Transgender and nonbinary patients have no regrets about top surgery, small study finds

By Jen Christensen, CNN

(CNN) — Some arguments in favor of laws that restrict gender-affirming care claim that patients may some day regret any irreversible or semi-irreversible part of their transition, but a small new study found that satisfaction with one such surgery is significant, even over the long term.

The study, published Wednesday in the journal JAMA Surgery, shows that people who had a gender-affirming mastectomy, sometimes called top surgery, had extremely low rates of decisional regret and extremely high levels of satisfaction with their decision to have the procedure.

The results are “overwhelmingly positive compared to other medical and nonmedical decisions,” the study said.

Not every person who gets gender-affirming care will have surgery. Those who do usually have it as one of the later steps in their medical transition.

Gender-affirming mastectomy is a procedure that shapes the chest skin and tissue of people who identify as transmasculine or nonbinary so that their chest aligns more closely with the contour of what is typically thought of as a male chest. It’s the most common gender-affirming procedure in the US, the study says.

For the study, researchers surveyed 235 people who had a gender-affirming mastectomy at the University of Michigan. When the survey was conducted last year, the participants were between two and 23.6 years past their surgeries.

The survey captures the overall quality of life post-procedure. But rather than being specifically designed for trans patients who had this surgery, the survey was one that is often used in oncology to assess how someone feels about their treatment or screening. It can also be used in nonclinical settings to determine how someone feels about a particular medical procedure.

Of the participants, 139 – nearly 60% – answered the survey accurately and returned it to the researchers. Their median Satisfaction With Decision Scale score was 5 on a 5-point scale, indicating the highest possible level of satisfaction. The median Decision Regret Scale score was 0 on a 100-point scale, meaning not a single patient regretted their choice to have the surgery.

None of the survey respondents underwent a reversal procedure. About a quarter underwent an additional gender-affirming procedure after their mastectomy, the study says, results that “suggest sustained intent and consistency in decision making.”

The research involved only a single medical center, so for the findings to be generalizable, future research will need to involve people at multiple centers, the study authors said. And because of the variation in follow-up time, the researchers say there may also be a possibility of recall bias.

This research builds on earlier work that found deep satisfaction among people who had some form of a surgical procedure as a part of gender-affirming care. But many of those studies focused more on short-term satisfaction surveys.

One review of multiple studies published in 2021 involved patients’ short- and long-term satisfaction scores after surgery and found that of those who underwent transfeminine and transmasculine procedures, only 1% regretted it.

“I have to say that the regret rate was very, very, very low, which I was surprised by,” said Dr. Oscar Manrique, a co-author on that review who was not involved with the new research.

“I was thinking we’d see a little bit of higher regret numbers like we sometimes do with other kinds of surgeries,” said Manrique, a plastic surgeon at the University of Rochester Medical Center School of Medicine and Dentistry. “I believe the main reason, especially here in the US, the regret rate is so low is because there’s strict guidelines with these surgeries.”

At most medical centers, before a person can have surgery, they must participate in holistic care that involves a multidisciplinary approach with a team of doctors. Most get therapy and take a number of other steps to address any gender dysphoria, the gender-associated distress a person can feel that may include anxiety, depression, low self-esteem, self-harm, suicidality or trauma responses like hypervigilance.

Most US medical centers follow guidelines from the World Professional Association for Transgender Health. To even qualify for a gender-affirming mastectomy, the guidelines require a person to have the capacity to make a fully informed decision and consent to treatment. They have to be the age of majority and have significant medical or mental health concerns that are reasonably well-controlled at the time of surgery. Hormone therapy is not a prerequisite for surgery.

The guidelines also require that the person must have persistent, well-documented gender dysphoria, so a surgical procedure is something that they’ve typically been thinking about for some time.

“It’s not that if Mary or John decides to come in today and say ‘hey, I need surgery,’ that we would just go ahead and do that,” Manrique said. “Any patient that comes in gets assessed from head to toe, and then we walk through their expectations, the risks and benefits of any operation. I believe that’s the reason why the regret rate is so low. These guidelines allow patients access to adequate medical care.”

Dozens of states have recently passed or are considering laws that restrict gender-affirming care, mostly for people under 18. Restrictions will probably be a hot political topic going forward, but nearly every major medical association has recognized that gender-affirming care is a medical necessity and that it can include these surgeries.

A gender-affirming surgery can be transformative for an adult and may even be life-saving.

“It changes their life completely and allows them to be more confident in society, be more productive, and allow someone to live their full lives,” Manrique said. “That’s huge.”

In an editorial published alongside the new study, Dr. Loren Schechter of the Division of Plastic and Reconstructive Surgery at Rush University Medical Center in Chicago wrote that “when rates of regret in gender-affirming surgery are compared with other surgical interventions, the results are striking.”

A review of satisfaction and regret surveys across a wide variety of surgical specialties found a 14.4% mean rate of regret, the editorial said, meaning many more people regret other kinds of surgeries than those who undergo gender-affirming surgery.

“Interestingly,” the commentary noted, “no legislative efforts are aimed at banning these procedures.”

Correction: A previous version of this story mischaracterized the number of states that have passed laws to restrict gender-affirming care.

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