123. Voices Of Trans Youth: A Qualitative Exploration of Expectations for Top Surgery

PURPOSE: Top surgery is an important aspect of gender-affirming healthcare, particularly for transgender and gender diverse (TGD) adolescents, who often navigate complex physical, social, and emotional challenges. This qualitative study aimed to identify TGD youths’ voices regarding their expectations for top surgery. The term expectation refers to a belief or anticipation about what will happen in the future, after top surgery. It can reflect a hope, desire, or assumption about how a situation will unfold, often shaped by past experiences or knowledge. METHODS: Concept elicitation interviews were conducted with 47 TGD youth from Canada and the USA to develop GENDER-Q Youth, a new patient-reported outcome measure. Of the 47, 35 who were: assigned female at birth, identified as trans male or nonbinary, and were interested in or had top surgery, provided data to address the study aim. RESULTS: We identified six themes regarding youth’s expectations: appearance, body image, binding, clothing, physical activity, and social comfort. A major motivator for surgery was the desire for an appearance aligned with one’s gender identity. Nearly all participants expressed a preference for a flat chest contour. The prevalence of strong patient expectations around aesthetic goals emphasizes the importance of shared decision-making between patients and clinicians. Achieving a flatter chest was intertwined with body image, where many adolescents discussed feelings of disconnect and distress, which had an impact on activities such as taking a shower or looking into mirrors. Postoperative participants reported feeling more connected to their bodies and more confident, which impacted how they interact with themselves and others. The social-related expectations were particularly evident in preoperative participants’ discussions of how top surgery could positively affect their relationships with friends, peers, and intimate partners. Postoperative participants described how top surgery improved their comfort in interacting with others. In addition to social considerations, participants highlighted the functional challenges of binding, often relying on commercial binders. Binding, while providing temporary relief, was frequently uncomfortable or painful and was cited as a common motivation for surgery while postoperative participants discussed feeling relief and freedom because they no longer had to bind. Participants also expected top surgery to enable greater participation in physical activities, an important factor in adolescent well-being. Those who had top surgery discussed being able to participate more freely in activities they enjoyed such as swimming, or hiking. While mental health is a common outcome focus of gender-affirming care research, our analysis suggests that top surgery’s impact on mental health may be more indirect. By improving aspects of health-related quality of life, such as body image, social support, and physical activity, surgery contributes to greater resilience, which may be more meaningful metrics than focusing solely on mental health outcomes. CONCLUSION: Overall, this study captures common expectations that TGD youth’s have for top surgery. Shared decision-making that incorporates these patient-important outcomes is essential for optimizing care and ensuring post-operative satisfaction. Future research should continue exploring the diverse experiences of TGD youth and develop patient-reported outcome measures (PROMs) that capture the full scope of top surgery’s impact.