永久損失：經歷去性別轉換的女性因乳房切除術後無法哺乳而悲痛

胸部男性化乳房切除術和去性別轉換後的哺乳悲痛

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

伊麗莎白被診斷為性別認同障礙，18 歲時被開立睪固酮。20 歲時切除雙乳，乳頭再移植回去。她回憶說沒有人談到這會如何影響哺乳。
手術留下厚而疼痛的疤痕，乳頭會痛並滲漏。加上被跨性別朋友排擠，以及睪固酮造成陰道乾燥和變薄，導致了危機，她在 24 歲時中止了過渡。
伊麗莎白表示，她當時可能會拒絕談論哺乳。她現在認為那是逃避，把她的性別困擾當成「王牌」來阻止討論。
她在 30 歲懷孕時，為無法哺乳而哀傷。助產士叫她「直接餵配方奶」，一位醫師則一直稱她為男人。這種混亂導致了一份兒童保護通報，而母乳銀行則好心地提供她捐贈母乳。
作者指出，國際與澳洲的跨性別健康指引（WPATH、AusPATH 和 PATHA）並未建議在這項手術前談論哺乳。他們主張，將乳頭移植幾乎必然導致無法哺乳。
他們主張，關於去過渡頻率以及切除乳房（尤其是對青少年）益處的研究品質不佳：追蹤時間很短，且許多人退出研究。
他們建議在手術前進行誠實的哺乳諮詢、對產科人員進行關於去過渡女性的培訓、為哺乳的悲傷提供情感支持，以及提供捐贈母乳的管道。

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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