Plastic Surgery Research Council

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Prevalence of Psychosocial and Body Image Distress Among Transmen Seeking Gender Mastectomies
Michael J. Kirsch, BS1, Megan Lane, MD1, Emily C. Sluiter1, Graham C. Ives, MD2, Jennifer B. Hamill, MPH1, Juan Orozco1, Kaitlyn Hines1, Jasmine Penny1, Robert H. Gilman, MD1, William M. Kuzon, MD1, Paul S. Cederna, MD1, Edwin G. Wilkins, MD1.
1University of Michigan, Ann Arbor, MI, USA, 2University of Southern California, Los Angeles, CA, USA.

Purpose: In the 2015 US Transgender Survey, 97% of transmen reported either previously having undergone, or being interested in undergoing gender mastectomy (otherwise known as top surgery). Despite this overwhelming interest in, as well as frequent anecdotal reports of improvements in, psychosocial functioning and patient reported outcomes (PROs) following this procedure, there is a dearth of prospective data supporting these observations. Existing PRO studies have largely been limited by lack of preoperative assessments, cross-sectional or retrospective designs, use of ad hoc questionnaires, small patient populations, or by their failure to evaluate a comprehensive range of domains. As part of a prospective study assessing the effects of gender mastectomy on PROs, we evaluated preoperative psychosocial functioning, anxiety, depression, and body image in transmen seeking these procedures.
Methods: In this prospective study, adult transmen presenting to a university-based plastic surgery clinic for gender-affirming chest reconstruction are being recruited for study participation. Surveys are completed at two time points: pre-operatively and six-months post-operatively. The panel includes demographic questions; the Patient Health Questionnaire-9 (PHQ-9) assessing depression; the Generalized Anxiety Disorder 7 Item Scale (GAD-7); the Body Image Quality of Life Index (BIQLI); and chest-specific body image items from the BREAST-Q and BODY-Q. All instruments have been previously validated. In this initial analysis, preoperative responses were scored and compared to available general population norms.
Results: From November, 2017 to November 2018, a total of 77 transmen have been enrolled and successfully completed the preoperative survey. Fifty-seven patients (74.0%) screened positive for mild to severe depression (mean sum score = 8.86, SD 6.06). Preoperatively, transmen reported significantly worse depression compared to cis-men in general (population mean sum score = 2.7), t(75) = 8.85, 95% CI (7.47, 10.24), p < 0.0001. Additionally, 55 patients (71.4%) screened positive for mild to severe anxiety (mean sum score = 8.8, SD 5.55). The mean transman reported significantly worse anxiety (t(74) = 9.5754, 95% CI (7.52, 10.08), p < 0.0001) and body image (t(67) = -5.71, 95% CI (-20.85, -9.48), p < 0.0001), than the mean cis-male (population mean sum score = 2.66 and 1.10, respectively). BIQLI mean sum score was, on average, -14.84, SD 23.49.
Conclusions: Overall, transmen presenting for top surgery had significantly higher levels of depression and anxiety, compared with population norms. This is consistent with known elevated levels of depression and anxiety in the trans community, but has yet to be documented in preoperative patients. Compared to age-matched peers, transmen also had significantly poorer body image. In our study, this pre-operative cohort presented with significant psychosocial distress, demonstrating the need to evaluate the impact of gender mastectomy on these measures post-operatively. In its next phase, our study will be assessing these results.


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