Mastectomy Under 26: High Certainty Only for Physical Complications

Mastectomy for Individuals with Gender Dysphoria Younger Than 26 Years: A Systematic Review and Meta-Analysis

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

The review found 39 studies, searched up to June 2023: only 3 compared groups and 2 measured people before and after surgery; the other 34 only described operated patients.
High-quality evidence came only from studies of surgical complications: no deaths (5 studies), about 20 in 1,000 lost the nipple or skin graft through tissue death (13 studies), about 10 in 1,000 lost a skin flap (3 studies), and about 50 in 1,000 had thick scarring (12 studies).
Two studies comparing surgery with chest binding gave very weak evidence on chest-related gender distress and on satisfaction with body and chest.
One study comparing surgery with no surgery gave very weak evidence on distress and suicide attempts, and weak evidence that people were about half as likely to self-harm (without suicidal intent) after surgery.
Quality of life, depression, death by suicide, chest satisfaction and regret were all rated very weak evidence, mostly because there was no comparison group.
Planned checks on whether results differed by other mental health conditions, age when distress began or sexual orientation could not be done, and suicidal thoughts, sexual function and later operations were not assessed.
The authors call for studies that follow patients forward in time and, if ethical, randomised trials, to inform patients, surgeons, guideline writers and policymakers.

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