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 MD, PhD, MS; Pedro Ciudad, MD, PhD; Esther A. Kim, MD; Howard N. Langstein, MD; Oscar J. Manrique MD, FACS


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

In This Article

Abstract and Introduction


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 physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study 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-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

Results: A total 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 <1%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin's 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.


Discordance or misalignment between gender identity and sex assigned at birth can translate into disproportionate discomfort, configuring the definition of gender dysphoria.[1–3] This population has increased risk of psychiatric conditions, including depression, substance abuse disorders, self-injury, and suicide, compared with cis-gender individuals.[4,5] Approximately 0.6% of adults in the United States identify themselves as transgenders.[6] Despite advocacy to promote and increase awareness of the human rights of transgender and gender non-binary (TGNB) individuals, discrimination continue to afflict the daily life of these individuals.[4,7]

Gender-affirmation care plays an important role 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 will help decrease psychological distress.[5,10] These interventions should be addressed by a multidisciplinary team, including psychiatrists, psychologists, endocrinologists, physical therapists, and surgeons.[1,9] The number of GAS has consistently increased during the last years. In the United States, from 2017 to 2018, the number of GAS increased to 15.3%.[8,11,12]

Significant improvement in the quality of life, body image/satisfaction, and overall psychiatric functioning in patients who underwent GAS has been well documented.[5,13–19] 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 an important burden of physical, social, and mental distress, which raises concerns about the appropriateness and effectiveness of these procedures in selected patients. Special attention should be 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 last estimation by Pfafflin in 1993, due to improvements in standard of care, patient selection, surgical techniques, and gender confirmation care. Therefore, the aim of this study was to evaluate the prevalence of regret and assess associated factors in TGNB patients 13-years-old or older who underwent GAS.[20]