סקר מנתחים מעריך חרטה אחרי ניתוח מגדרי ב-0.2–0.3% — על סמך שיעור מענה של 30% וזיכרונות המנתחים

הנחיית השיחה — סוגי חרטה לאחר ניתוח מאשר מגדר והאטיולוגיות הנלוות

Authors: Sasha Karan Narayan, Rayisa Hontscharuk, Sara Danker, Jess Guerriero, Angela Carter, Gaines Blasdel, Rachel Bluebond-Langner, Randi Ettner, Asa Radix, Loren Schechter, Jens Urs Berli
Journal: Annals of Translational Medicine
Year: 2021
Source: https://doi.org/10.21037/atm-20-6204

Summary

Gender surgeons who attended WPATH and USPATH conferences (meetings of trans health professionals) were asked how many patients they had seen who regretted surgery or wanted it reversed. Fewer than a third replied. Together they recalled 62 such patients out of an estimated 18,000 to 27,000 they had operated on, so the authors put regret at 0.2–0.3%. Where reasons were known, the most common was a change in gender identity or a wrong diagnosis, then family or social rejection, then relationship problems. The authors suggest sorting regret into three types: 'true gender-related', 'social' and 'medical'. This grouping is useful for discussion. But the regret figure cannot be trusted: it depends on surgeons' memory, on regretful patients going back to a surgeon, and on numbers from a self-selected minority who answered.

Key findings

46 מתוך 154 מנתחים שהוזמנו (30%) השיבו; רובם עבדו בארה"ב (67%) או באירופה (22%), ל-65% היה ותק של מעל 10 שנים.
הם העריכו שניתחו 18,125 עד 27,325 מטופלים טרנס וזכרו 62 שהתחרטו על הניתוח או ביקשו היפוך, כ-0.2–0.3%.
57% מהמנתחים ראו לפחות מטופל אחד עם חרטה; 45 מתוך 62 המקרים (73%) כללו ניתוח איברי מין ו-13 (21%) ניתוח חזה או שדיים.
במקום שבו הסיבות היו ידועות (46 מטופלים), ב-42% היה שינוי בזהות מגדרית או אבחנה שגויה, ב-15% דחייה משפחתית או חברתית, וב-11% בעיות זוגיות.
המחברים מיינו בקשות היפוך לחרטה 'מגדרית אמיתית' (42%), חרטה 'חברתית' (37%) וחרטה 'רפואית' (8%); ל-24% מהמטופלים האלה היו סיבוכים אחרי הניתוח.
91% מהמנתחים ידרשו הערכת בריאות נפשית חדשה לפני ניתוח היפוך, ו-88% רצו שהנחיות WPATH הבאות יכסו ניתוחי היפוך.
המחברים מודים שסקרים אינם מתאימים לקביעת השכיחות של דבר, ושסקירת המחקרים הקודמים שלהם לא הייתה שיטתית.

Abstract

Background: A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.

Methods: This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review.

Results: The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature.

Conclusions: In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Conclusion

In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Methodological limitations

Numbers don't match up: The regret count includes patients who had surgery with any surgeon, but the total patients figure is only the replying surgeons' own patients. So the result is not a true rate. Cohn (2023) called the method hard to interpret.
Few surgeons replied: Only 30% answered. Surgeons who rarely see regret may have been more or less likely to reply, and the experience of the rest is unknown.
Many regretful patients never return: Many people with regret, or who detransition, never go back to their surgeon or gender clinic. Littman (2021) found only 24% told their clinicians. So the survey probably undercounts regret.
Based on memory and rough ranges: Patient numbers and regret cases were recalled from memory and given as ranges, which were added up to get 18,125 to 27,325.
Regret not defined, follow-up unknown: The survey deliberately left 'regret' undefined. Surgeons did not routinely ask about regret, and how long they kept track of patients is unknown.
Narrow view: Only breast and genital surgery were covered, and only surgeons were asked. Mental health clinicians and hormone doctors, who may hear about regret first, were not surveyed.
Informal review of past studies: The authors admit their review was not systematic and may have picked studies selectively. It mostly repeats older low-regret figures that had their own dropout problems (for example Wiepjes 2018, which lost track of 36% of patients).
Untested categories: The 'true', 'social' and 'medical' regret types come from expert opinion and have not been tested to see if they work reliably.
Authors' roles: Several authors hold leadership roles in WPATH or on its guideline committee, and most are surgeons or clinicians who provide these treatments. These roles are unpaid and disclosed, but they matter for how the low-regret conclusion is presented.
Possible double counting: The authors note that a patient may have seen more than one of the surgeons who replied, which could inflate the count.

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Summary

Key findings

Abstract

Conclusion