Along the Spectrum from Reduction to Mastectomy: Comparing the Opinions of the Transmasculine and Gender-diverse Community on an Algorithmic Approach to Gender-Affirming Top Surgery

BACKGROUND: Gender diverse patients, including those identifying as non-binary, genderqueer, and genderfluid, may have different preferences for top surgery, often undergoing multiple procedures compared to transgender men (1). There is little discussion in the literature on the options available to these patients that differ from well-described techniques for surgery in binary transgender men. The purpose of our study was to assess the differential experiences, preferences, and needs of transgender men and non-binary individuals, soliciting feedback on a pictorial algorithm to facilitate discussions in surgical decision-making (2). METHODS: An IRB-approved survey was distributed through various Reddit gender-based platforms. A total of 799 responses were collected, of which 647 met inclusion criteria for gender diversity. Respondents were grouped by transgender males, non-binary, and others on the transmasculine spectrum. The survey consisted of demographic information, experiences with top surgery care, and an algorithmic questionnaire for top surgery. Group differences were assessed using t-tests and chi-squared tests (p<0.05 for significance). RESULTS: Non-binary and other transmasculine respondents were significantly more likely to desire “non-standard” chest wall reconstruction (p=0.002), including desiring a breast mound (13.94 and 8.40%) compared to transgender men (2.95%, p=0.006) and the standard approach was selected 15-22% more by transmasculine respondents. Non-binary and other transmasculine respondents were less likely to desire nipple and areolar complex (NAC) reconstruction, but 10-20% amongst all three groups were “unsure.” Non-binary and other transmasculine respondents were more likely to have seen a surgeon (p=0.002), feel like they were educating their surgeons on various options (p=0.0001) with greater comfort (p=0.003). However, their understanding after meeting a surgeon for top surgery was significantly lower compared to transgender men (4.55 and 4.51 vs 4.71, p=0.04). Compared to transgender men, non-binary and other gender respondents were older and had higher levels of education (p<0.0001). CONCLUSIONS: Non-binary and other transmasculine individuals had different preferences and experiences compared to binary transgender men in this survey. In addition to more often desiring a breast mound or foregoing NAC reconstruction, non-binary respondents reported that more often they were educating surgeons on options for aesthetic outcomes. Surgeons performing “standard” top surgery have the requisite technical skills to achieve a spectrum of aesthetic results for non-binary patients. The pictorial algorithm examined in the present study may assist patients and surgeons establish a shared vision for their top surgery outcomes. While most transmasculine individuals across the spectrum prefer a standard top surgery approach, the desire for “non-standard” options was evident across all genders in this survey, indicating that a more open discussion will benefit binary transgender men as well. REFERENCES: 1. McTernan M, Yokoo K, Tong W. A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients. Ann Plast Surg. 2020;84(5S Suppl 4):S323-S8. 2. Garvey SR, Friedman R, Nanda AD, Boustany AN, Lee BT, Lin SJ, et al. Along the continuum from reduction to mastectomy: An algorithmic approach to the gender diverse top surgery patient. J Plast Reconstr Aesthet Surg. 2023;83:246-9.