永久の喪失：性別適合を戻した女性が乳房切除後の授乳不能を嘆く

胸部男性化乳房切除術と性別適合戻し後の授乳の悲しみ

Authors: Karleen D. Gribble, Susan Bewley, Hannah G. Dahlen
Journal: Frontiers in Global Women's Health
Year: 2023
Source: www.frontiersin.org/articles/10.3389/fgwh.2023.1073053/full

Summary

This paper tells the story of one woman who had her breasts removed as part of a gender transition, later stopped transitioning, and then grieved deeply when she could not breastfeed her baby. The authors point out that the main transgender health guidelines (WPATH, AusPATH and PATHA) do not tell surgeons to discuss breastfeeding before this surgery. They also describe how midwives and doctors who did not understand detransition made her pregnancy and early motherhood harder. They call for honest talks about breastfeeding before surgery, better training for maternity staff, emotional support and access to donor milk. It is a vivid and useful warning, but it is one person's account, told from memory and not checked against her surgical or clinic records, so it cannot tell us how common this experience is.

Key findings

エリザベスは性同一性障害と診断され、18歳でテストステロンを処方されました。20歳で両方の乳房を切除し、乳首を移植し直しました。これが授乳にどう影響するかについて話があった記憶はありません。
手術によって厚くて痛みのある瘢痕が残り、乳首は痛んで分泌物が出ました。トランスジェンダーの友人から拒絶されたことや、テストステロンによる膣の乾燥と萎縮もあって危機に陥り、24歳でトランジションをやめました。
エリザベスは、当時なら授乳の話はおそらく断っていただろうと述べています。今ではそれを回避だったと捉えており、性別への苦痛が議論を閉ざす「切り札」として使われていたと考えています。
30歳で妊娠したとき、授乳できないことを嘆き悲しみました。助産師は「ミルクだけにすればいい」と言い、医師は彼女を男性と呼び続けました。この混乱は児童保護への通報につながりましたが、母乳バンクが親切にも提供母乳を提供してくれました。
著者らは、国際およびオーストラリアのトランスジェンダー保健ガイドライン（WPATH、AusPATH、PATHA）が、この手術の前に授乳について話し合うことを勧めていないと指摘しています。乳首の移植によって授乳はほぼ確実に不可能になると主張しています。
著者らは、デトランジションする人の割合や、特に10代における乳房切除の利益に関する研究は不十分だと主張しています。追跡期間は短く、多くの人が研究から脱落しているためです。
手術前の率直な授乳に関するカウンセリング、デトランジションした女性についての産科スタッフへの研修、授乳に関する悲しみへの感情面の支援、提供母乳の利用を勧めています。

Abstract

An increasing number of young females are undergoing chest masculinisation mastectomy to affirm a gender identity and/or to relieve gender dysphoria. Some desist in their transgender identification and/or become reconciled with their sex, and then revert (or detransition). To the best of our knowledge, this report presents the first published case of a woman who had chest masculinisation surgery to affirm a gender identity as a trans man, but who later detransitioned, became pregnant and grieved her inability to breastfeed. She described a lack of understanding by maternity health providers of her experience and the importance she placed on breastfeeding. Subsequent poor maternity care contributed to her distress. The absence of breast function as a consideration in transgender surgical literature is highlighted. That breastfeeding is missing in counselling and consent guidelines for chest masculinisation mastectomy is also described as is the poor quality of existing research on detransition rates and benefit or otherwise of chest masculinising mastectomy. Recommendations are made for improving maternity care for detransitioned women. Increasing numbers of chest masculinisation mastectomies will likely be followed by more new mothers without functioning breasts who will require honest, knowledgeable, and compassionate care.

Conclusion

Until recently, it would be extremely unusual for a new mother to have had a mastectomy. With increasing numbers of female adolescents and young adults obtaining chest masculinisation mastectomies, more new mothers will present without functioning breasts. Some will retain a transgender identification and others will have detransitioned. Each requires an individualised approach to provide them and their infants with honest, knowledgeable, and compassionate care.

Methodological limitations

Only one person: The report describes one woman's experience. As the authors say, we don't know how typical it is of detransitioned women, and it cannot show how often breastfeeding grief or poor maternity care happen.
Told from memory years later: The account comes from one three-hour interview a decade or more after surgery. Her memory that breastfeeding was never discussed, and her views on what her doctors thought, cannot be checked.
Key records missing: Elizabeth provided pregnancy records, a milk bank referral and photos of her scars. Her surgery, consent and gender clinic records were not reported, so what she was told before surgery is known only from her memory.
How she was found isn't explained: The report does not say how the authors came across Elizabeth. She describes being a 'trans activist' and later 'persona non grata', so she may have been found through detransition networks.
Story written with her: The case was written 'in consultation with Elizabeth' and she approved the final paper. This respects her, but it means the authors were less independent in how they told the story.
Authors have stated views: The authors have written before about sex-based language in maternity care and about regret after gender surgery (three of the cited papers are their own), and they frame the case as 'unanticipated harm'. They declare no financial conflicts, but readers should know their positions.
Staff side not heard: The midwife, doctor and surgeon were not asked for their views. Explanations for how they acted, for example that they were following transgender care training, rest on the patient's interpretation.
Breastfeeding claims borrowed from other surgery: The authors admit there is no research on how different breast removal methods for transition affect breastfeeding, so they rely on breast reduction studies. The case is strong for grafted nipples, but less certain for other methods.
Evidence judged unevenly: The report sharply criticises studies that find low regret for short follow-up and dropouts, but cites surveys of self-selected detransitioners (such as Littman 2021) without the same criticism.
Some details changed: The authors say 'some details have been changed to preserve anonymity'. This is reasonable, but readers can't know which details are exact.

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Conclusion