Purpose: This study aims to assess whether lay individuals found surgically augmented breasts to be more feminine than breast development from hormone therapy in transgender patients.
Methods: We obtained pre-operative (maximal breast growth on hormone therapy) and post-operative chest (after primary augmentation) images of 22 patients. The images were age and BMI matched with cisgender male (n=17) and cisgender female control patients (n=21).Survey participants evaluated 20 randomly selected images (n=271). Demographic information gathered included race (183 White, 56 Asian, 32 other), gender identity (179 male, 91 female, 1 non-binary; 74 transgender, 193 not transgender, 4 prefer not to answer), and sexual orientation (163 heterosexual or straight, 101 bisexual, 7 gay or lesbian). The masculinity of each chest image (1=very feminine to 5=very masculine) determined by each evaluator was recorded. The results of the survey were averaged across participants and a mixed methods linear model was constructed to analyze differences in respondent ratings across image groups.
Results: As determined by all survey participants, there was a significant difference in mean masculinity score between all image types (α=0.05). Cis-females and post-op transgender patients were rated 1.077 and 0.843 points less masculine than cis-males, respectively. The mean masculinity score for transgender patients fell by 0.478 points after surgery (p<0.0001).We compared the average masculinity score across four different survey respondent subgroups: participants who self-identified as cisgender and straight, cisgender and lesbian, gay, or bisexual (LGB), transgender and straight, and transgender and LGB.For survey participants who identified as both cisgender and LGB, there was significant difference in mean masculinity score between cis-male controls vs. cis-female controls and cis-male controls vs. post-op transgender patients. Furthermore, this group’s average rating for the cis-female controls and post-op transgender patients differed by only 0.001.For participants identifying as transgender and LGB, there was only a significant difference in mean masculinity score between cis-male and cis-female controls. This was the lowest difference for this comparison across the four respondent subgroups.Finally, for participants who identified as transgender and heterosexual, there was a significant difference in mean masculinity score between all image groups, as compared to cis-female controls; however, there was not a significant difference between cis-male controls and pre-op or post-op transgender patients, or between pre-op and post-op transgender patients.
Conclusion: This study objectively shows that hormone therapy alone increases the perceived chest femininity of transgender patients as compared to cisgender male controls. In addition, the addition of breast augmentation increased perceived femininity of transgender patients to nearly the same level of cisgender patients. Survey participant sub-group analysis found these trends to be consistent in the cisgender and LGB sub-group. However, for transgender and LGB participants, as well as transgender and heterosexual participants, there was no significant difference in perceived femininity between cisgender male controls vs. pre-op or post-op transgender patients or between pre-op and post-op transgender patients.