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


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 <1%–2%), and the prevalence for transmasculine surgeries was <1% (CI <1%–<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 author's own clinical practice.[20] In the former, the author compiled a total of approximately 1000–1600 transfemenine, and 400–550 transmasculine. In the latter, the author 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 after GAS in this study was of 0.9%, and 3% for transmasculine and <0.12% for transfemenine.[23] Because these studies were conducted several years ago and were limited 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 Table 6. Overall, the most common reason for regret was psychosocial circumstances, particularly due to difficulties generated by return to society with the new gender in both social and family enviroments.[23,29,32,33,36,44] In fact, some patients opted to reverse 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 two most important risk factors predicting regret were "poor support from the family" and "belonging to the non-core group of transsexuals."[46] In addition, a study in Italy hypothesized that the high 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.[20,23,36] Loss of clitoral sensation and postoperative chronic abdominal pain were the most common reported factors associated with surgical outcomes.[14,36] In addition, aesthetic outcomes played an important role 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 physical results of surgery are by far the most influential in determining satisfaction or regret after GAS than any preoperative factor.[36] Concordantly, previous studies have shown absence 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 study who experienced regret were heterosexual transmen.[32] On the contrary, Lawrence et al in 2003 did not find 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 hand, Blanchard et al did not find a correlation among patient's education, age at surgery, and gender assigned at birth.[32]

In the present review, nearly half of the patients experienced major regret (based on Pfäfflin classification), meaning that they underwent or desire de-transition surgery, that will never pass through the same 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, 2 phalloplasties, 2 testicular implants removal, and 1 breast 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 role 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 after GAS, all of which have a temporary course.[20] This is an important consideration meaning that the actual true regret rate will always remain uncertain, as temporarity and types of regret can bring a huge challenge for assessment.

Regret after GAS may result 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 functioning, and mental health problems are factors associated with regret.[15] Hence, assessing all these potential factors preoperatively and controlling them if possible could reduce regret rates even more and increase postoperative patient satisfaction.

Regarding transfemenine surgery, vaginoplasty was the most prevalent.[14,19,23,30–33,35,36,44,45] Interesintgly, regret rates were higher in vaginoplasties.[14,36,44] In this study, we estimated that the overall prevalence of regret after vaginoplasty was 2% (from 11 studies reviewed). This result is slightly higher than a metanalysis of 9 studies from 2017 that reported a prevalence of 1%.[13] Moreover, vaginoplasty has shown to increase the quality of life in these patients.[13] Mastectomy was the most prevalent transmasculine surgery. Also, it showed a very low prevalence of regret after mastectomy (<1%). Olson-Kennedy et al demonstrated that chest surgery decreases chest dysphoria in both minors and young adults, which might be the major reason behind our findings.[38]

In the current study, we identified a total of 7928 cases from 14 different countries. To the best of our knowledge, this is the largest attempt to compile the information on regret rates in this population. However, limitations such as significant heterogeneity among studies and among instruments used to assess regret rates, and moderate-to-high 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 factor. In addition, bias can occur because patients might restrain from expressing regrets due to fear of being 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-analysis, the prevalence of regret is 1%. We believe this reflects and corroborates the increased in accuracy of patient selection 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]