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Women’s Health and Elective Double Mastectomies

As well as the invaluable health benefits to both mother and newborn, breastfeeding is often celebrated as a profound emotional bonding experience. However, an increasing number of young women are seeking chest masculinisation mastectomy – also known as “top surgery” – to relieve gender dysphoria or affirm a perceived gender identity. Unfortunately, most transgender guidelines do not include the impact of this surgery on future breastfeeding function as part of the surgical consent process. These young women are not being warned that they are likely to lose the ability to breastfeed if they go on to have a baby in the future. In this article, Tracy Donegan R.M, a member of The Countess Healthcare Working Group discusses the devastating impact of healthcare professionals failing to address this outcome.

What if you had a teen daughter who came to you asking questions about breast binding, starting testosterone or “top surgery”? How about chest masculinisation? Would you know what she’s talking about?

Do you feel you could have a meaningful discussion with her about the potential health risks young women are exposed to with these permanent body-altering treatments?  If, like many parents in Ireland these days, you feel out of your depth when it comes to gender speak, we hope we can shed some unbiased light on this harmful trend.

In this article we explore the trend of double mastectomies in young gender-dysphoric women. Within the context of breastfeeding function and the associated long-term health benefits for mothers and infants, what do parents need to know?  According to the National Gender Institute, there is currently no public access to gender-affirming top surgery in Ireland. Candidates must be attending a HSE endocrine clinic and on hormones for a minimum of six months before being considered eligible for a mastectomy, and a minimum of one year before being referred for surgical assessment.

Many reading this will associate double mastectomies with breast cancer and can barely imagine voluntarily undergoing that surgery, yet it is promoted on TikTok like one of their many other “trends”. The catchphrase “TikTok made me do/buy it” has never been more sinister.

Women and girls who take testosterone may lose the ability to breastfeed in the future. If they do not, their breastmilk is likely to contain a certain amount of testosterone. It is unclear what, if any, effect this could have on infants. Nevertheless, on the BBC Radio show LGTea, one mother describes how her daughter wants testosterone and to have her breasts removed. The host laughs, saying “You will be amazed how happy they will be…at the end you will think back and wonder, ‘Oh why was I so worried?’”. The BBC presents double mastectomy surgery and irreversible hormones and surgery as risk free.

Gender Dysphoria and Breast Removal

Any woman reading this will understand that surgically removing your breasts is a big deal. Sure, we all complain about how big/small/lopsided our girls are, but to remove a part of the body that is so intrinsic to our health and that of the next generation must give us pause for thought.

Karleen Gribble, Susan Bewley and Professor Hannah Dahlen recently published a case study on the impact of chest masculinisation, usually defined as double mastectomy of healthy breasts in young women. It may be a difficult read for some.

It’s well documented that breastfeeding confers significant health benefits for newborns, as well as reducing cancers and diabetes in women. International guidelines recommend nursing newborns within the first hour. In this heartbreaking case, a woman who identified as transgender and had her breasts surgically removed at age 20 shares her grief over not being able to breastfeed her baby. Elizabeth – not her real name – underwent chest masculinisation mastectomy (commonly known as top surgery) after being formally diagnosed with gender dysphoria as a teenager.   

Elizabeth is now a detransitioned woman in her thirties. She first experienced discomfort in her female body as a 10-year-old when her breasts began to develop. She described being teased by other children and getting sexually harassed by adult men as “really negative experiences” that led her to hate her breasts. At age 18, Elizabeth sought treatment at an adult gender identity service, where she was formally diagnosed with gender identity disorder and prescribed testosterone. At age 19, she was referred for chest masculinisation mastectomy and at 20 she underwent a double incision subcutaneous mastectomy with free nipple grafts. Throughout the process, she recollects no discussion of the potential impact on breastfeeding function.

Due to complications, Elizabeth was left with extensive, thick, raised scarring, that was painful to the extent that even wearing clothing was uncomfortable. Her right nipple continually leaked a watery fluid and tissue voids in her scarred left nipple graft accumulated a smelly paste that had to be regularly squeezed out.

Elizabeth felt unsupported by her transgender friends; they saw her surgical outcome as reflecting badly on transition and advised her not to tell others about her experience because she was “making trans surgery look bad”.

Two years later, Elizabeth underwent surgery to reduce the scars; leaving her chest sunken and nipple-less, while scarring and nerve pain remained. Elizabeth felt unsupported by her transgender friends; they saw her surgical outcome as reflecting badly on transition and advised her not to tell others about her experience because she was “making trans surgery look bad”. She describes how she went from being a trans activist “to being persona non grata because I was complaining about these botched chest surgeries, and it was just really devastating.” Attempts to silence detransitioners is a common strategy used by trans rights activists.

At age 24, Elizabeth detransitioned, stopping testosterone, disassociating from the transgender community, and considering her previous identification and medicalisation a “terrible mistake”.

Although Elizabeth doesn’t recall any discussion with her surgeon about breastfeeding functionality, she believed that she would not have welcomed the conversation. “I don’t think I would have been receptive, I would have felt insulted and I would have said it was triggering my gender dysphoria.” However, Elizabeth explains that this response would have been an avoidance tactic: “That wouldn’t really have been true. It would have been because…maybe I did want children… but it’s like this trump card, gender dysphoria, meaning you can’t have any conversation.” That is, mention of gender dysphoria shuts down any further exploration.

Several years later, Elizabeth became pregnant and, like so many mothers, felt that breastfeeding was important to her. “It was clear to me that I wanted to give my child the best possible start in life. And I did all the research, I knew that breastfeeding was really important.”  Other than gestational diabetes, Elizabeth’s pregnancy was uneventful. However, when she initiated a discussion about breastfeeding, she was told to “just formula feed”. Elizabeth shared her distress at not being able to breastfeed and her concern that she would be an inadequate mother because of this. She described the trauma of her breast surgeries. Her midwife appeared shocked but seemed to lack experience of women without breasts following chest masculinisation mastectomy, and so Elizabeth was referred to an obstetrician.

This obstetrician had received training in transgender care but kept referring to Elizabeth as a man. Elizabeth realised that he was trained only to “affirm” transgender identification and to prioritise gender over sex. Her distress and her health providers’ confusion resulted in a child protection report. After Elizabeth’s child was born, by C-section, he was placed skin-to-skin on her chest and began to search for her breast. She describes how it was really hard knowing that he wanted to breastfeed, and I couldn’t give him that…And when, when they put him on my stomach, he crawled up, he was looking for my breasts, and he couldn’t find them. And he tried to suck on my chin. And he spent so much time in his early life trying to find my breasts.”

Due to her gestational diabetes diagnosis, Elizabeth was successful in obtaining banked donor milk. While grateful for the respect given at the milk bank and for the milk itself, and despite knowing that sick infants were prioritised in the system, Elizabeth felt guilty about taking this milk. She said, “I always had the feeling that even if I knew that the babies who really needed it more, were getting served first, I was worried that a baby who might have needed it was going to be deprived because of me.”

Seeing her infant exhibiting instinctual feeding cues was difficult, “I’d be cuddling with him. And I could feel like this is the time he would want the breast. It was so obvious.” She recognised a relational aspect to breastfeeding that they both missed.

Elizabeth wants to raise awareness of the experiences of others like her, “to help try to make things less uncomfortable for pregnant, or shortly after pregnancy, detransitioned women who are trying to feed their babies.” She wants health providers to know that “you can’t assume based on how someone looks that they believe in gender identity and that they are going to want to be interacted with as if they are transgender.”

Transition regret is commonly reported in existing research. Young and childless detransitioners who have had mastectomies have spoken specifically of regret about inability to breastfeed. It has been falsely claimed by Hoffkling, Obedin-Maliver & Sevelius (2017) that it’s not possible to predict breastfeeding outcomes after chest masculinisation surgery based on surgical technique. However, the most common chest masculinisation technique may result in a modified nipple with no functionality for breastfeeding, even should glandular tissue remain. Other known complications include necrosis of the nipple (tissue rots and dies).

In-depth discussion of these risks is required for the patient to make an informed decision, which may include deferring surgery if there is the possibility of pregnancy in the future, or surgery which attempts to preserve some breastfeeding function.

Most transgender guidelines do not include the impact of chest masculinising mastectomy on breastfeeding as a part of the surgical consent process. Notably, the World Professional Association for Transgender Health (WPATH) Standards of Care and guidelines from Australia (AusPATH) and New Zealand (PATHA) make no recommendation for counselling on breastfeeding function before surgery.

As chest masculinisation mastectomies become more popular, more new mothers without functioning breasts will require knowledgeable, sensitive and compassionate support. We are grateful to Elizabeth for her courage in sharing her experiences and urge women having undergone chest masculinisation to consult with a midwife or obstetrician during pregnancy if they have any concerns.

Known Risks, Complications and Side Effects of Double Mastectomies

Scars: In chest masculinisation procedures, scars may appear as horizontal lines across the chest, or circles around the areolas. It is important to avoid sun exposure, which can darken scars and make them more obvious.

Haematoma: Blood can gather in the tissues after surgery and form clots, with symptoms such as pain, swelling and discoloration, as well as increased risk of infection. Haematoma forms in about 1% to 2% of double mastectomies.

Seroma: Fluid can collect under the skin. Small seromas may not require treatment and resolve on their own. Seromas in top surgery can be prevented by inserting drains in the surgical area and wearing a compression vest consistently after the procedure.

Infection: A rare though not unknown complication of double mastectomy. Cellulitis in the surgical area may require treatment with oral antibiotics and drainage.

Breakdown of nipple graft: While some skin sloughing is no cause for concern, deeper tissue death (necrosis) can indicate that the graft is not successful, and more surgery may be necessary.

Reduced nipple sensitivity: Numbness or tingling can happen if a nerve is disrupted or damaged during surgery. The double incision approach for chest masculinisation involves removing and repositioning the nipple, which involves cutting the nerves. Nipple numbness may improve over time, but full restoration of sensation is unlikely.

Irregular contours: Additional surgery to address chest contour may be called for in up to 32% of procedures.

If you or your child is considering body altering treatments, we encourage you to take some time to consider the potential short- and long-term health risks, as well as quality of life.

Content Warning: Graphic images below.

Source of images: HuffPost UK

Upcoming article:  Breast Binders – How the painful tradition of Chinese foot binding is returning, but for teen breasts.