Teen Mastectomies Rose 13-Fold at Kaiser; 0.95% Regret Reported, But Only From Chart Notes Over ~2 Years

Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents

Cohort & registry studies Detransition & regret Surgery

Authors: Annie Tang, J. Carlo Hojilla, Jordan E. Jackson, Kara A. Rothenberg, Rebecca C. Gologorsky, Douglas A. Stram, Colin M. Mooney, Stephanie L. Hernandez, Karen M. Yokoo
Journal: Annals of Plastic Surgery
Year: 2022
Source: https://doi.org/10.1097/SAP.0000000000003135

Summary

Surgeons and researchers at Kaiser Permanente Northern California reviewed the records of 209 teenagers, referred between ages 12 and 17, who had their breasts removed for gender dysphoria (distress about one's sex) between 2013 and mid-2020. The rate of these operations among teenage girls in the health system rose 13-fold. Surgical problems were uncommon (7.3%) and about 1 in 9 needed a repeat operation. Only two patients had regret recorded in their notes, and neither had surgery to reverse it. The authors concluded the surgery is safe and has good results for teenagers. However, nobody was asked directly about regret; it was searched for in clinic notes. Typical follow-up was only about two years, a third were not followed for even one year, there was no comparison group, and satisfaction, quality of life and mental health were not measured.

Key findings

209 teenagers aged 12 to 17 when referred had breast removal for gender reasons at Kaiser Permanente Northern California between January 2013 and July 2020.
The rate of these operations rose 13-fold, from about 4 to about 48 per 100,000 teenage girls in the health system each year.
The typical age at referral was 16; before surgery, 60% had depression, 61% anxiety and 5% an eating disorder.
88% were taking testosterone before surgery, and 85% had the most common technique, which leaves two long scars.
Among the 137 patients (about two-thirds) followed for at least a year, 7.3% had a surgical problem and 10.9% needed a repeat operation.
Two patients (about 1 in 100), both nonbinary and operated on at 16, had regret noted in their records; neither had surgery to reverse it.
Typical follow-up was about 2 years, and satisfaction, quality of life and mental health were not measured.

Abstract

BACKGROUND: There are over 150,000 transgender adolescents in the United States, yet research on outcomes following gender-affirming mastectomy in this age group is limited. We evaluated gender-affirming mastectomy incidence, as well as postoperative complications, including regret, in adolescents within our integrated health care system. METHODS: Gender-affirming mastectomies performed from January 1, 2013 - July 31, 2020 in adolescents 12-17 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 ages 12-17 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 chi-squared tests. RESULTS: The incidence of gender-affirming mastectomy increased 13-fold (3.7 to 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) 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. CONCLUSION: Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two 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.

Conclusion

Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two 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. (In the discussion the authors add that the study shows gender-affirming mastectomy in adolescents is 'safe, successful, and increasing in need', and argue that state legislation could create barriers to it.)

Methodological limitations

Nobody was asked about regret: Regret was found only by reading surgery and mental-health notes and searching them for keywords, not by asking patients. The authors admit regret may be under-counted.
Short follow-up: Typical follow-up was about 2 years, but studies of detransition suggest regret and detransition often show up several years after transition. So the 1-in-100 figure is a short-term minimum.
Many people not followed: Only 137 of 209 (about two-thirds) were followed for at least a year for surgical problems, and patients who left Kaiser or got care elsewhere were missed.
Reversal surgery is a poor sign of regret: Not having breast reconstruction does not mean no regret. Reconstruction is costly and complex, and rarely sought even by people who regret the surgery.
No proper measures of benefit: Patients were not asked about satisfaction, quality of life, distress about their chest or mental health, so any benefit cannot be judged.
No comparison group: Without teenagers who did not have surgery to compare with, the study cannot show that surgery led to better results than other options.
Narrow count of problems: Only five types of surgical problem were counted. Loss of feeling, shape problems and unhappiness with appearance only show up indirectly through repeat operations (10.9%).
Mental-health history not explored: About 60% had depression or anxiety before surgery, but the study did not look at whether this was linked to later problems or regret.
Select, insured group: Patients came from one health system with insurance and access to a full gender clinic team. The authors note the results may not apply elsewhere.
Authors provide the treatment: The authors work in the Kaiser program that performs these surgeries, said their aim was to confirm their 'favorable clinical experience', and used the paper to argue against state laws restricting it. They declared no conflicts of interest.

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Summary

Key findings

Abstract

Conclusion