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Мастэктомия до 26 лет: высокая достоверность только для физических осложнений

Мастэктомия для лиц с гендерной дисфорией младше 26 лет: систематический обзор и метаанализ

Систематические обзоры и обзоры доказательствХирургия
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

  • Обзор нашёл 39 исследований, поиск до июня 2023 года: лишь 3 сравнивали группы и 2 измеряли людей до и после операции; остальные 34 лишь описывали прооперированных пациентов.
  • Доказательства высокого качества получены только из исследований хирургических осложнений: смертей не было (5 исследований), около 20 из 1 000 потеряли сосок или кожный трансплантат из-за гибели тканей (13 исследований), около 10 из 1 000 потеряли кожный лоскут (3 исследования) и около 50 из 1 000 имели толстые рубцы (12 исследований).
  • Два исследования, сравнивающие операцию с утяжкой груди, дали очень слабые доказательства по гендерному дистрессу, связанному с грудью, и по удовлетворённости телом и грудью.
  • Одно исследование, сравнивающее операцию с её отсутствием, дало очень слабые доказательства по дистрессу и попыткам самоубийства и слабые доказательства того, что после операции людям вдвое реже были свойственны самоповреждения (без суицидального намерения).
  • Качество жизни, депрессия, смерть от самоубийства, удовлетворённость грудью и сожаление были оценены как очень слабые доказательства, в основном из-за отсутствия группы сравнения.
  • Запланированные проверки того, различались ли результаты при других состояниях психического здоровья, возрасте начала дистресса или сексуальной ориентации, провести не удалось, а суицидальные мысли, сексуальная функция и последующие операции не оценивались.
  • Авторы призывают к исследованиям, наблюдающим пациентов во времени, и, если этично, к рандомизированным испытаниям, чтобы информировать пациентов, хирургов, авторов руководств и политиков.

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.