Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy

Abstract

ImportanceThere has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments.ObjectiveTo evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy.Design, Setting, and ParticipantsFor this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020.ExposureDecisional regret and satisfaction with decision to undergo gender-affirming mastectomy.Main Outcomes and MeasuresLong-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders.ResultsA total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses.Conclusions and RelevanceIn this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today

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“…The overall rates of detransition and regret in people who began medical transition as children are largely unknown; there are no large-scale studies with long-term follow-up on this cohort (Cohn, 2023 ; MacKinnon et al, 2023 ). Studies describing low rates of regret (i.e., 1–2%) focused primarily on people who transitioned as mature adults and/or are from an era when people had to undergo rigorous psychological screening to be eligible for hormonal therapy and surgery (Bruce et al, 2023 ; Dhejne et al, 2014 ; Wiepjes et al, 2018 ). Moreover, they frequently used narrow definitions of regret such as the application to have birth sex reinstated as legal sex (Dhejne et al, 2014 ) or request for surgical reversal, to the extent possible (Narayan et al, 2021 ).…”

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