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
- समीक्षा को 39 अध्ययन मिले, जून 2023 तक खोजे गए: केवल 3 ने समूहों की तुलना की और 2 ने सर्जरी के पहले और बाद में लोगों को मापा; अन्य 34 ने केवल ऑपरेशन पाए मरीज़ों का वर्णन किया।
- उच्च गुणवत्ता का साक्ष्य केवल सर्जिकल जटिलताओं के अध्ययनों से आया: कोई मृत्यु नहीं (5 अध्ययन), प्रति 1,000 में लगभग 20 ने ऊतक मरने से निप्पल या त्वचा ग्राफ़्ट खोया (13 अध्ययन), प्रति 1,000 में लगभग 10 ने त्वचा का फ़्लैप खोया (3 अध्ययन), और प्रति 1,000 में लगभग 50 को मोटे निशान हुए (12 अध्ययन)।
- सर्जरी की छाती बाँधने से तुलना करने वाले दो अध्ययनों ने छाती संबंधी लिंग परेशानी और शरीर व छाती से संतुष्टि पर बहुत कमज़ोर साक्ष्य दिया।
- सर्जरी की बिना सर्जरी से तुलना करने वाले एक अध्ययन ने परेशानी और आत्महत्या के प्रयासों पर बहुत कमज़ोर साक्ष्य दिया, और इस पर कमज़ोर साक्ष्य कि सर्जरी के बाद लोगों के खुद को नुकसान पहुँचाने (आत्महत्या के इरादे के बिना) की संभावना लगभग आधी थी।
- जीवन की गुणवत्ता, अवसाद, आत्महत्या से मृत्यु, छाती से संतुष्टि और पछतावा, सभी को बहुत कमज़ोर साक्ष्य आँका गया, ज़्यादातर इसलिए कि कोई तुलना समूह नहीं था।
- यह जाँचने की नियोजित जाँचें नहीं हो सकीं कि परिणाम अन्य मानसिक स्वास्थ्य स्थितियों, परेशानी शुरू होने की उम्र या यौन अभिविन्यास के अनुसार भिन्न थे या नहीं, और आत्महत्या के विचारों, यौन कार्य और बाद के ऑपरेशनों का आकलन नहीं हुआ।
- लेखक मरीज़ों, सर्जनों, दिशानिर्देश लेखकों और नीति-निर्माताओं को सूचित करने के लिए ऐसे अध्ययनों की माँग करते हैं जो मरीज़ों का समय में आगे अनुसरण करें और, यदि नैतिक हो, यादृच्छिक परीक्षण।
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.