Transgender, or trans, is a catch-all umbrella term used to describe individuals whose gender identity and gender expression differ from their sex assigned at birth. In this article, the term transmasculine refers to transgender people who were assigned female at birth but who identify more strongly with masculinity, which includes but is not limited to transgender men. Nonbinary individuals identify outside of the gender binary, either as not exclusively feminine or masculine, or as another gender entirely. It should be noted that an individual may identity as both transmasculine and nonbinary.
Transgender people living in the United States report lower quality of life and routinely encounter provider insensitivity and discriminatory practices when seeking health care. Transgender individuals also have heightened rates of depression and suicidality (attempts and ideation) compared with the general public.1,2 These higher rates of depression and suicidality are attributable to societal and structural discrimination experienced by trans and nonbinary people.
Some trans individuals experience gender dysphoria, or distress related to the incongruence between their gender identity and body.3 This incongruence, compounded by the aforementioned widespread societal discrimination, can be associated with immense bodily and emotional distress.
Gender-affirming surgery, defined as any surgical procedure that modifies an individual’s body to reach congruence with their gender identity and expression, is one treatment option available for gender dysphoria. Not all transmasculine individuals seek or need surgery; however, gender-affirming surgery is a medically necessary standard-of-care treatment, if in line with a patient’s goals.4
Masculinizing top surgery (bilateral mastectomy with chest wall reconstruction) is one form of gender-affirming surgery commonly sought by transmasculine and nonbinary patients. Currently, it is often the first and only form of gender-affirming surgery they pursue.1,5 Obtaining a male chest contour may allow transmasculine and nonbinary individuals to inhabit their bodies more comfortably, improving self-confidence and conferring a greater sense of safety in public and private settings.6,7
Many transmasculine individuals who desire top surgery bind their chest as an interim measure until surgery can be obtained. Some transmasculine individuals who do not desire surgery also use chest binding as a means of masculine gender expression and/or to cope with gender dysphoria. Chest binding refers to any activity that involves the compression of breast tissue to achieve the appearance of a flatter chest. For many, chest binding markedly improves mental and emotional health. However, long-term chest binding is associated with a host of negative health impacts, including but not limited to musculoskeletal, neurologic, gastrointestinal, respiratory, and dermatologic problems that may cause discomfort and affect future surgical outcomes.8 Top surgery may facilitate relief from many of these negative health impacts.9,10
Relatively minimal research has been conducted to evaluate how masculinizing top surgery, independent of other gender-affirming operations, affects patient-reported mental health, quality of life, and sexual confidence. Existing literature primarily evaluates surgical techniques, aesthetic results, and complication rates. Although technical and aesthetic outcomes are critical to the success of this procedure, the primary goal of top surgery, and gender-affirming surgery more generally, is ultimately subjective: to alleviate symptoms of gender dysphoria experienced by individual patients and improve quality of life.
In this research study, an anonymous online survey was designed to examine the psychosocial effects of masculinizing top surgery for transmasculine and nonbinary patients who underwent surgery at New York University Langone Health performed by a single surgeon. Primary outcome measures included patient-reported quality of life, mental health, and sexual confidence. Secondary outcome measures included patient satisfaction with surgical outcomes, the role of top surgery in the gender-affirmation process, and incidence of postoperative regret.
PATIENTS AND METHODS
Survey Development and Design
Survey questions were generated following a comprehensive literature review. Three matrices from the BREAST-Q, a validated patient-reported outcomes instrument used in cosmetic and reconstructive breast surgery, were modified to suit the unique psychosocial needs of transmasculine patients.11 As we rarely differentiate between cisgender and transgender men and women in medical research, there are few, if any, validated instruments for the transgender population, and there are none related to top surgery satisfaction. Modified instruments have thus become the standard in transgender health research, as there is an urgent need to build an evidence base for this underserved and marginalized population.
The preliminary survey was revised by the principal investigator (A.H.) and her colleagues, drawing from extensive clinical experience in the field. As there is significant medical mistrust in the trans and nonbinary communities, we also sought feedback from three transmasculine individuals who had previously completed top surgery. They further revised our survey for appropriateness of terminology, structure, and content.
The final survey consisted of multiple-choice questions, matrices, and short answer prompts for qualitative data collection. All multiple-choice questions and matrices included additional space for comments and elaboration. The study was approved by the New York University School of Medicine Institutional Review Board in August of 2016.
An invitation to participate in the research study was e-mailed to 81 eligible subjects using the secure, Health Insurance Portability and Accountability Act of 1996–compliant Qualtrics Survey Platform (Qualtrics, LLC, Provo, Utah). Eligible individuals were those who (1) were assigned female at birth; (2) identified as transmasculine, nonbinary, or as a trans man; (3) underwent top surgery at New York University Langone Health performed by the senior author (A.H.); (4) were at least 3 months postoperative; (5) were at least 18 years old, and (6) had authorized New York University Langone Health to contact them by means of e-mail.
Participation was voluntary and respondents did not receive any form of compensation for survey completion. Responses were anonymous and Internet Protocol addresses were not collected. All portions of the survey were optional and could be left blank without penalty. Over a 6-month period (November of 2016 through April of 2017), 58 surveys (response rate, 72 percent) were anonymously submitted.
Survey responses were summarized using frequencies and percentages for categorical data. McNemar tests were conducted to compare paired preoperative and postoperative nominal data. Five-point Likert scales were grouped into three categories for data analysis: “satisfied,” “neutral,” or “dissatisfied.” Additional exploratory analysis was performed using exact linear association chi-square testing to detect relationships between surgical timing and surgical satisfaction. To do this, respondents were divided into two groups: those who underwent surgery less than 1 year ago (n = 36) and those who underwent surgery 1 or more years ago (n = 22). Further analysis was undertaken to detect differences in surgical satisfaction and quality of life between the following groups: those who reported chest binding before top surgery compared to their nonbinding counterparts, and those who reported preoperative hormone therapy compared to those who did not. Statistical analyses were conducted using IBM SPSS Version 24.0 software (IBM Corp., Armonk, N.Y.), and significance was held at p < 0.05.
In nonexclusive gender identity categories, respondents identified as male [n = 25 (43 percent)], trans male [n = 39 (66 percent)], genderqueer or nonbinary [n = 14 (22 percent)], and/or “different identity (please state)” [n = 3 (5 percent)]. Respondents completed top surgery at a mean age of 33 years (range, 18 to 58 years) and were less than 1 year [n = 33 (57 percent)], 1 to 2 years [n = 13 (22 percent)], 3 to 4 years [n = 1 (2 percent)], 4 to 6 years [n = 5 (9 percent)], and 6 or more years [n = 6 (10 percent)] postoperative. Most respondents [n = 46 (81 percent)] reported preoperative hormone therapy for an average duration of 1.9 years (range, 0.25 to 8 years) (Table 1).
Preoperative chest binding was reported by the majority (n = 47 (81 percent)] of respondents for a mean duration of 5 years (range, 1 month to 20 years). Of these, 91 percent reported at least one negative health effect. Skin irritation (63 percent), back pain (61 percent), difficulty breathing (49 percent), and chest pain (13 percent) were the most common (Table 2).
Top surgery was the first gender-affirming surgery for all but two individuals [n = 56 (97 percent)], both of whom reported prior hysterectomies. Only nine respondents (17 percent) had undergone additional gender-affirming surgery since their top surgery—eight had hysterectomies (with and without oophorectomies) and three had phalloplasties.
Preoperative and Postoperative Quality of Life, Sexual Confidence, and Mental Health
Most respondents rated their quality of life and sexual confidence before top surgery as very low; no more than 30 percent of respondents were satisfied on any given measure that asked about preoperative life. Following top surgery, subjects’ quality of life and sexual confidence improved significantly in all domains (p < 0.001): feeling self-confident (91 percent reported improvement), confident in a social setting (85 percent), attractive (83 percent), comfortable in their clothes (96 percent), satisfied with their bodies (94 percent), less dissatisfied with their bodies (96 percent), emotionally able to do the things they wanted to do (83 percent), and emotionally healthy (78 percent) (Fig. 1). Similar improvements (76 to 94 percent) were observed in the context of sexuality: degree of sexual confidence (77 percent reported improvement), satisfaction with sex life overall (76 percent), comfort and ease during sexual activity (81 percent), feeling sexually attractive while clothed (91 percent), feeling sexually attractive unclothed (94 percent), sexual confidence without a shirt on (91 percent), and likely to remove shirt for sex (85 percent) (Fig. 2).
Preoperatively, approximately half [n = 30 (53 percent) of participants characterized their overall mental health as “poor,” and 46 (81 percent) reported depression, anxiety, and/or another mental health condition related to gender dysphoria. Of the 49 respondents who reported being on medication before top surgery, 26 (46 percent) reported taking selective serotonin reuptake inhibitors and benzodiazepines. In optional free response prompts that corresponded with questions about preoperative life, respondents’ recounted experiences with depression, suicidal ideation, self-harm, ongoing discomfort from chest binding, physical and emotional bodily discomfort, stress headaches, and anxiety in social settings. After top surgery, 38 (86 percent) reported improvement in their mental health. Only one respondent characterized their mental health as “unchanged” since top surgery, and zero reported diminished mental health.
There were no statistically significant differences in postoperative quality of life, sexual confidence, or mental health detected based on time elapsed since top surgery. Patients who had top surgery less than 1 year previously were at least as satisfied as respondents who had top surgery over 1 year previously.
Satisfaction with Decision
Respondents were highly satisfied with the decision to undergo top surgery (Table 3); 53 (98 percent) said that top surgery positively impacted their life, and 85 percent characterized that impact as “huge.” Almost universally, respondents reported that undergoing top surgery was important in their public [n = 49 (91 percent)] and private [n = 50 (93 percent)] sphere gender-affirmation process, and that having a masculine chest was important in affirming their personal gender identity and expression [n = 52 (96 percent)] (Table 4).
Respondents were satisfied with how much their reconstructed chest felt like a “natural” part of their body [n = 49 (91 percent)], how their reconstructive chest felt now compared to before surgery [n = 50 (93 percent)], and the quality of their scars [n = 40 (74 percent)]. Although most respondents [n = 53 (96 percent)] reported some loss of nipple sensation, only 13 (24 percent) expressed complete dissatisfaction with current nipple sensation.
Fears of postoperative regret were not substantiated in the six respondents (11 percent) who indicated that fear of later regretting surgery hindered their surgical decision-making process. Almost all (n = 52) respondents reported never experiencing any postsurgical regret, two people (4 percent) reported occasional misgivings related to aesthetic outcomes, and zero reported complete regret.
Existing research into transmasculine experiences with gender-affirming surgery is disproportionately concerned with genital reconstruction surgery (i.e., phalloplasty and metoidioplasty), despite the fact that, currently, few transgender men in the United States undergo these procedures.1,5,12,13 Relatively minimal research has evaluated how masculinizing top surgery, independent of other gender-affirming procedures, affects patient-reported mental health, quality of life, and sexual confidence.
The overwhelming majority of respondents in this study experienced statistically significant and clinically important improvements in quality of life, mental health, and/or sexual confidence. In general, technical goals of top surgery include removing breast tissue and excess skin, repositioning and reshaping the nipple-areola complex, and minimizing chest wall scars.14,15 Surgical technique is chosen based on patient characteristics—most notably breast size and body habitus—and may have important implications for aesthetic outcomes, postoperative nipple sensation, and patient satisfaction. Our data represent an aggregate of several surgical techniques, which could not be parsed out because of an anonymous survey design that precluded access to respondents’ medical records.
Our findings corroborate the stance that the primary goal of gender-affirming surgery is subjective rather than technical. Although 96 percent of respondents in this study reported some loss of nipple sensation, only 24 percent expressed outright dissatisfaction with their current nipple sensation. It is generally normal to have acutely diminished nipple sensation during the healing process, which is separate from “long-term” sensation that never returns. Anecdotally, patients report that nipple sensation is different from their sensation previously, but most are not bothered by the difference. For many patients, the potential benefits of masculinizing top surgery far outweigh the potential for sensation loss, but it is nevertheless a crucial aspect of surgery that must be discussed preoperatively. Similarly, respondents who expressed lower satisfaction with the appearance and feel of their chest wall and/or the size, color, and projection of their nipple-areola complex did not report decreased satisfaction with top surgery overall.
It is notable that preoperative chest binding was a major source of physical and mental distress for the vast majority (81 percent) of study participants. On average, participants practiced binding for 5 years. At the extreme, patients reported having endured a long list of negative health impacts for 15 to 20 years. Having top surgery likely facilitated relief from many of these negative health impacts.
Although not all respondents expressed complete satisfaction with their postsurgical bodies, none completely regretted their decision to undergo top surgery. Gender dysphoria is a complicated and multifactorial issue tied to numerous factors beyond the appearance of the chest wall. In this regard, top surgery alone cannot be expected to completely alleviate gender dysphoria and associated impairments to quality of life, mental health, and sexual confidence. One recurrent theme in qualitative analysis was that top surgery did not alleviate bottom dysphoria or dissatisfaction with genitalia, which can also negatively impact quality of life. Furthermore, even the “ideal” surgical result does not address the systemic social discrimination that contribute to precipitating gender dysphoria. Despite these considerations, top surgery significantly improved overall quality of life for participants in this research study.
Our findings have several important limitations. First, this was a retrospective survey study comparing subjective feelings at two different time points in the past, predisposing to error. Because all survey questions were optional, some surveys were incomplete or missing data. The respondents, who completed top surgery at a private academic medical center in New York City and agreed to complete an online survey, represent only a small sample of patients, and their experiences are not representative of all transmasculine and/or nonbinary individuals. The study follow-up period was variable between subjects and relatively short term (range, 3 months to ≥6 years). Although survey questions were designed by a panel of experts and transmasculine patients to address the issues being studied, they were not themselves validated. Notably, no validated patient-reported outcome instruments currently exist in gender-affirming surgery.16,17 Finally, like any major surgery, top surgery comes with complications. This study did not include review of participants’ medical records, severely limiting the validity of revision and complication data.
Despite these limitations, our results strongly demonstrate the relative positive impact that top surgery can have for transmasculine and nonbinary individuals. The results of this survey study suggest that the gains in bodily satisfaction, psychosocial well-being, and sexual satisfaction following top surgery are both clinically meaningful to the patient and statistically significant as early as 3 months and as late as 6 or more years after surgery.
Patient-reported satisfaction is a critical marker of surgical success. In clinical practice, the degree to which masculinizing top surgery enhances the lives of patients is strikingly apparent, and perhaps this partially accounts for the lack of systematic data collection on quality-of-life outcomes and long-term patient satisfaction. Although numerous articles have addressed advancements in surgical techniques, aesthetic outcomes, and complication rates, the active voices of patients to corroborate surgical success have not been adequately represented.
Our findings from a survey study of individuals ranging from 3 months to over 6 years postoperatively provide unquestionably powerful evidence that masculinizing top surgery enacts statistically significant and clinically meaningful improvements in patient-reported quality of life, sexual confidence, and psychosocial well-being. Patient satisfaction with the procedure was very high, and complete regret was not reported by any subjects.
In our experience, positive results of this magnitude are not typical of most plastic surgery operations. As public and private insurance coverage for top surgery remains inconsistent throughout the United States, our findings contribute to a much-needed body of evidence that top surgery improves the quality of life and mental health of transmasculine individuals to a marked extent.
1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. 2016. Washington, DC: National Center for Transgender Equality; Available at: https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF
. Accessed October 2, 2017.
2. Adams N, Hitomi M, Moody C. Varied reports of adult transgender suicidality: Synthesizing and describing the peer-reviewed and gray literature. Transgend Health 2017;2:6075.
3. American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015;70:832864.
4. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011. 7th ed. World Professional Association for Transgender Health; Available at: https://www.wpath.org/publications/soc
. Accessed October 2, 2017.
5. Rachlin K, Green J, Lombardi E. Utilization of health care among female-to-male transgender individuals in the United States. J Homosex. 2008;54:243258.
6. Nelson L, Whallett EJ, McGregor JC. Transgender patient satisfaction following reduction mammaplasty. J Plast Reconstr Aesthet Surg. 2009;62:331334.
7. Richards C, Barrett J. The case for bilateral mastectomy and male chest contouring for the female-to-male transsexual. Ann R Coll Surg Engl. 2013;95:9395.
8. Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding among transgender adults: A community-engaged, cross-sectional study. Cult Health Sex. 2017;19:6475.
9. MacDonald T, Noel-Weiss J, West D, et al. Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: A qualitative study. BMC Pregnancy Childbirth 2016;16:106.
10. Motosko CC, Pomeranz MK, Hazen A. Caught in a bind. JAMA Dermatol. 2018;154:202.
11. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345353.
12. Rachlin K, Hansbury G, Pardo ST. Hysterectomy and oophorectomy experiences of female-to-male transgender individuals. Int J Transgend. 2010;12:155166.
13. Yerke AF, Mitchell V. Am I man enough yet? A comparison of the body transition, self-labeling, and sexual orientation of two cohorts of female-to-male transsexuals. Int J Transgend. 2011;13:6476.
14. Monstrey S, Selvaggi G, Ceulemans P, et al. Chest-wall contouring surgery in female-to-male transsexuals: A new algorithm. Plast Reconstr Surg. 2008;121:849859.
15. Wolter A, Diedrichson J, Scholz T, Arens-Landwehr A, Liebau J. Sexual reassignment surgery in female-to-male transsexuals: An algorithm for subcutaneous mastectomy. J Plast Reconstr Aesthet Surg. 2015;68:184191.
16. Barone M, Cogliandro A, Di Stefano N, Tambone V, Persichetti P. A systematic review of patient-reported outcome measures following transsexual surgery. Aesthetic Plast Surg. 2017;41:700713.
17. Morrison SD, Crowe CS, Wilson SC. Consistent quality of life outcome measures are needed for facial feminization surgery. J Craniofac Surg. 2017;28:851852.