Quick Review: Pink News' Evidence on the Benefits of "Top Surgery"

Following the concerns raised over the Costa Coffee sign that features a bare-chested woman with mastectomy scars, Pink News has published another of its highly misleading articles.

As we have seen before, they have a habit of linking to studies that they hope no one will actually read, and focus instead on pulling out soundbites, usually from the abstract, which superficially support their argument.

If we delve deeper, we can usually see that the actual data is nothing like as compelling as they would have us believe, and sometimes shows the exact opposite.

The article references another article in Pink News to back up its claim that “top surgery [has been] found to improve young trans people’s quality of life”. That article references 4 studies to back up its position. So, let’s take a look at those…

Study #1: Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults

The full article is not available without a subscription, but we can glean a number of things from the abstract.

Firstly, it lists those receiving surgery as being between ages 13 and 24. So, for anyone insisting these surgeries are not carried out on those under 18, this clearly demonstrates this is untrue.

Secondly, the methodology tells us that patients were assessed “preoperatively and 3 months postoperatively”. Three months is a very short timescale, not much beyond the 4-6 weeks it typically takes for recovery from mastectomy and this would be very early to experience any regret.

Lastly, it does not examine a large number of patients: 36 in total who underwent surgery. It also states that 11 patients were lost to follow up, so we have no idea what their feelings were. Combined with the short follow up period, it doesn’t make for any sort of remotely compelling case for a longer-term improvement in quality of life.

Study #2: The case for bilateral mastectomy and male chest contouring for the female-to-male transsexual

This study did not involve any experimental work itself but is an analysis of existing literature. Pink News cite its finding that double mastectomy “acts as a prophylaxis against distress, ameliorates extant distress as well as providing improved quality of life and global functioning”.

However, the study itself does not provide solid evidence for this conclusion. For instance, they provide a somewhat disturbing quote: “The first and arguably most important surgical procedure performed in the female-to-male transsexual is the creation of an aesthetically pleasing male chest”, which is from a study on surgical techniques (Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm). The study did no follow up on distress, mental health or any of the implied benefits.

Similarly, other studies cited with claims such as that surgery “not only enhances the [female-to-male] transgender identity, increases self esteem, and improves body image, but provides some security and safety for those who remove their shirts in public areas” (Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects). However, if you look at the detail of the study, it did not measure self-esteem, mental health or body image in any way - measurements focus exclusively on physical attributes such as bone density, height and hormone levels.

Another quoted study, with the claim “a male chest contour is of utmost importance for [female-tomale] transsexuals” (Surgical therapy in transsexual patients: a multi-disciplinary approach) focusses exclusively on the cooperation between surgical teams and not on patients.

As far as I can tell with the resources currently at my disposal, this second study Pink News reference appears to be conjecture based on other quoted conjecture.

If we were bending over backwards to be charitable we could conclude that the patients and surgeons consulted in the referenced papers are of the opinion these things are important. I don’t think that was in doubt, though: what is in doubt is whether there is evidence that this is a good idea in the longer term. Feel free to correct me if you can find otherwise, but I find nothing that backs this notion up here.

Study #3: Assessing Quality of Life and Patient-Reported Satisfaction with Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study

This study is quoted as finding that “top surgery had major positive effects on all mental health and quality-of-life metrics”. I’ve managed to find a full copy of this paper here. It was a non-random survey of previous patients at a New York clinic. The responses received do report patients feeling positive about surgery. However, there are a number of issues here:

• The non-random nature of the survey means potential for selection bias

• The vast majority had surgery recently (79% two years ago or less, only 6 individuals more than 5 years) and therefore there is (again) little evidence for long term satisfaction or regret

• The age range is very broad, from 18 up to 58 - although this is not an issue in itself, it does call into question the applicability to adolescents receiving this surgery and the potential for regret

• Not all feedback was positive, for example, 24 percent expressed “complete dissatisfaction” with their resulting nipple sensation

Again, far from compelling, especially in the case of major concern: promoting surgery to adolescents.

Study #4: Quantifying the Psychosocial Benefits of Masculinizing Mastectomy in Trans Male Patients with Patient-Reported Outcomes: The University of California, San Francisco, Gender Quality of Life Survey

The study is quoted as reporting “a significant improvement in quality of life 6 weeks and 1 year after chest surgery” and we can see this quote within the abstract. Again the full paper requires a subscription, but we can see a number of things from the abstract:

• The quote listed by Pink News itself indicates that the follow up was short term, leaving no real scope for detecting any longer-term regret

• Only 22 (43%) of participants responded to the 1 year survey, making a small sample size, and raising the question as to how the remaining 57% felt after a year, and the reason for their lack of response

• The study used a completely new survey to measure results that has not been validated elsewhere and therefore the findings may simply reflect the design of the survey rather than the actual experiences of the participants

Once again, very, very far from a slam dunk proving the necessity of surgery.

So, what do we actually know from these studies?

There is some evidence that, shortly after having surgery, “transmen” typically feel positive about it. However, that does not mean the same thing as it definitively being a good decision in the longer term. Participants are likely receiving much positive reinforcement from their social circle, and may also be taking testosterone, which has been reported to have mood enhancing properties.

There are many unknowns and many regrets are not likely to surface until later in life. For example, anecdotally, many teenagers state their intent to never have kids, but change their minds when older. It is logical that regrets about reproductive function would be likely to come later in life, much longer than a few months or a couple of years after surgery.

The numbers in these studies are small, the timescales are short, and the circumstances do not match many of the groups that are of most concern in encouraging mastectomies, such as teenagers. There are no longer term follow-ups on, for example, suicide rates in those in the control groups who did not have surgery and, given the way suicide is touted as the inevitable outcome of not having such surgery, you might think this would be monitored carefully.

We have seen from the studies quoted, that this is happening in under 18s, and the data listed here is not, in my opinion, anywhere near sufficient to justify such a radical and destructive procedure.

Nothing Pink News quotes here establishes that Maya Forstater is anything other than legitimate in her criticism that it is deeply wrong to trivialize these procedures - we do not have the evidence that would be needed to justify such a destructive act on girls’ bodies.