Reply: Mastectomy for Individuals with Gender Dysphoria Younger Than 26 Years: A Systematic Review and Meta-Analysis

We appreciate the opportunity to respond to the comments from Armstrong et al. regarding our systematic review.1 We find that they refute and critique points we did not make. We encourage the reader to read our work without preconceptions of our intentions. We take issue with the implication that we deem gender-affirming mastectomy (GAM) as inappropriate. The primary purpose of our research was to provide an evidence evaluation to assist surgeons engaged in shared decision-making with patients. The onus falls on surgeons to counsel individual patients preoperatively regarding the risks and benefits of surgery and alternatives to surgery. We do not advocate one way or another regarding whether GAM should be performed. However, we believe that those making decisions should be provided with sound evidence syntheses outlining the certainty of evidence regarding treatment outcomes, as such information is critical to decision-making regarding life-changing, largely irreversible surgery. Indeed, without such information, patients cannot provide informed consent. To that end, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess and report the certainty of evidence, and presented our findings in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The rationale for downgrading followed GRADE, as detailed in the article. We concur that due to the nature of the specialty of plastic surgery, randomized controlled trials are not feasible due to ethical issues. Indeed, a review of plastic surgery literature reports primarily levels 4 and 3.2 We have not advocated for randomized control trials. However, comparative studies, conducted with methodological rigor, can provide moderate-certainty evidence. We maintain that all populations, particularly historically marginalized communities, deserve quality medical care. Armstrong et al. state, “We frequently advocate for improved access to surgical procedures because we understand their value before robust evidence becomes available.” It is not clear how the value of a treatment may be determined without sound evidence. As the Cardiac Arrythmia Suppression Trials3–5 notably demonstrated, even well-intended clinical judgment grounded in pathophysiologic reasoning and clinical consensus can lead to harm when not validated by rigorous, outcome-based evidence. Armstrong et al. claim that our focus on mental health outcomes pathologizes this population. While gender dysphoria is not a pathologic condition, it is a mental health diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,6 and Fifth Edition, Text Revision.7 A wealth of literature has emerged recently arguing that gender-affirming treatments are medically necessary. The World Professional Association for Transgender Health Standard of Care Version 88 clearly considers GAM as not cosmetic but “medically necessary” (p. 6), stating that gender-affirming treatments are “associated with improvements in psychological functioning, including reductions in depression, anxiety, and suicidality” (p. S192). Numerous studies have evaluated outcomes such as psychological distress, gender dysphoria, suicidality, anxiety, depression, substance abuse, and use of psychiatric medications in both youth and adults.9–14 In the 39 studies included in our systematic review, nearly all participants were diagnosed with gender dysphoria, and 20 articles make strong claims that GAM reduces gender dysphoria, a key clinical rationale for surgery. Another 8 articles make strong claims that GAM improves a person’s well-being. Table 1 presents a sample of claims made in the studies in our systematic review.15–23 Table 1. - Sample of Claims Regarding Mental Health Benefits of Gender-Affirming Surgery Study Claim Ayyala et al., 202015 “Chest masculinization can help to alleviate gender dysphoria and improve mental, psychosocial, sexual, and physical well-being” Bustos et al., 202016 “[T]hese surgeries are essential components in the treatment for gender dysphoria” Junn et al., 202117 “[T]he ultimate goal of chest masculinization surgery is to alleviate gender dysphoria” Kelly-Schuette et al., 202218 “[I]s not considered a cosmetic procedure, but a reconstructive surgery for treatment of gender dysphoria” Marinkovic and Newfield, 201719 “[M]ay reduce their dysphoria and the risk of suicide” Stein et al., 202120 “[E]fficacy of chest wall contouring in alleviating symptoms of gender dysphoria in transmale and nonbinary patients is well established” Kaur et al., 202321 “[S]ecuring a chest masculinization surgery date may have had a positive impact on psychological well-being” Lane et al., 202322 “[T]here were significant improvements in anxiety, depression, body image, and psychosocial functioning postoperatively” Wolter et al., 201523 “[C]reating a new male-like personality physically as well as emotionally helps FTMTS to improve their psychosocial state of mind” FTMTS, female-to-male transsexuals. In evaluating the benefits of breast reduction surgery in youth, factors such as improvement in musculoskeletal symptoms, activity levels, and clothing comfort have been considered, as well as the psychosocial and mental health benefits.24–26 Thus, it is reasonable to evaluate the quality of evidence of these outcomes, especially if the argument is for medical necessity. Unlike with GAM, no one has argued that breast augmentation in adolescents should be considered medically necessary. To dismiss GAM as “no different from the other body image– and psychosocial functioning–enhancing operations we perform as plastic surgeons” is inconsistent with the position of the World Professional Association for Transgender Health and the larger gender-affirming communities advocating medical necessity. If, however, GAM is to be considered akin to adolescent rhinoplasty or breast augmentation, then it should be treated as such—a cosmetic procedure. We disagree with the claim by Armstrong et al. that patients seeking gender-affirming care are inherently different from those who do not or who engage in binding. Research suggests that binding among transmasculine youth may be a predictor of surgery interest and that binding behavior may be used in the assessment of readiness for GAM.14 Thus, cohort studies and studies tracking patients as they move from binding to surgery may provide evidence of benefit of surgery. As to the allegation of political motivation, none of the authors are members of the Society for Evidence-based Gender Medicine (SEGM). Although SEGM commissioned the study, they were only involved in the development of the patient, intervention, comparison, and outcome (PICO) framework and did not have access to the work in progress, including the manuscripts. We maintain that our work is entirely a scientific endeavor, and not political. DISCLOSURE The authors have no conflicts of interest to disclose. No funding support was received for this communication. The authors received a travel stipend for their presentation at a conference organized by the Society of Evidence-based Gender Medicine in September of 2025, after their involvement with the systematic reviews and after submission of this Reply. Dr. Kulatunga-Moruzi presented the findings of the systematic review. Dr. Montante presented on his experience with gender-affirming mastectomy.