What Does the Research Say About Top Surgery for Trans Youth?
Several small studies suggest that the risks are low and there are many benefits to chest masculinization surgery for young people with gender dysphoria about their breasts. The politicization of surgery for minors has made discussing this evidence deeply taboo.
by Veronica Esposito
In the overheated debate around gender-affirming medical care for transgender minors, the conversation around surgeries has reached a fever pitch, with anti-trans rhetoric asserting that countless children are being mutilated by “gender ideology.” Even president Joe Biden’s White House has been swept up in the hysteria, recently issuing a series of statements weakening their support for trans minors who need surgeries, saying such procedures should be reserved for adults.
These statements are misleading. Although this is an area in need of further study, research currently supports the efficacy and safety of mastectomy surgeries for trans and nonbinary minors (often referred to as “top surgery”). This research is a part of why the guidelines from the World Professional Association for Transgender Health, the Endocrine Society, and American Academy of Pediatrics, have supported this surgery in rare cases for years.
First of all, it must be emphasized that, when we talk about trans surgeries, we are talking about a minuscule number of minors. It is virtually unheard of for trans minors to receive genital surgeries, and the vast majority of surgeries carried out on minors is mastectomy surgery.
For these procedures, the number of minors receiving them is extremely low. For example, Diaddigo et al. were only able to find 189 adolescents total receiving top surgery between 2010 and 2023—compare that to the estimated 42,000 individuals age 6 to 17 diagnosed with gender dysphoria in 2021 alone. Another study, Tang et al., found 209 top surgeries over the period from 2013 to 2020. When compared to comparable procedures in cis children, there is evidence many more cisgender adolescent males receive breast removal surgeries than do transgender minors. This is true despite the fact that teenage gynecomastia (the condition that causes young cis men to develop breasts) is a malady that—unlike gender dysphoria—tends to resolve on its own over time.
So what about the trans minors that do get this surgery? Well, the scientific research is very clear—these surgeries are incredibly beneficial. Boskey et al., Sasson et al., and Ascha et al. all found that top surgery brought statistically significant improvements in mental health indicators like chest dysphoria, gender congruence, and body image. Olson-Kennedy et al. and Tang et al. found virtually nonexistent regret rates after receiving these surgeries. All of these studies declared these surgeries safe, in that they had extremely low rates of serious medical complications. In the face of all this research showing the benefits of top surgery, our reporting could find no research indicating that this surgery is harmful for minors; this is backed up by Ascha, which states: “There is no evidence to support delaying surgery for eligible patients based on age.”
There are some notable aspects of these studies. Boskey was a longitudinal study, which followed up at intervals of six months and one year—the study found that the mental health gains of those receiving surgery remained consistent over time. Ascha featured a control group (although it was difficult to retain the group, as many participants left the control group to pursue top surgery); as one would imagine, chest dysphoria decreased significantly among the surgery group and did not change at all for the control group. Diaddigo found that nonwhite minors tended to get surgery at an older age, indicating potentially more barriers for nonwhite youth; it also found higher rates of complication among Black or African American patients, potentially indicating Black patients received poorer treatment due to race.
Another study—Olson-Kennedy et al.—studied minors who did and did not receive top surgery; they found that, among those who did not get surgery, “chest dysphoria was higher for those who had been taking testosterone longer, increasing by 0.33 points for each month taking testosterone.” This indicates that, while hormone replacement therapy can help transmasculine minors, top surgery (when desired) can help even more than hormones alone.
Ascha advocated against using age cutoffs in favor of an individualized approach to surgeries: “In our practice, there is no predetermined timeline for gender-affirming medical or surgical treatment; patients are assessed individually by a multidisciplinary team for readiness. There is no evidence to support delaying surgery for eligible patients based on age.”
After all of these quantitative studies, there is also one notable qualitative study to include. Qualitative studies are often considered the awkward stepchild to quantitative ones, as they are generally considered too “low quality” to provide scientific evidence for or against a treatment. They do, however, give the voices of trans youth themselves a rare chance to be heard. The experiences captured in Mehringer et al. are too numerous to be exhaustively reported here, and I do encourage readers to seek out the paper and read it for themselves.
Mehringer offers ample evidence to just how much psychological pain its subjects are in. Here are a few choice quotes:
“I was really self-loathing… the chest dysphoria–it just ate away at me”
“It felt like there was this burden that I was just constantly carrying around with me and this sort of insecurity…like I had a secret that I was trying to hide…this constant feeling of being uneasy and sort of on edge.”
“[My chest dysphoria] made me feel like shit, honestly. It made me suicidal. I would have breakdowns.”
“I’ve been suicidal quite a few times over just looking at myself in the mirror and seeing [my chest]. That’s not something that I should have been born with.”
Mehringer also puts the lie to suggestions—like that found in the Cass Report—that trans people can just wear binders as an alternative to surgery. While some individuals may choose to bind on an ongoing basis, many of the youths in this study found that to be an untenable—and potentially dangerous—proposition.
“I don’t really do any physical activities really because I’d have to bind if I did them in public, and I really cannot do that safely.… I can’t really do intense physical activity with this [binder] on, and I don’t want to not have it on.”
“Binding’s really uncomfortable.… I don’t like doing it, but at the same time, I have no other option. I don’t really leave my room unless I have a binder on.”
“[My binder] was incredibly restricting with my breathing. And if I wasn’t wearing my binder, I wouldn’t go out and do things. So I’d wear it even if I was unable to breathe.”
Lastly, Mehringer also speaks to the joy that happens when these minors are able to get the surgeries that they have long advocated for:
“[Top surgery] just makes everything a million times better…I can’t even describe how much. It is amazing. That’s about the only words that are coming to my brain—because it doesn’t just help with the chest dysphoria—but it’s also just like you’re so much more confident in yourself after you have it.… I’m happy with it…just like having–like closer to the body that I am supposed to have.”
“It’s been a relief.… Now that the problem is basically solved…I can basically focus the energy that I was focusing on [my chest] and redirect it somewhere way more productive.… I can now do actual exercise for the first time in my life.”
“It was liberating, because I just could finally live a normal life like the rest of kids my
age.”
With gender-affirming medicine a very new concept for most people, it’s understandable that some people may find it uncomfortable to contemplate, especially when that medicine takes the form of surgeries for those under 18. However, the research shows that this is a promising treatment that has helped many young people, and that there is currently no evidence that this treatment does harm. Whenever the medical community encounters a treatment with such research, the course is clear—its thoughtful use must be continued, with continued research alongside, so that it can improve the lives of those who need it and be improved in turn over time.
Veronica Esposito (she/her) is a writer and therapist based in the Bay Area. She writes regularly for The Guardian, Xtra Magazine, and KQED, the NPR member station for Northern California, on the arts, mental health, and LGBTQ+ issues.