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


Study Selection

A total of 74 articles were identified in the search, and 2 additional records were identified through other sources. After the first-step screening process, 39 articles were relevant based on the information provided in their titles and abstracts. After the second-step process, a total of 27 articles were included in the systematic review and metanalysis (Figure 1).

Quality Assessment

Based on the NIH quality assessment tool, the majority of article ranged between "poor" and "fair" categories.[24] (See Supplemental Digital Content 2, which displays the score of each reviewed study.

Study Characteristics

In total, the included studies pooled 7928 cases of transgender individuals who underwent any type of GAS. A total of 2578 (33%) underwent transmasculine procedures, 5136 (67%) underwent transfemenine surgeries, and 1 non-binary patient underwent surgery. In Table 2 characteristics of studies are listed. Without discriminating type of surgical technique, from all transfemenine surgeries included, 772 (39.3%) were vaginoplasty, 260 (13.3%) were clitoroplasty, 107 (5.5%) were breast augmentation, 72 (3.7%) were labioplasty and vulvoplasty, and a small minority were facial feminization surgery, vocal cord surgery, thyroid cartilage reduction, and oophorectomy surgery. The rest did not specify type of surgery. In regard to transmasculine surgeries, 297 (12.4%) were mastectomies, 61 (2.6%) were phalloplasties, and 51 (2.1%) hysterectomies (Table 3 and Table 4). Overall, follow-up time from surgery to the time of regret assessment ranged from 0.8 to 9 years (Table 2).

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 "most certainly," "very likely," "maybe," "rather not," or "definitely not." [14,18,19,23,27–38] Other studies used semi-structured interviews.[34,37,39–43] However, in both circumstances, some studies provided further 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 most 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 achieve their surgical goals in an aesthetic level and psychological level.[29,32,36,47] Based on the reasons presented, we classified the types of regrets according to Pfäfflin's types of regret and Kuiper and Cohen-Kettenis classification. According to Pfäfflin's types, 28 patients had minor regret, and 34 patients had major regret.[14,20,23,29,32,36,41,44,45] Based on the Kuiper and Cohen-Kettenis regret classification, 35 patients had clear regret, 26 uncertain regret, 1 regret, and none presented with regret assumed by others.[23] In Table 5 and Table 6, the reasons and classifications are shown.

Prevalence of Regret

The pooled prevalence of regret among the TGNB population after GAS was 1% (95% Confidence interval [CI] <1%–2%; I2 = 75.1%) (Figure 2). The prevalence for transmasculine surgeries was <1% (CI <1%–<1%, I2 = 28.8%), and for transfemenine surgeries, it was 1% (CI <1%–2%, I2 = 75.5%) (Figure 3). The prevalence of regret after vaginoplasty was of 2% (CI <1%–4%, I2 = 41.5%) and that after mastectomy was <1% (CI <1–<1%, I2 = 21.8%) (Figure 4).

Figure 2.

Pooled prevalence of regret among TGNB individuals after gender confirmation surgery. Heterogeneity χ2 = 104.31 (d.f. = 26), P = 0.00, I2 [variation in effect size (ES) attributable to heterogeneity] = 75.08%, Estimate of between-study variance Ʈ2 = 0.02, Test of ES = 0, z = 4.22, P = 0.00.

Figure 3.

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

Figure 4.

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

Meta-regression and Publication Bias

No covariates analyzed affected the pooled endpoint in this metanalysis. The Funnel Plot shows asymmetry between studies (Figure 5). The Egger test resulted in a P value of 0.0271, which suggests statistical significance for publication bias. The Trim & Fill method imputed 14 approximated studies, with limited impact of the adjusted results. The change in effect size was from 0.010 to 0.005 with no statistical significance (Figure 6).

Figure 5.

Funnel plot.

Figure 6.

Funnel plot of the Trim & Fill method.

Sensitivity Analysis

When excluding studies with sample sizes less than 10 and high-risk biased studies, the pooled prevalence was similar 1% (CI <1%–3%) compared with the pooled prevalence when those studies were included 1% (CI <1%–2%).