I Regret to Report the Cis Are at It Again

• Journal List
• Plast Reconstr Surg Glob Open
• 5.9(3); 2021 Mar
• PMC8099405

Plast Reconstr Surg Glob Open. 2021 Mar; 9(3): e3477.

Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

Valeria P. Bustos, MD,^* Samyd S. Bustos, MD,^† Andres Mascaro, MD,^‡ Gabriel Del Corral, MD, FACS,^§ Antonio J. Forte, Dr., PhD, MS,^¶ Pedro Ciudad, MD, PhD,^∥ Esther A. Kim, Doc,^** Howard Due north. Langstein, MD,^†† and Oscar J. Manrique, Doctor, FACS ^††

Valeria P. Bustos

From the ^*Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Samyd Southward. Bustos

^†Section of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa.

Andres Mascaro

^‡Department of Plastic and Reconstructive Surgery, Cleveland Dispensary, Weston, Fla.

Gabriel Del Corral

^§Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C.

Antonio J. Forte

^¶Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Fla.

Pedro Ciudad

^∥Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru

Esther A. Kim

^**Division of Plastic and Reconstructive Surgery, Academy of California, San Francisco, Calif.

Howard Due north. Langstein

^††Sectionalization of Plastic and Reconstructive Surgery, University of Rochester Medical Middle, Potent Memorial Hospital, Rochester, N.Y.

Oscar J. Manrique

^††Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Stiff Memorial Hospital, Rochester, N.Y.

Received 2020 Jul 27; Accepted 2021 January 25.

Abstract

Background:

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to concrete and mental morbidity and questions the ceremoniousness of these procedures in selected patients. The aim of this written report was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

Methods:

A systematic review of several databases was conducted. Random-effects meta-assay, meta-regression, and subgroup and sensitivity analyses were performed.

Results:

A full of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <i%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret amongst patients undergoing transmasculine and transfemenine surgeries was <1% (IC <ane%–<1%) and 1% (CI <one%–two%), respectively. A full of 77 patients regretted having had GAS. 20-eight had minor and 34 had major regret based on Pfäfflin'south regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions:

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Introduction

Discordance or misalignment between gender identity and sex activity assigned at birth can translate into disproportionate discomfort, configuring the definition of gender dysphoria.^i–3 This population has increased risk of psychiatric weather, including depression, substance abuse disorders, cocky-injury, and suicide, compared with cis-gender individuals.^four,v Approximately 0.half dozen% of adults in the United states of america place themselves equally transgenders.⁶ Despite advancement to promote and increase awareness of the human rights of transgender and gender not-binary (TGNB) individuals, discrimination continue to afflict the daily life of these individuals.^four,vii

Gender-affirmation care plays an important function in tackling gender dysphoria.^{5, 8–10} Gender-affirmation surgeries (GAS) aim to align the patients' appearance with their gender identity and help achieve personal comfort with one-self, which volition help decrease psychological distress.^v,10 These interventions should exist addressed past a multidisciplinary squad, including psychiatrists, psychologists, endocrinologists, concrete therapists, and surgeons.^one,9 The number of GAS has consistently increased during the last years. In the U.s.a., from 2017 to 2018, the number of GAS increased to 15.iii%.^8,eleven,¹²

Pregnant improvement in the quality of life, body image/satisfaction, and overall psychiatric performance in patients who underwent GAS has been well documented.^v,^{13–nineteen} However, despite this, there is a minor population that experiences regret, occasionally leading to de-transition surgeries.²⁰ Both regret and de-transition may add together an important brunt of physical, social, and mental distress, which raises concerns about the appropriateness and effectiveness of these procedures in selected patients. Special attention should exist paid in identifying and recognizing the prevalence and factors associated with regret. In the present study, we hypothesized that the prevalence of regret is less than the terminal estimation by Pfafflin in 1993, due to improvements in standard of care, patient selection, surgical techniques, and gender confirmation intendance. Therefore, the aim of this written report was to evaluate the prevalence of regret and assess associated factors in TGNB patients thirteen-years-old or older who underwent GAS.²⁰

Methods

Search Methodology

Post-obit the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive research of several databases from each database'due south inception to May 11, 2020, for studies in both English and Castilian languages, was conducted.²¹ The databases included Ovid MEDLINE(R) and Epub Alee of Print, In-Procedure & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Cardinal Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced librarian, with input from the report's principal investigator. Controlled vocabulary supplemented with keywords was used to search for studies of de-transition and regret in developed patients who underwent gender confirmation surgery. The actual strategy list all search terms used and how they are combined is bachelor in Supplemental Digital Content one. (See Supplemental Digital Content 1, which displays the search strategy. http://links.lww.com/PRSGO/B598.)

Study Pick

Search results were exported from the database into XML format and and so uploaded to Covidence.²² The written report option was performed in a two-stage screening process. The beginning step was conducted by 2 screeners (V.P.B. and Southward.S.B.), who reviewed titles and abstracts and selected those of relevance to the research question. So, the same two screeners reviewed total text of the remaining articles and selected those eligible according to the inclusion and exclusion criteria (Fig. ​ 1). If disagreements were encountered, a third reviewer (O.J.G.) moderated a give-and-take, and a joint decision betwixt the three reviewers was made for a final determination. Inclusion criteria were all the manufactures that included patients aged 13 years or more who underwent GAS and report regret or de-transition rates, and observational or interventional studies in English or Castilian linguistic communication. Exclusion criteria were alphabetic character to the editors, case serial with <ten patients, instance reports correspondences, and animal studies.

PRISMA flow diagram for systematic reviews.

Data Extraction/Synthesis

After selecting the articles, we assessed report characteristics. Nosotros identified year of publication, country in which the report was conducted, population size, and number of transmasculine and transfemenine patients with their respective mean historic period (expressed with SD, range, or interquartile range if included in the study). In addition, we extracted information of the method of information drove (interviews versus questionnaires), number of regrets following GAS, too as the type of surgery, time of follow-up, and de-transition procedures. Nosotros classified the type of regret based on the patient'due south reasons for regret if they were mentioned in the studies. We used the Pfäfflin and Kuiper and Cohen-Kettenis classifications of regret (Tabular array ​ 1).^xx,23

Table one.

Pfäfflin and Kuiper and Cohen-Kettenis Categories of Regret

Pfäfflin, 1993	Minor	Feeling of regret secondary to surgical complications or social problems.
	Major	"Truthful" regret. Feeling of dysphoria secondary to the new appearance, or desires of pursuing a de-transition surgery.
Kuiper and Cohen-Kettenis, 1998	Clear regret	Patients openly express their regret and take role reversal either by undergoing de-transition surgery or returning to their quondam gender role.
	Regret uncertain	Patients don't have office reversal, but freely express their regret by never considering doing GAS or laissez passer through the same preoperative scenario once again. They are truly disappointed with the results of GAS. Also, they don't consider the new gender role so hard and might consider a second GAS.
	Regret	Patients have role reversal only don't express their feelings of regret. Some might country that they are happy about their decision and consider themselves as transgender. Nonetheless, they live every bit their former gender role for applied and social reasons.
	Regret assumed by others	Don't accept role reversal and don't express feelings of regret only have unfavorable social circumstances or psychological disturbances that raise concerns to relatives, clinicians, and others that patient might be regretful (eg, feeling loneliness, suicide attempts).

Quality Cess

To assess the chance of bias within each study, the National Institute of Health (NIH) quality assessment tool was used.²⁴ This tool ranks each article as "good," "off-white," or "poor," and with this, nosotros categorized each commodity into "low risk," "moderate risk," or "loftier risk" of bias, respectively.

Outcomes

Our primary result of involvement was the prevalence of regret of transgender patients who underwent any blazon of GAS. Secondary outcomes of involvement were discriminating the prevalence of regrets past blazon gender transition (transfemenine and transmasculine), and type of surgery.

Data Analysis and Synthesis

The binominal data were analyzed, and the pooled prevalence of regret was estimated using proportion meta-analysis with Stata Software/IC (version 16.1).²⁵ Given the heterogeneity between studies, nosotros conducted a logistic-normal-random-effect model. The study-specific proportions with 95% verbal CIs and overall pooled estimates with 95% Wald CIs with Freeman-Turkey double arcsine transformation were used. The effect size and percentage of weight were presented for each private report.^25,26

To evaluate heterogeneity, I² statistics was used. If P < 0.05 or I^two > 50%, significant heterogeneity was considered. A univariate meta-regression analysis was performed to assess the significance in country of origin, tools of measurement, and quality of the studies.

To appraise publication bias, we used funnel plot graphic and the Egger test. If this test showed us no statistical significance (P > 0.05), nosotros causeless that the publication bias had a low bear on on the results of our metanalysis. To assess the impact of the publication bias on our missing studies, we used the trim-and-make full method.

A sensitivity analysis was conducted to assess the influence of sure characteristics in the magnitude and precision of the overall prevalence of regret. The post-obit characteristics were excluded: <10 participants included, and the presence of a high hazard of bias.

Results

Report Pick

A total of 74 manufactures were identified in the search, and 2 additional records were identified through other sources. After the showtime-step screening process, 39 articles were relevant based on the information provided in their titles and abstracts. Later the 2nd-pace process, a total of 27 articles were included in the systematic review and metanalysis (Fig. ​ i).

Quality Assessment

Based on the NIH quality cess tool, the majority of commodity ranged between "poor" and "fair" categories.²⁴ (Meet Supplemental Digital Content 2, which displays the score of each reviewed study. http://links.lww.com/PRSGO/B599.)

Report Characteristics

In total, the included studies pooled 7928 cases of transgender individuals who underwent whatever blazon of GAS. A total of 2578 (33%) underwent transmasculine procedures, 5136 (67%) underwent transfemenine surgeries, and 1 non-binary patient underwent surgery. In Table ​ ii characteristics of studies are listed. Without discriminating blazon of surgical technique, from all transfemenine surgeries included, 772 (39.iii%) were vaginoplasty, 260 (13.three%) were clitoroplasty, 107 (5.v%) were breast augmentation, 72 (three.vii%) were labioplasty and vulvoplasty, and a small minority were facial feminization surgery, song cord surgery, thyroid cartilage reduction, and oophorectomy surgery. The rest did non specify type of surgery. In regard to transmasculine surgeries, 297 (12.4%) were mastectomies, 61 (2.six%) were phalloplasties, and 51 (2.1%) hysterectomies (Table ​ 3 and ​ four). Overall, follow-up fourth dimension from surgery to the fourth dimension of regret assessment ranged from 0.viii to nine years (Table ​ 2).

Table 2.

Report Characteristics

Authors and Twelvemonth of Publication	Country	Sample Size	Transmasculine	Mean Age (y)	Transfemenine	Mean Age (y)	Mean Follow-up (y)	Cess Tool	Risk of Bias
Blanchard et al, 1989	Canada	111	61	28.v	50	41.4 (He), 29.0 (Ho)	iv.4	Q	H
Bouman, 1988	Netherlands	55	NA	NA	55	NS	2.3	NS	M
Cohen-Kettenis et al, 1997	Netherlands	xix	fourteen	22*	v	22*	2.vi	I	H
De Cuypere et al, 2006	Belgium	62	27	33.iii	35	41.4	Transmasculine = 7.6	I	Yard
							Transfemenine = iv.1
Garcia et al, 2014	London	25	25	34 –RAP without	NA	NA	RAP without = half-dozen.eight	I	H
				39.two – RAP			RAP = two.2
				35.1 – SP			SP = 2.2
Imbimbo et al, 2009	Italia	139	NA	NA	139	31.iv	1–1.6	Q	H
Jiang et al, 2018	USA	80	NA	NA	79 (+ 1 NB)	57.9 – Vulvoplasty	0.7	NS	H
						39.2 – Vaginoplasty†
Johansson et al, 2010	Sweden	32	xiv	38.9	18	46	9	Q/I	Fifty
Krege et al, 2001	Germany	31	NA	NA	31	Me 36.9	0.5	Q	H
Kuiper et al, 1998	Netherlands	1100	300	46.iv*	800	46.four*	NS	Q	H
Lawrence, 2003	USA	232	NA	NA	232	44	3	Q	One thousand
Lobato et al, 2006	Brazil	19	1	31.2*	18	31.2*	2.1	Q/I	One thousand
Nelson et al, 2009	Great britain	17	17	31	NA	NA	0.8	Q	Thousand
Olson-Kennedy et al, 2018	Usa	68	68	eighteen.ix	NA	NA	<ane–5	Q	Yard
Papadopulos et al, 2017	Germany	47	NA	NA	47	38.3	1.6	Q	50
Pfafflin, 1993	Federal republic of germany	295	99	NS	196	NS	Range: 1–29	NS	M
Rehman et al, 1999	U.s.a.	28	NA	NA	28	38.0	NS	Q	L
Smith et al, 2001	Netherlands	20	13	21*	7	21*	ane.iii	I	Thousand
Song et al, 2011	Singapore	19	19	NS	NA	NA	Range: i–10	Q	H
Van de Grift et al, 2018	Netherlands, Belgium, Germany, Norway	132	51	36.3*	81	36.three*	NS	Q	K
Wiepjes et al, 2018	Netherlands	4863	1733	Adults: Me 23	3130	Adults: Me 33	eight.v	Q	M
				Adolescents: Me 26		Adolescents: Me 16
Zavlin et al, 2018	Germany	40	NA	NA	40	38.6	0.9	Q	K
Approximate et al, 2014	Ireland	55	19	32.2‡	36	36.2‡	NS	I	M
Vujovic et al, 2009	Serbia	118	59	25.7	59	25.4	NS	NS	H
Weyers et al, 2009	Belgium	50	NA	NA	50	43.one	6.3	Q	L
Poudrier et al, 2019	Usa	58	58	33	NA	NA	NS	Q	M
Laden et al, 1998	Sweden	213	NS	NS	NS	NS	NS	Medical records and verdicts	M

Table iii.

Studies Differentiating Type of Surgery amidst Transfemenine Patients

Blazon of Surgery	No. Procedures
Chest Augmentation
Smith et al, 2001	vii
Van de Grift et al, 2018	33
Judge et al, 2014	19
Weyers et al, 2009	48
Total	107
Vaginoplasty
Blanchard et al, 1989	50
Bouman, 1988	7
Cohen-Kettenis et al, 1997	5
Imbimbo et al, 2009	139
Jiang et al, 2018	64
Krege et al, 2001	31
Kuiper et al, 1998	8
Lawrence, 2003	232
Papadopulos et al, 2017	47
Rehman et al, 1999	28
Van de Grift et al, 2018	71
Zavlin et al, 2018	40
Weyers et al, 2009	fifty
Full	772
Vulvoplasty
Rehman et al, 1999	28
Jiang et al, 2018	16
Total	44
Others
Lawrence, 2003	Clitoroplasty 232
Rehman et al, 1999	Clitoroplasty + labioplasty 28 + Orchiectomy v
Van de Grift et al, 2018	Thyroid cartilage reduction ix, facial surgeries vii, and vocal cord 3
Wiepjes et al, 2018	Gonadectomy 2868 (adults), 262 (adolescents)
Judge et al, 2014	Facial surgeries 6, laryngeal surgeries 2, GAS not specified xv
Weyers et al, 2009	Vocal cord surgeries 20, cricoid reduction 15

Table 4.

Studies Differentiating the Type of Surgery among Transmasculine Patients

Type of Surgery	No. Procedures
Mastectomy
Blanchard et al, 1989	61
Cohen-Kettenis et al, 1997	14
Kuiper et al, 1998	one
Nelson et al, 2009	17
Olson-Kennedy et al, 2018	68
Smith et al, 2001	13
Van de Grift et al, 2018	49
Judge et al, 2014	16
Poudrier et al, 2019	58
Total	297
Phalloplasty
Cohen-Kettenis et al, 1997	1
Garcia et al, 2014	25
Smith et al, 2001	1
Song et al, 2011	19
Van de Grift et al, 2018	15
Total	61
Hysterectomy
Kuiper et al, 1998	1
Smith et al, 2001	two
Van de Grift et al, 2018	48
Total	51
Others
Cohen-Kettenis et al, 1997	Neoscrotum 2
Kuiper et al, 1998	Oophorectomy 1
Van de Grift et al, 2018	Metoidioplasty 3
Wiepjes et al, 2018	Gonadectomy 1361 (adults), 372 (adolescents)
Gauge et al, 2014	GAS non specified 9

Regrets and De-transition

Almost all studies conducted non-validated questionnaires to assess regret due to the lack of standardized questionnaires available in this topic.^{15, 19–33} Most of the questions evaluating regret used options such as, "yes," "sometimes," "no" or "all the time," "sometimes," "never," or "about certainly," "very likely," "maybe," "rather not," or "definitely not." ^{fourteen, 18, 19, 23, 27–38} Other studies used semi-structured interviews.^{34,37,39–43} However, in both circumstances, some studies provided farther specific information on reasons for regret.^{14,20,23,29,32,36,41,44–46} Of the 7928 patients, 77 expressed regret (12 transmen, 57 transwomen, 8 not specified), understood by those who had "sometimes" or "always" felt it.

Reasons for Regret

The nigh prevalent reason for regret was the difficulty/dissatisfaction/acceptance in life with the new gender role.^{23,29,32,36,44} Other less prevalent reasons were "failure" of surgery to reach their surgical goals in an artful level and psychological level.^29,32,36,47 Based on the reasons presented, we classified the types of regrets according to Pfäfflin'southward types of regret and Kuiper and Cohen-Kettenis classification. According to Pfäfflin'southward types, 28 patients had pocket-sized regret, and 34 patients had major regret.^{xiv,20,23,29,32,36,41,44,45} Based on the Kuiper and Cohen-Kettenis regret classification, 35 patients had clear regret, 26 uncertain regret, ane regret, and none presented with regret assumed by others.²³ In Table ​ 5 and ​ six, the reasons and classifications are shown.

Table 5.

Type of Regret

Studies	No. Regrets	Transmasculine	Transfeminine	Blazon of Regrets based on Pfafflin, 1993		Type of Regrets based on Kuiper and Cohen-Kettenis, 1998				Surgery	De-transition (Y/North)
				Pocket-size	Major	1	2	three	4
Blanchard et al, 1989	iv	—	4	four	—	2	2	—	—	Vaginoplasty	N
Bouman, 1988	1	—	1	—	1	1	—	—	—	Vaginoplasty	NS
De Cuypere et al, 2006	ii	1	1	2	—	—	2	—	—	NS	NS
Imbimbo et al, 2009	8	—	viii	NS	NS	NS	NS	NS	NS	Vaginoplasty	NS
Jiang et al, 2018	ane	—	1	ane	—	—	one	—	—	Vulvoplasty	NS
Kuiper et al, 1998	ten	ane	nine	4	6	six	3	1	—	NS	1 testicles implant removal and underwent breast augmentation
Lawrence, 2003	15	—	xv	13	ii	ii	13	—	—	Vaginoplasty	NS
Olson-Kennedy et al, 2018	one	1	—	NS	NS	NS	NS	NS	NS	Mastectomy	NS
Pfafflin, 1993	3	iii	—	—	3	3	—	—	—	NS (complication urethral-vaginal fistula)	NS
Van de Grift et al, 2018	2	i	1	ii	—	—	2	—	—	Transfemenine = Vaginoplasty Transmasculine = mastectomy and uterus extirpation (hematoma)	NS
Wiepjes et al, 2018	14	three	11	0	xiv	13	1	0	0	Gonadectomy	Y (10)*
Zavlin et al, 2018	i	—	i	NS	NS	NS	NS	NS	NS	Vaginoplasty	NS
Approximate et al, 2014	3	—	3	NS	NS	NS	NS	NS	NS	NS	NS
Weyers et al, 2009	2	—	2	NS	NS	NS	NS	NS	NS	Vaginoplasty	NS
Poudrier et al, 2019	2	two	—	2	—	—	2	—	—	Mastectomy	NS
Laden et al, 1998	viii	NS	NS	—	8	viii	—	—	—	NS	Y

Table 6.

Causes of Regret

Studies	Reasons of Regrets
Blanchard et al, 1989	• one patient was dissatisfied with life as a woman and considered returning to the masculine office
	• 1 patient reported that surgery failed to produce the coherence of mind and the body he wanted
	• 1 patient would non opt for a new surgery as it had not achieved what she wanted
	• 1 patient dressed equally a man but didn't felt as feminine nor masculine
Bouman, 1988	Piece of work and social acceptance
De Cuypere et al, 2006	• Transmasculine = Physiologic period before GAS (delusional disorder-erotomaniac blazon), scored very low in credibility
	• Transfemenine = Emotionally troubled past a break-up with his girlfriend
Imbimbo et al, 2009	NS
Jiang et al, 2018	Didn't want to expect genital electrolysis prior vaginoplasty
Kuiper et al, 1998	• 4 patients mentioned they were not transsexual
	• 1 patient after surgery she realized she did not want to live as a woman. one never wished for the surgery (forced by the partner)
	• 2 patients lost the partner and had social bug
	• 1 patient had no doubts (double function requested past the partner)
Lawrence, 2003	• eight patients felt disappointed with physical or functional outcomes of surgery (lost clitoris sensation)
	• 2 participants reported reversion to living as a man after GAS. There were family and social problems
Olson-Kennedy et al, 2018	NS
Pfafflin, 1993	NS
Van de Grift et al, 2018	• Transmasculine = Body does non meet the feminine platonic
	• Transfemenine = Recurrent abdominal pains, dependence on exogenous hormones
Wiepjes et al, 2018	• five patients had social regret (still as their former role/"ignored by environment" or "the loss of relatives is a large sacrifice")
	• 7 patients had true regret (though that the surgery was the solution)
	• 2 patients felt non-binary
Zavlin et al, 2018	NS
Gauge et al, 2014	NS
Weyers et al, 2009	NS
Poudrier et al, 2019	Aesthetic outcomes
Laden et al, 1998	NS

Prevalence of Regret

The pooled prevalence of regret among the TGNB population afterwards GAS was i% (95% Conviction interval [CI] <one%–2%; I² = 75.1%) (Fig. ​ 2). The prevalence for transmasculine surgeries was <1% (CI <1%–<1%, I² = 28.viii%), and for transfemenine surgeries, information technology was ane% (CI <1%–two%, I² = 75.v%) (Fig. ​ 3). The prevalence of regret later vaginoplasty was of ii% (CI <1%–4%, I² = 41.five%) and that after mastectomy was <one% (CI <one–<1%, I² = 21.viii%) (Fig. ​ 4).

Pooled prevalence of regret among TGNB individuals afterward gender confirmation surgery. Heterogeneity χtwo = 104.31 (d.f. = 26), P = 0.00, I² [variation in effect size (ES) owing to heterogeneity] = 75.08%, Gauge of betwixt-study variance Ʈ² = 0.02, Test of ES = 0, z = 4.22, P = 0.00.

Subgroup analysis of the prevalence of regret among TGNB individuals after gender confirmation surgery based on gender. ES, effect size.

Subgroup analysis of the prevalence of regret among TGNB individuals after gender confirmation surgery based on the type of surgery. ES, upshot size.

Meta-regression and Publication Bias

No covariates analyzed afflicted the pooled endpoint in this metanalysis. The Funnel Plot shows asymmetry between studies (Fig. ​ 5). The Egger test resulted in a P value of 0.0271, which suggests statistical significance for publication bias. The Trim & Fill up method imputed fourteen approximated studies, with limited bear on of the adjusted results. The change in effect size was from 0.010 to 0.005 with no statistical significance (Fig. ​ 6).

Funnel plot of the Trim & Fill method.

Sensitivity Analysis

When excluding studies with sample sizes less than 10 and high-hazard biased studies, the pooled prevalence was similar one% (CI <1%–3%) compared with the pooled prevalence when those studies were included 1% (CI <1%–ii%).

Word

The prevalence of regret in the TGNB population after GAS was of 1% (CI <1%–2%). The prevalence of regret for transfemenine surgeries was 1% (CI <i%–2%), and the prevalence for transmasculine surgeries was <1% (CI <one%–<1%). Traditionally, the landmark reference of regret prevalence after GAS has been based on the study by Pfäfflin in 1993, who reported a regret rate of 1%–1.5%. In this study, the author estimated the regret prevalence by analyzing two sources: studies from the previous 30 years in the medical literature and the writer's own clinical practise.^twenty In the former, the author compiled a full of approximately k–1600 transfemenine, and 400–550 transmasculine. In the latter, the writer included a total of 196 transfemenine, and 99 transmasculine patients.²⁰ In 1998, Kuiper et al followed 1100 transgender subjects that underwent GAS using social media and snowball sampling.²³ Ten experienced regret (9 transmasculine and 1 transfemenine). The overall prevalence of regret subsequently GAS in this written report was of 0.nine%, and 3% for transmasculine and <0.12% for transfemenine.²³ Because these studies were conducted several years agone and were express to specific countries, these estimations may not be generalizable to the entire TGNB population. However, a clear trend towards low prevalences of regret can be appreciated.

The causes and types of regrets reported in the studies are specified and shown in Table ​ 5 and ​ 6. Overall, the near common reason for regret was psychosocial circumstances, particularly due to difficulties generated past return to club with the new gender in both social and family enviroments.^{23,29,32,33,36,44} In fact, some patients opted to contrary their gender role to achieve social acceptance, receive better salaries, and preserve relatives and friends relationships. These findings are in line with other studies. Laden et al performed a logistic regression analysis to assess potential risk factors for regret in this population.⁴⁶ They found that the ii most of import run a risk factors predicting regret were "poor back up from the family" and "belonging to the non-core group of transsexuals."⁴⁶ In addition, a study in Italy hypothesized that the loftier percentage of regret was attributed to social experience when they return after the surgery.³³

Another factor associated with regret (although less prevalent) was poor surgical outcomes.^xx,23,³⁶ Loss of clitoral awareness and postoperative chronic abdominal pain were the nearly mutual reported factors associated with surgical outcomes.^14,36 In addition, artful outcomes played an important office in regret. Two studies mentioned concerns with aesthetic outcomes.^14,47 Only one of them quoted a patient inconformity: "body doesn't meet the feminine ideal."¹⁴ Interestingly, Lawrence et al demonstrated in their study that concrete results of surgery are by far the well-nigh influential in determining satisfaction or regret afterwards GAS than whatsoever preoperative factor.³⁶ Concordantly, previous studies have shown absenteeism of regret if sensation in clitoris and vaginal is achieved and if satisfaction with vaginal width is present.³⁶

Other factors associated to regret were identified. Blanchard et al in 1989 noted a strong positive correlation between heterosexual preference and postoperative regret.³² All patients in this report who experienced regret were heterosexual transmen.³² On the contrary, Lawrence et al in 2003 did non notice such correlation and attributed their findings to the increase in social tolerance in North American and Western European societies.³⁶ Bodlund et al found that clinically evident personality disorder was a negative prognostic factor for regret in patients undergoing GAS.⁴⁸ On the other manus, Blanchard et al did not find a correlation among patient's education, historic period at surgery, and gender assigned at birth.³²

In the present review, well-nigh half of the patients experienced major regret (based on Pfäfflin classification), meaning that they underwent or desire de-transition surgery, that will never laissez passer through the aforementioned process again, and/or experience increase of gender dysphoria from the new gender. One study found that 10 of 14 patients with regret underwent de-transition surgeries (8 mastectomies, 2 vaginectomies, two phalloplasties, ii testicular implants removal, and 1 chest augmentation) for reasons of social regret, true regret or feeling non-binary.²³ On the other hand, based on the Kuiper and Cohen Kettenis' classification, half of the patients in this review had clear regret and uncertain regret. This means that they freely expressed their regret toward the procedure, but some had office reversal to the former gender and others did not. Interestingly, Pfäfflin concluded that from a clinical standpoint, trangender patients suffered from many forms of minor regrets later GAS, all of which take a temporary course.²⁰ This is an important consideration meaning that the actual true regret rate volition always remain uncertain, as temporarity and types of regret tin can bring a huge challenge for assessment.

Regret after GAS may effect from the ongoing discrimination that afflicts the TGNB population, affecting their freely expression of gender identity and, consequently feeling regretful from having had surgery.¹⁵ Poor social and group support, late-onset gender transition, poor sexual performance, and mental wellness problems are factors associated with regret.^fifteen Hence, assessing all these potential factors preoperatively and decision-making them if possible could reduce regret rates even more and increase postoperative patient satisfaction.

Regarding transfemenine surgery, vaginoplasty was the most prevalent.^{14, 19, 23, xxx–33, 35, 36, 44, 45}Interesintgly, regret rates were college in vaginoplasties.^{xiv,36, 44} In this report, we estimated that the overall prevalence of regret after vaginoplasty was 2% (from 11 studies reviewed). This effect is slightly higher than a metanalysis of 9 studies from 2017 that reported a prevalence of ane%.¹³ Moreover, vaginoplasty has shown to increase the quality of life in these patients.¹³ Mastectomy was the most prevalent transmasculine surgery. Also, information technology showed a very low prevalence of regret after mastectomy (<one%). Olson-Kennedy et al demonstrated that breast surgery decreases chest dysphoria in both minors and young adults, which might be the major reason backside our findings.³⁸

In the electric current written report, nosotros identified a total of 7928 cases from 14 different countries. To the best of our cognition, this is the largest try to compile the data on regret rates in this population. Withal, limitations such as significant heterogeneity among studies and among instruments used to assess regret rates, and moderate-to-loftier risk of bias in some studies represent a big barrier for generalization of the results of this study. The lack of validated questionnaires to evaluate regret in this population is a significant limiting cistron. In improver, bias can occur considering patients might restrain from expressing regrets due to fear of existence judged by the interviewer. Moreover, the temporarity of the feeling of regret in some patients and the variable definition of regret may underestimate the real prevalence of "true" regret.

Based on this meta-assay, the prevalence of regret is 1%. Nosotros believe this reflects and corroborates the increased in accuracy of patient choice criteria for GAS. Efforts should be directed toward the individualization of the patient based on their goals and identification of risk factors for regrets. Surgeons should continue to rigorously follow the current Standard of Care guidelines of the World Professional Association for Transgender Health (WATH).⁴⁹

CONCLUSIONS

Our study has shown a very low per centum of regret in TGNB population later on GAS. We consider that this is a reflection on the improvements in the choice criteria for surgery. However, further studies should be conducted to assess types of regret besides as clan with different types of surgical procedure.

Acknowledgments

All the authors have completed the ICMJE uniform disclosure class. The authors are accountable for all aspects of the work in ensuring that questions related to the accurateness or integrity of any part of the work are appropriately investigated and resolved.

Supplementary Material

Footnotes

Published online 19 March 2021

Disclosure: The authors accept no financial interest to declare in relation to the content of this commodity.

Related Digital Media are available in the full-text version of the commodity on www.PRSGlobalOpen.com.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099405/

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