Mastectomie avant 26 ans : haute certitude uniquement pour les complications physiques

Mastectomie pour les personnes souffrant de dysphorie de genre de moins de 26 ans : une revue systématique et une méta-analyse

Revues systématiques & des données probantes Chirurgie

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

La revue a trouvé 39 études, recherchées jusqu'en juin 2023 : seules 3 comparaient des groupes et 2 mesuraient les personnes avant et après la chirurgie ; les 34 autres décrivaient seulement des patients opérés.
Des preuves de haute qualité ne provenaient que des études sur les complications chirurgicales : aucun décès (5 études), environ 20 sur 1 000 ont perdu le mamelon ou la greffe de peau par mort des tissus (13 études), environ 10 sur 1 000 ont perdu un lambeau de peau (3 études), et environ 50 sur 1 000 ont eu des cicatrices épaisses (12 études).
Deux études comparant la chirurgie au port d'un binder thoracique ont donné des preuves très faibles sur la détresse de genre liée à la poitrine et sur la satisfaction envers le corps et la poitrine.
Une étude comparant la chirurgie à l'absence de chirurgie a donné des preuves très faibles sur la détresse et les tentatives de suicide, et des preuves faibles que les personnes avaient environ deux fois moins de risques de s'automutiler (sans intention suicidaire) après la chirurgie.
La qualité de vie, la dépression, le décès par suicide, la satisfaction envers la poitrine et le regret ont tous été jugés étayés par des preuves très faibles, surtout faute de groupe de comparaison.
Les vérifications prévues pour savoir si les résultats différaient selon les autres troubles de santé mentale, l'âge de début de la détresse ou l'orientation sexuelle n'ont pas pu être faites, et les pensées suicidaires, la fonction sexuelle et les opérations ultérieures n'ont pas été évaluées.
Les auteurs appellent à des études qui suivent les patients dans le temps et, si c'est éthique, à des essais randomisés, pour éclairer les patients, les chirurgiens, les rédacteurs de recommandations et les décideurs.

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