evidenzberichte Detransition & Reue Operationen

Authors: Valeria P. Bustos, Samyd S. Bustos, Andres Mascaro, Gabriel Del Corral, Antonio J. Forte, Pedro Ciudad, Esther A. Kim, Howard N. Langstein, Oscar J. Manrique
Journal: Plastic and Reconstructive Surgery Global Open
Year: 2021
Source: https://doi.org/10.1097/GOX.0000000000003477

Summary

This review combined 27 studies of nearly 8,000 people who had gender surgery and estimated that about 1% regretted it. The authors concluded regret is extremely rare and credited better screening of patients. The 1% figure is now widely quoted. But the authors themselves say the evidence underneath is weak: most studies were rated poor or fair, almost none used tested ways of measuring regret, and results varied a lot between studies. Critics point out that people were often followed for only one or two years, while regret typically shows up after about eight years. Many people were lost track of (36% in the largest study), and some numbers were copied wrongly. Most people studied were adults treated under older, stricter rules. The 1% is best seen as a minimum drawn from incomplete data, not a reliable regret rate for today's patients.

Key findings

Die Übersicht schloss 27 Studien mit 7.928 Operationspatienten aus 14 Ländern ein; 67 % hatten Operationen von männlich zu weiblich und 33 % von weiblich zu männlich, und nur ein Patient war als nichtbinär verzeichnet.
Insgesamt bereuten etwa 1 % der Patienten die Operation (wahrscheinlich zwischen unter 1 % und 2 %), doch die Ergebnisse unterschieden sich zwischen den Studien stark; insgesamt gaben 77 Personen Reue an.
Reue lag bei unter 1 % nach Operationen von weiblich zu männlich und Brustentfernung, bei 1 % nach Operationen von männlich zu weiblich und bei 2 % nach der Operation zur Bildung einer Vagina.
Die häufigsten Gründe für Reue waren Schwierigkeiten, in der neuen Geschlechterrolle von Familie und Gesellschaft akzeptiert zu werden, gefolgt von schlechten chirurgischen oder körperlichen Ergebnissen.
Fast alle Studien nutzten selbst gemachte Fragen oder Interviews, die meisten wurden als schlechte oder mittlere Qualität eingestuft, und die Nachbeobachtung reichte von unter 1 Jahr bis 9 Jahre.
Es gab Anzeichen, dass Studien mit niedriger Reue eher veröffentlicht wurden; die Anpassung daran senkte die Schätzung von 1 % auf 0,5 %.
Eine Korrektur von 2022 berichtigte Tabellen und Abbildungen, nachdem die Autoren die Übersicht erneut durchgeführt hatten, und veröffentlichte Briefe (Expósito-Campos & D'Angelo 2021; Bewley 2022) stellten die Methoden und Schlussfolgerungen in Frage.

Abstract

Background: There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

Methods: A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

Results: A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%-2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%-<1%) and 1% (CI <1%-2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin's regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions: Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Conclusion

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Methodological limitations

People not followed for long enough: Follow-up ranged from under 1 year to 9 years, and many studies followed people for only 1–2 years. Regret has been estimated to appear on average after 8 to 8.5 years. Cohn (Archives of Sexual Behavior, 2023) found no included study that kept track of over 85% of people for at least 8 years each.
Many people lost track of: The largest study (Wiepjes et al. 2018), about half of all people in the review, lost track of 36%. Even the five better-quality studies (174 people, 3% of the total) lost 28% to over 40%, including people who had died (Expósito-Campos & D'Angelo, PRS Global Open 2021).
Weak underlying studies: Most studies were rated "poor" or "fair" quality. Critics count 23 of 27 as at moderate-to-high risk of giving misleading results. None had a comparison group, and many just looked back at old medical files.
Regret measured in different, untested ways: Almost all studies made up their own questions, and each defined regret differently. The authors admit this, and add that patients may hide regret from the surgeons or clinics that treated them.
Number errors and a correction: Critics said the number of people counted from Wiepjes et al. was inflated from 2,627 to 4,863, which makes regret look rarer. The authors defended their figure, but a 2022 correction fixed the tables and figures after the review was re-run.
Questionable choice of studies: Letter writers said well-known relevant studies were missed. One included study asked about regret over the surgical technique chosen, not about having surgery at all.
No plan registered in advance, and missing details: Bewley (PRS Global Open 2022) found the authors did not publicly register their plan beforehand, left out standard reporting items, did not give each study's design or missing-data rates, and did not check whether weaker studies gave different answers.
Results varied a lot and may be skewed by publication: The studies disagreed with each other a great deal, and there were signs that low-regret studies were more likely to be published.
May not apply to today's patients: Most people studied were adults treated under older, stricter rules. Today's patients are more often teens when distress starts, more often born female and more often non-binary, and the claim that results apply to non-binary people rests on one patient.
Credit given without evidence: The authors say low regret shows that better patient screening works, but the data never tested this. Studies using different screening rules were not compared.
Narrow search: The search only covered English and Spanish papers up to May 2020 and found only 74 records in the databases.
Possible conflicts of interest: The authors said they had no financial interests. Bewley noted that several are plastic surgeons who perform these operations and questioned whether that statement holds.

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Summary

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Abstract

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