Adolescents report low regret and high satisfaction following gender-affirming chest surgery

Adolescents who undergo gender-affirming chest surgery report low levels of regret and high levels of satisfaction, experiencing outcomes similar to those of young adults. These findings suggest that age restrictions on these medical procedures lack support from actual patient experiences. The research was published in the International Journal of Transgender Health.

Gender-affirming care includes a range of medical and psychological services designed to help align a person’s body with their gender identity. For some transgender and nonbinary individuals, this involves surgical interventions. One common operation is gender-affirming chest surgery, which typically involves a mastectomy, or the surgical removal of breast tissue, to create a flat chest contour.

In recent years, policymakers in the United States have introduced legislation aiming to restrict youth access to these treatments. Proponents of these bans frequently point to the possibility that teenagers might eventually regret undergoing irreversible physical changes. Until now, most data showing low regret and high satisfaction rates following chest surgeries have come from adult populations.

Researchers Maya Younoszai, Caleb Haley, Cole V. Roblee, and their colleagues sought to fill this gap in the scientific literature. They designed a study to compare the postoperative experiences of adolescents and young adults. Their goal was to see if patients who had surgery before age 18 felt differently about their decisions than those who waited until adulthood.

The research team conducted a cross-sectional study, meaning they collected data from participants at a single point in time. They focused on patients who received chest surgeries at a pediatric hospital between January 2018 and April 2023. To be eligible, patients had to be at least one year out from their operation.

Prior to surgery, the hospital required patients to meet established medical protocols for gender-affirming care. This involved psychological evaluations by both a surgeon and a mental health provider. For patients under age 18, all legal guardians had to consent to the procedure. If any guardian was unsupportive, the surgery was not offered.

The researchers sent surveys to 183 eligible patients, and 77 completed the questionnaires. Of these respondents, 42 had their surgeries as adolescents under age 18, and 35 had their surgeries as young adults between the ages of 18 and 26. The surveys included standardized tools used widely in healthcare to measure how people feel about past medical choices.

One tool, the Decision Regret Scale, scores regret from zero to 100, with higher numbers indicating more regret. The other tool, the Satisfaction with Decision scale, rates satisfaction from one to five, with higher scores showing greater contentment. The researchers calculated the scores for both age groups and compared them.

The results showed high satisfaction and low regret across the board. The median regret score for both the adolescent and young adult groups was exactly zero. The median satisfaction score for both groups was five, the highest possible rating. The differences in average scores between the two age groups were not statistically significant.

The researchers also administered a third survey to evaluate family dynamics. This tool measures a person’s sense of belonging and support within their family environment. The researchers wanted to see if family support played a role in how patients felt after surgery.

When comparing the scores, the researchers found a positive correlation between family support and surgical satisfaction. Patients who felt more supported by their families tended to be more satisfied with their decision to have surgery. However, the connection between family support and decisional regret was not statistically significant.

The team also analyzed a smaller subset of participants who reported either higher regret scores or a mismatch between their regret and satisfaction scores. Out of the 77 participants, five fell into this category. The researchers looked at written responses and conducted interviews to understand what was driving these scores.

These patients reported dissatisfaction with specific aesthetic results rather than regretting the transition itself. Some expressed frustration with how their bodies healed, mentioning issues like keloids, which are raised, thickened scars. Others noted uneven chest contours.

Clinicians categorize regret into several types, distinguishing between medical regret over surgical outcomes and true gender-related regret. True gender-related regret involves a desire to return to the sex assigned at birth. None of the interviewed individuals reported true gender-related regret.

Even among the five patients with higher regret scores, those who provided qualitative feedback stated that the surgery improved their overall quality of life. They noted that the procedure allowed them to stop wearing restrictive chest binders. They also mentioned feeling more confident in their clothing and social interactions.

In addition, the researchers found that 13 participants had experienced a shift in their specific gender identity since the operation. For example, someone might have identified as a transgender man at the time of surgery but later identified as nonbinary. The regret and satisfaction scores for this group did not differ from the rest of the participants.

Most patients in the study were white, identified as male, and had a history of using testosterone. The researchers collected data on underlying health conditions, noting that high percentages of patients had documented diagnoses of depression and anxiety prior to surgery. Despite these mental health conditions, the patients navigated the surgical process with a very low complication rate.

Several factors limit the reach of these findings. First, the median time since surgery for participants was about 1.8 years. Because feelings about medical decisions can evolve, this timeframe might not capture long-term regret that could emerge many years later.

Another limitation is the 42 percent participation rate to the survey. This introduces the possibility of selection bias, a scenario where the people who chose to participate might differ fundamentally from those who did not. It is possible that individuals with higher levels of regret ignored the survey, which would result in an underestimation of regret in the overall group.

Patients might also experience social pressures that influence how they answer these types of surveys. Because access to gender-affirming care is a highly publicized political issue, some participants might minimize their dissatisfaction. They could fear that expressing regret might provide ammunition for policies that restrict healthcare access for themselves or others.

Despite these limitations, the data align with earlier studies conducted on older patients. The researchers note that adolescents seem to process their surgical decisions with outcomes comparable to young adults.

The findings add to a growing body of scientific literature regarding the physical and mental health outcomes of transgender youth. The study, “Regret and satisfaction after adolescent gender-affirming chest surgery,” was authored by Maya Younoszai, Caleb Haley, Cole V. Roblee, Alisha Nguyen, Tannon Tople, Anna V. Faino, Cyndy Snyder, Maya Gopalan, Danielle J. Eble, Russell E. Ettinger, and Shane D. Morrison.