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Original Investigation
May 2018

Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young AdultsComparisons of Nonsurgical and Postsurgical Cohorts

Author Affiliations
  • 1Children’s Hospital Los Angeles, Los Angeles, California
  • 2University of Southern California, Los Angeles
JAMA Pediatr. 2018;172(5):431-436. doi:10.1001/jamapediatrics.2017.5440
Key Points

Question  Is chest dysphoria (distress about breasts) more common among transmasculine youth who have not had chest reconstruction compared with those who have undergone this surgery?

Findings  In this cohort study, chest dysphoria was significantly higher in the nonsurgical vs postsurgical cohort. Among the nonsurgical cohort, 94% perceived chest surgery as very important; among the postsurgical cohort, serious complications were rare, and 67 of 68 reported an absence of regret.

Meaning  Professional guidelines and clinical practice should recommend patients for chest surgery based on individual need rather than chronologic age.

Abstract

Importance  Transmasculine youth, who are assigned female at birth but have a gender identity along the masculine spectrum, often report considerable distress after breast development (chest dysphoria). Professional guidelines lack clarity regarding referring minors (defined as people younger than 18 years) for chest surgery because there are no data documenting the effect of chest surgery on minors.

Objective  To examine the amount of chest dysphoria in transmasculine youth who had had chest reconstruction surgery compared with those who had not undergone this surgery.

Design, Setting, and Participants  Using a novel measure of chest dysphoria, this cohort study at a large, urban, hospital-affiliated ambulatory clinic specializing in transgender youth care collected survey data about testosterone use and chest distress among transmasculine youth and young adults. Additional information about regret and adverse effects was collected from those who had undergone surgery. Eligible youth were 13 to 25 years old, had been assigned female at birth, and had an identified gender as something other than female. Recruitment occurred during clinical visits and via telephone between June 2016 and December 2016. Surveys were collected from participants who had undergone chest surgery at the time of survey collection and an equal number of youth who had not undergone surgery.

Main Outcomes and Measures  Outcomes were chest dysphoria composite score (range 0-51, with higher scores indicating greater distress) in all participants; desire for chest surgery in patients who had not had surgery; and regret about surgery and complications of surgery in patients who were postsurgical.

Results  Of 136 completed surveys, 68 (50.0%) were from postsurgical participants, and 68 (50.0%) were from nonsurgical participants. At the time of the survey, the mean (SD) age was 19 (2.5) years for postsurgical participants and 17 (2.5) years for nonsurgical participants. Chest dysphoria composite score mean (SD) was 29.6 (10.0) for participants who had not undergone chest reconstruction, which was significantly higher than mean (SD) scores in those who had undergone this procedure (3.3 [3.8]; P < .001). Among the nonsurgical cohort, 64 (94%) perceived chest surgery as very important, and chest dysphoria increased by 0.33 points each month that passed between a youth initiating testosterone therapy and undergoing surgery. Among the postsurgical cohort, the most common complication of surgery was loss of nipple sensation, whether temporary (59%) or permanent (41%). Serious complications were rare and included postoperative hematoma (10%) and complications of anesthesia (7%). Self-reported regret was near 0.

Conclusions and Relevance  Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age.

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