Transgender young people feel less distress after gender-confirming surgery, Northwestern study says

Transgender and nonbinary teens and young adults — who experience anxiety and depression at higher rates than others — often feel less mental distress after surgery to remove their breasts, according to a study out of Northwestern Medicine published Monday.

It’s a finding that comes as a number of states are attempting to ban gender-confirming surgery for people younger than 18, and as hospitals, including in Chicago, have been criticized, and sometimes threatened, for the care they provide to transgender, nonbinary and gender-nonconforming children.

“Our findings are that top surgery (to remove the breasts) benefits these teenagers and young adults,” said Dr. Sumanas Jordan, lead author of the study, which was published in the peer-reviewed journal JAMA Pediatrics. “It is so important to be able to have evidence and treat them not based on politics but based on science and medicine.”

The study’s authors compared two groups of patients ages 14 to 24 across three Chicago hospitals: one group of 36 patients who chose to undergo so-called top surgery and a control group of 34 patients who sought out gender-confirming care but did not undergo surgery. They questioned participants over time, and found that three months after the surgeries, the patients who had top surgery experienced significantly less chest dysphoria, which is distress related to development of the breasts, than they had before the surgeries, while patients in the control group experienced about the same levels of chest dysphoria as they had three months earlier.

Patients who underwent surgery also experienced less body image dissatisfaction and more gender congruence, which is when people feel that their appearance matches their gender identity.

Jordan called the decrease in feelings of chest dysphoria “pretty dramatic.” Chest dysphoria has been associated with higher levels of anxiety and depression. Research suggests that transgender and nonbinary youth struggle with depression and anxiety at higher rates than cisgender teens. Nearly 51% of female-to-male adolescents surveyed as part of a study published in 2018 in the journal Pediatrics had attempted suicide.

“Adolescence is a pretty turbulent time, but to have that burden of that extra chest dysphoria and gender dysphoria that’s untreated, I think does a lot of harm,” said Jordan, who is an assistant professor of plastic surgery at Northwestern University Feinberg School of Medicine and system director for the Gender Pathways Program at Northwestern.

Critics of gender-confirming surgery for teens say they are too young to make irreversible decisions about their bodies. Last year, Arkansas became the first state to ban gender-confirming treatments and surgery for people younger than 18, though courts have temporarily blocked that law from being enforced. Since then, more than a dozen other states have introduced similar legislation, according to the Kaiser Family Foundation.

In February, Texas Gov. Greg Abbott directed a state agency to investigate “gender-transitioning procedures,” including top surgeries, as child abuse when performed on minors.

In Illinois in 2019, half a dozen Republican lawmakers, including gubernatorial candidate Darren Bailey, sponsored a bill that aimed to make gender-confirmation surgeries and other treatments illegal for people under age 18. The bill didn’t go far.

“The procedure is irreversible,” said Rep. Tom Morrison, R-Palatine, who was the chief sponsor of the bill. “There are all kinds of practices that we prohibit minors from partaking in because they are not able to fully consent or have informed consent or have the maturity to understand the kind of lifelong decisions they’re making.”

Doctors involved with gender-confirming care, however, stress that no one takes the decision to perform such a surgery on a teen lightly.

Hospitals require parental consent for anyone under 18 in Illinois having top surgery, and patients must fully understand the surgery, its risks and benefits and be deemed mature enough to make a decision, said Dr. Loren Schechter, director of gender-confirmation surgery at Rush University Medical Center. Schechter is a co-lead author of the surgery chapter in the most recent standards of care from the World Professional Association for Transgender Health, which gender development programs at hospitals follow.

Not every transgender or nonbinary teen wants to or should have surgery, he said. Some teens might be treated with medication that can delay puberty or hormones. Others might not need or want medical intervention at all. Surgery happens after a thorough assessment by a team of doctors and discussions over time with parents and patients, he said.

“This is a very, very considered decision, and it’s a decision between parents, the individual seeking surgery, the surgeon and the multidisciplinary team, the mental health professional, the pediatrician,” Schechter said. “It’s taken very, very seriously, and that includes the times at which we perform the intervention.”

It’s uncommon for the surgery to be performed on teens younger than 16, but doctors consider patients on a case-by-case basis, he said. Other previous studies have also shown that top surgeries performed on teens and young adults are safe and effective, said Schechter, who was not involved with the Northwestern study.

Jordan, the new study’s lead author, said it doesn’t make sense to delay top surgery for all teens until age 18.

“If you had any other medical conditions where you said, ‘I’m not going to treat your diabetes or high blood pressure until you’re 18′ or ‘I’m going to hold off on treating you for years,’ it’s not ethical to withhold care for that long,” Jordan said.

She said she’s seen parents, who were initially against the surgery, change their minds when “they realize it’s either treat them or lose them.”

Jordan and other researchers plan to continue to follow the teens and young adults from the study to see how they fare long term.

One of those patients, Hunter Martin, is about two years out from his top surgery, and said it continues to be one of the best decisions he’s made.

Martin was 16 when he underwent top surgery. It took years to get to that point, he said.

Martin knew he wanted top surgery by the time he was 12. By freshman year of high school, Martin had told everyone that he went by Hunter and to use the pronouns he/him.

Throughout that time, he wore a chest compression garment, but it wasn’t a perfect solution. His back ached and the garment made it difficult for Hunter to sing, one of his passions in life.

He was a senior in high school by the time he had surgery. He remembers, clearly, the moment he opened his eyes after the procedure, to a nurse adjusting his bandages.

“As soon as I woke up, I just had this intense feeling of relief wash over me,” he said.

That feeling has only intensified over time, he said. He feels more present in his body, and appreciates things like being able to throw on a T-shirt and walk out the door.

“Every moment that I realize and recognize this is something I’m doing now that I couldn’t have done if I didn’t have access to this surgery is another moment of relief, of euphoria,” Martin said.