Breastfeeding grief after chest masculinisation mastectomy and detransition: A case report with lessons about unanticipated harm
An increasing number of young females are undergoing chest masculinsation mastectomy to affirm a gender identity and/or to relieve gender dysphoria. Some desist in their transgender identification and/or become reconciled with their sex, and then revert (or detransition). To the best of our knowledge, this report presents the first published case of a woman who had chest masculinisation surgery to affirm a gender identity as a trans man, but who later detransitioned, became pregnant and grieved her inability to breastfeed. She described a lack of understanding by maternity health providers of her experience and the importance she placed on breastfeeding. Subsequent poor maternity care contributed to her distress. The absence of breast function as a consideration in transgender surgical literature is highlighted. That breastfeeding is missing in counselling and consent guidelines for chest masculinisation mastectomy is also described as is the poor quality of existing research on detransition rates and benefit or otherwise of chest masculinising mastectomy. Recommendations are made for improving maternity care for detransitioned women1. Increasing numbers of chest masculinsation mastectomies will likely be followed by more new mothers without functioning breasts who will require honest, knowledgeable, and compassionate support.
Introduction Female individuals who experience a gender identity in conflict with their sex and/or who suffer from gender dysphoria may seek surgery to construct a male-appearing chest (1). This surgery is usually a type of subcutaneous mastectomy variously called “chest masculinisation”, “chest reconstruction”, “chest contouring”, or “top” surgery (2, 3). The surgical purpose is to affirm a gender identity as a trans man or non-binary person and/or to relieve psychological distress (1). Some breast tissue may be retained, unlike mastectomy for breast cancer, as aesthetic outcome is the priority (4). 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 makes no recommendation for counselling on breastfeeding before surgery (5) and nor do guidelines from Australia (AusPATH) (6) or New Zealand (PATHA) (7). Falck et al. (8) considered the experience of six transgender individuals who had chest masculinising surgery. They found the surgeon raised the impact on breastfeeding in just one case. This discussion occurred only because the patient had requested breast reduction (rather than chest masculinisation) and had not advised the surgeon of their transgender identification (8). This suggests a double standard may be at play in terms of warning patients about harms dependent on identity rather than procedure. The impact of different surgical techniques for chest masculinisation on breastfeeding is absent from the literature. Research on ordinary breast reduction surgery shows that where the nipple, areola and breast tissue underneath the areola remain in place (so-called “pedicle” techniques) some milk making and milk removal capacity may be retained (9). However, when the nipple-areolar complex is separated from underlying glandular tissue, milk removal is impossible (9). The most common chest masculinisation technique involves separation of the nipple-areola complex from underlying tissue and excision of the nipple and areola which are then grafted back onto the reduced breasts in what is called “free nipple grafting” (10). Nipple reduction is a common adjunct, for which variety of techniques are used (4, 11); many result in a modified nipple with no functional orifices for milk removal [e.g., (12)]. It has been falsely claimed it is not possible to predict breastfeeding outcomes after chest masculinisation surgery based on surgical technique (13). Where surgery removes and grafts the nipple-areola complex, there is little to no possibility of milk removal from the nipple, even should glandular tissue remain. Where the nipple is kept in place but tissue underneath it removed and duct connections cut or nipple integrity forfeited, milk removal is also impossible. Furthermore, surgical complications such as necrosis can result in nipple loss (4, 14, 15) and surgery that removes the nipple and areola entirely may be chosen (16, 17). Considered together, these factors mean that many, if not most, individuals who have undergone chest masculinisation mastectomy, are unlikely to retain ability to both produce and extract milk. Proper discussion is required for the patient to choose and consent. Without recognising that the future will include pregnancy for at least some patients, surgeons cannot offer a conservative approach; either of deferring surgery or attempting to preserve some function. The only breastfeeding-focussed research including participants who underwent chest masculinisation surgery is unfortunately unclear on the lactation and breastfeeding outcomes of all study participants (1). However, two individuals produced some milk that exited via their nipples; it seems in these cases, their surgeries did not involve nipple grafts and it can be assumed that some underlying breast tissue was retained. A further case involved an individual who had nipple grafts, sought to breastfeed but was unable to produce milk (1). Some people do not persist in a transgender identification, and/or become reconciled with their sex, and detransition (18). Social detransition may involve presenting in a way more typical for their sex, reverting a name change, using sex-based pronouns, or overtly rejecting a transgender identification (19). Medical detransition usually involves stopping cross-sex hormones and require sex hormone replacement therapy in cases of gonadectomy (19). The experiences of detransitioners have been little studied, but transition regret is commonly reported in existing research (18, 19). Young and childless detransitioners who had mastectomies have spoken specifically of regret about inability to breastfeed (20, 21). Case reports are a timely way for increasing knowledge of unusual or new conditions or circumstances and so help inform healthcare (22). They place the “care and treatment of the individual patient centre-stage” (23), can be valuable as an “early warning signal” and contribute to the health and wellbeing of others in the future (24). This paper presents a case report of a woman who identified as transgender and obtained a chest masculinisation mastectomy but later detransitioned. She experienced intense grief around her inability to breastfeed her infant. During a three-hour interview with the first author (KG), the woman, whom we are calling Elizabeth, told her story of transition, detransition, pregnancy, birth, and new motherhood. She also provided the authors with documentary support for her account including pregnancy medical records, her referral to the milk bank which described her reasons for seeking banked donor milk, and photographs of her mastectomy scarring. KG with the assistance of the second author (SB) developed the case description based on the transcribed interview in consultation with Elizabeth, with a focus on her experiences and feelings regarding her breasts, mastectomy, and breastfeeding and the impact of this on her as a pregnant woman and new mother. Some details have been changed to preserve anonymity. Written consent for publication and approval of the finalised paper was obtained from Elizabeth. Ethical approval for publication was granted by the Human Research Ethics Committee of Western Sydney University (approval H14913). The detailed experience of detransitioned women who had chest masculinisation mastectomies and then became mothers has not, to our knowledge, previously been described. This case report provides guidance to assist health professionals to better support detransitioned women who become mothers.