Quality of life improvement after chest wall masculinization in female-to-male transgender patients: A prospective study using the BREAST-Q and Body Uneasiness Test☆
Introduction
Transgender individuals feel a discrepancy between their perceived gender identity and the gender assigned to them at birth. Gender dysphoria occurs when these individuals experience significant distress from this condition.1 Along with counseling, hormones, and other modalities, gender affirming surgery can be an important element for treating gender dysphoria by allowing the individuals to present and interact socially as their perceived gender.2 The frequency of gender affirming surgery has increased in recent years including, but not limited to, chest wall masculinization, hysterectomy, phalloplasty and/or metoidioplasty for female-to-male (FTM) patients, and breast augmentation, vaginoplasty, and facial contouring for male-to-female (MTF) patients.3 Not every patient desires surgery and not every surgery is required or indicated for each patient. In FTM patients, chest reconstruction, sometimes referred to as chest wall masculinization or “top surgery,” is often the initial surgical procedure performed and sometimes the only surgical procedure performed.4, 5, 6, 7, 8, 9 While cross-sex hormone treatment goes a long way in allowing FTM patients to “pass” in public as their preferred gender, distress over the presence of their breasts contributes to numerous social, physical and psychological problems. Most have to bind their breasts daily in order to conceal them, a process that is uncomfortable, cumbersome, and can lead to rashes, acne, restriction in activity, and even difficulty breathing.
Existing literature has shown that chest wall masculinization offers a number of important benefits to FTM transgender patients including improvement in psychological functioning, reduction in gender dysphoria symptoms, improvement in self-esteem and physical well-being. Pauly and Lindgren first showed that body image was improved in transsexuals after surgical treatment in a cross-sectional analysis of a large population in 1976.10 Fleming et al. demonstrated increased body satisfaction and increased self-esteem in FTM patients after a variety of medical and surgical interventions.11 The most comprehensive demonstration of improvement in psychological functioning after medical and surgical treatment in transgender patients was by De Vries et al. in which 55 patients were followed longitudinally over their entire treatment utilizing the “Dutch approach” which involves a three step sequence of pubertal suppression, cross-sex hormones, and finally gender affirmation surgery.12 These patients not only experienced improvements in psychological functioning, but also alleviation of gender dysphoria symptoms and overall improvement in well-being. Other studies demonstrated similar findings, but most used a cross-sectional population with multiple variables and were not prospective.13, 14, 15, 16 As health policy evolves in developing standard of care for transgender patients, prospective studies with outcomes data and validated measurements of improved quality of life are needed to convincingly argue for the medical necessity of specific surgeries.
At our institution, female-to-male transgender patients undergo chest wall reconstruction in accordance with the guidelines set out by the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 7.2 Surgical techniques for chest masculinization include predominantly double incision with free nipple grafting, with less often techniques being periareolar mastectomies, and hybrid techniques with nipple areolar complexes maintained on a pedicle with various patterns of skin excision (Figure 1, Figure 2). Techniques and surgical outcomes in a larger cohort have been described in detail in recent publications.17, 18 The aim of this study was twofold: to evaluate the demographics of patients undergoing FTM chest masculinization, and to prospectively evaluate changes in body image, physical well-being, sexual satisfaction and breast satisfaction following chest masculinization surgery using validated questionnaires. We selected the BREAST-Q survey and the Body Uneasiness Test (BUT-A)19, 20 as together they provide a broad evaluation of body-part specific questions and also address general well-being, body image, and quality of life factors. While these survey tools have not been specifically validated in the transgender population, we felt that they were the best tools currently available to evaluate quality of life improvement after chest surgery.
Section snippets
Methods
After obtaining approval from the University of Utah Institutional Review Board, we surveyed all FTM transgender patients 18 years of age or older undergoing chest wall reconstruction by a single surgeon (C.A.) between April 2015 and June 2016. The surveys were optional and anonymous and were distributed to patients by email using the REDCap database program.
Results
Out of 87 eligible patients, a total of 43 completed both the preoperative and postoperative surveys, of which 42 were able to be linked to their chart data through the provided email address, for a response rate of 48%. Of the 42 patients in the cohort, the average age was 27.7 years, with a range from 18–50 years. Self-identified race was 88% (37/42) White, 2% (1/42) Asian, 2% (1/42) African American, 4% (2/42) as biracial (African American/White), and one who chose not to answer. When asked
Discussion
Gender affirmation surgery in the form of chest wall masculinization is critical to allow many FTM individuals to present and interact socially as their perceived gender. The results of this prospective study demonstrate statistically significant improvement in a number of quality of life measurements for FTM transgender individuals following chest wall masculinization. These include physical, sexual and psychosocial well-being as determined by the BREAST-Q survey, as well as improvement in
Conclusions
Our study demonstrates dramatic improvement in quality of life for FTM transgender individuals undergoing chest wall masculinization using the most applicable currently available survey tools. Our patient reported outcomes results show positive, statistically significant changes in several different domains including physical, psychosocial, sexual well-being, and self-esteem. As health care policies continue to evolve, proof of positive effect is increasingly important for determination of
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All research was performed in accordance with the ethical standards of the University of Utah Institutional Review Board.
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Parts of this article have been presented at the following meetings: 1. Mountain West Society of Plastic Surgeons (MWSPS) Meeting, March 18, 2017, Park City, Utah; 2. World Professional Association of Transgender Health (WPATH) Meeting, June 17, 2016, Amsterdam; 3. US Professional Association of Transgender Health (USPATH) Inaugural Meeting, February 2, 2017, Los Angeles. ASPS 2017 Residents Day, October 7, 2017.