Metaanalys rapporterar 1 % ånger efter könskirurgi, men inkluderade studier hade kort uppföljning och stort bortfall

Ånger efter könsbekräftande kirurgi: en systematisk översikt och metaanalys av förekomst

Systematiska översikter Av-transition & ånger Kirurgi

Authors: Valeria P. Bustos, Samyd S. Bustos, Andres Mascaro, Gabriel Del Corral, Antonio J. Forte, Pedro Ciudad, Esther A. Kim, Howard N. Langstein, Oscar J. Manrique
Journal: Plastic and Reconstructive Surgery Global Open
Year: 2021
Source: https://doi.org/10.1097/GOX.0000000000003477

Summary

This review combined 27 studies of nearly 8,000 people who had gender surgery and estimated that about 1% regretted it. The authors concluded regret is extremely rare and credited better screening of patients. The 1% figure is now widely quoted. But the authors themselves say the evidence underneath is weak: most studies were rated poor or fair, almost none used tested ways of measuring regret, and results varied a lot between studies. Critics point out that people were often followed for only one or two years, while regret typically shows up after about eight years. Many people were lost track of (36% in the largest study), and some numbers were copied wrongly. Most people studied were adults treated under older, stricter rules. The 1% is best seen as a minimum drawn from incomplete data, not a reliable regret rate for today's patients.

Key findings

Översikten inkluderade 27 studier som omfattade 7 928 operationspatienter från 14 länder. 67 % hade genomgått kirurgi från man till kvinna och 33 % från kvinna till man, och bara en patient var registrerad som icke-binär.
Sammanlagt ångrade cirka 1 % av patienterna operationen (troligen mellan under 1 % och 2 %), men resultaten varierade mycket mellan studier. 77 personer rapporterade totalt ånger.
Ånger var under 1 % efter operation från kvinna till man och bröstborttagning, 1 % efter operation från man till kvinna och 2 % efter operation för att skapa en vagina.
De vanligaste skälen till ånger var svårigheter att bli accepterad av familj och samhälle i den nya könsrollen, följt av dåliga kirurgiska eller fysiska resultat.
Nästan alla studier använde hemmagjorda frågor eller intervjuer, de flesta bedömdes som dålig eller acceptabel kvalitet och uppföljningen varade från under 1 år till 9 år.
Det fanns tecken på att studier med låg ånger oftare publicerades. Justering för detta sänkte uppskattningen från 1 % till 0,5 %.
En rättelse 2022 åtgärdade tabeller och figurer efter att författarna kört om översikten, och publicerade brev (Expósito-Campos & D'Angelo 2021; Bewley 2022) ifrågasatte metoderna och slutsatserna.

Abstract

Background: There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

Methods: A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

Results: A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%-2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%-<1%) and 1% (CI <1%-2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin's regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions: Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Conclusion

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Methodological limitations

People not followed for long enough: Follow-up ranged from under 1 year to 9 years, and many studies followed people for only 1–2 years. Regret has been estimated to appear on average after 8 to 8.5 years. Cohn (Archives of Sexual Behavior, 2023) found no included study that kept track of over 85% of people for at least 8 years each.
Many people lost track of: The largest study (Wiepjes et al. 2018), about half of all people in the review, lost track of 36%. Even the five better-quality studies (174 people, 3% of the total) lost 28% to over 40%, including people who had died (Expósito-Campos & D'Angelo, PRS Global Open 2021).
Weak underlying studies: Most studies were rated "poor" or "fair" quality. Critics count 23 of 27 as at moderate-to-high risk of giving misleading results. None had a comparison group, and many just looked back at old medical files.
Regret measured in different, untested ways: Almost all studies made up their own questions, and each defined regret differently. The authors admit this, and add that patients may hide regret from the surgeons or clinics that treated them.
Number errors and a correction: Critics said the number of people counted from Wiepjes et al. was inflated from 2,627 to 4,863, which makes regret look rarer. The authors defended their figure, but a 2022 correction fixed the tables and figures after the review was re-run.
Questionable choice of studies: Letter writers said well-known relevant studies were missed. One included study asked about regret over the surgical technique chosen, not about having surgery at all.
No plan registered in advance, and missing details: Bewley (PRS Global Open 2022) found the authors did not publicly register their plan beforehand, left out standard reporting items, did not give each study's design or missing-data rates, and did not check whether weaker studies gave different answers.
Results varied a lot and may be skewed by publication: The studies disagreed with each other a great deal, and there were signs that low-regret studies were more likely to be published.
May not apply to today's patients: Most people studied were adults treated under older, stricter rules. Today's patients are more often teens when distress starts, more often born female and more often non-binary, and the claim that results apply to non-binary people rests on one patient.
Credit given without evidence: The authors say low regret shows that better patient screening works, but the data never tested this. Studies using different screening rules were not compared.
Narrow search: The search only covered English and Spanish papers up to May 2020 and found only 74 records in the databases.
Possible conflicts of interest: The authors said they had no financial interests. Bewley noted that several are plastic surgeons who perform these operations and questioned whether that statement holds.

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Summary

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Abstract

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