Summary

Surgeons and researchers at Kaiser Permanente Northern California reviewed the records of 209 teenagers, referred between ages 12 and 17, who had their breasts removed for gender dysphoria (distress about one's sex) between 2013 and mid-2020. The rate of these operations among teenage girls in the health system rose 13-fold. Surgical problems were uncommon (7.3%) and about 1 in 9 needed a repeat operation. Only two patients had regret recorded in their notes, and neither had surgery to reverse it. The authors concluded the surgery is safe and has good results for teenagers. However, nobody was asked directly about regret; it was searched for in clinic notes. Typical follow-up was only about two years, a third were not followed for even one year, there was no comparison group, and satisfaction, quality of life and mental health were not measured.

Key findings

• วัยรุ่น 209 คนอายุ 12 ถึง 17 ปีตอนส่งตัวผ่าตัดเอาเต้านมออกด้วยเหตุผลเรื่องเพศที่ Kaiser Permanente แคลิฟอร์เนียเหนือ ระหว่างมกราคม 2013 ถึงกรกฎาคม 2020
• อัตราการผ่าตัดเหล่านี้เพิ่มขึ้น 13 เท่า จากประมาณ 4 เป็นประมาณ 48 ต่อเด็กหญิงวัยรุ่น 100,000 คนในระบบสุขภาพในแต่ละปี
• อายุโดยทั่วไปตอนส่งตัวคือ 16 ปี ก่อนผ่าตัด 60% มีภาวะซึมเศร้า 61% มีความวิตกกังวล และ 5% มีความผิดปกติทางการกิน
• 88% ใช้เทสโทสเทอโรนก่อนผ่าตัด และ 85% ได้เทคนิคที่พบบ่อยที่สุด ซึ่งทิ้งแผลเป็นยาวสองแผล
• ในผู้ป่วย 137 คน (ประมาณสองในสาม) ที่ติดตามอย่างน้อยหนึ่งปี 7.3% มีปัญหาจากการผ่าตัด และ 10.9% ต้องผ่าตัดซ้ำ
• ผู้ป่วยสองคน (ประมาณ 1 ใน 100) ซึ่งเป็นนอนไบนารีทั้งคู่และผ่าตัดตอนอายุ 16 ปี มีบันทึกความเสียใจในเวชระเบียน ไม่มีใครผ่าตัดย้อน
• การติดตามผลโดยทั่วไปประมาณ 2 ปี และไม่ได้วัดความพึงพอใจ คุณภาพชีวิต และสุขภาพจิต

Abstract

BACKGROUND: There are over 150,000 transgender adolescents in the United States, yet research on outcomes following gender-affirming mastectomy in this age group is limited. We evaluated gender-affirming mastectomy incidence, as well as postoperative complications, including regret, in adolescents within our integrated health care system. METHODS: Gender-affirming mastectomies performed from January 1, 2013 - July 31, 2020 in adolescents 12-17 years of age at the time of referral were identified. The incidence of gender-affirming mastectomy was calculated by dividing the number of patients undergoing these procedures by the number of adolescents assigned female at birth ages 12-17 within our system at the beginning of each year and amount of follow-up time within that year. Demographic information, clinical characteristics (comorbidities, mental health history, testosterone use), surgical technique, and complications, including mention of regret, of patients who underwent surgery were summarized. Patients with and without complications were compared to evaluate for differences in demographic or clinical characteristics using chi-squared tests. RESULTS: The incidence of gender-affirming mastectomy increased 13-fold (3.7 to 47.7 per 100,000 person-years) during the study period. Of the 209 patients who underwent surgery, the median age at referral was 16 years (range 12-17) and the most common technique was double-incision (85%). For patients with greater than 1-year follow-up (n=137, 65.6%), at least one complication was found in 7.3% (n=10), which included hematoma (3.6%), infection (2.9%), hypertrophic scars requiring steroid injection (2.9%), seroma (0.7%), and suture granuloma (0.7%); 10.9 % underwent revision (n=15). There were no statistically significant differences in patient demographics and clinical characteristics between those with and without complications (p>0.05). Two patients (0.95%) had documented postoperative regret but neither underwent reversal surgery at follow-up of 3 and 7 years postoperatively. CONCLUSION: Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two expressed regret, neither of which underwent a reversal operation. Our study provides useful and positive guidance for adolescent patients, their families, and providers regarding favorable outcomes with gender-affirming mastectomy.

Conclusion

Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two expressed regret, neither of which underwent a reversal operation. Our study provides useful and positive guidance for adolescent patients, their families, and providers regarding favorable outcomes with gender-affirming mastectomy. (In the discussion the authors add that the study shows gender-affirming mastectomy in adolescents is 'safe, successful, and increasing in need', and argue that state legislation could create barriers to it.)