Recognizing the Importance of Chest Surgery for Transmasculine Youth

Transmasculine youth and adults often report that masculinizing chest surgery (MCS) is an important step toward gender affirmation. In a sample of 133 transmasculine youth attending a pediatric gender clinic, 82% reported being dissatisfied with breasts and 93% reported a desire for MCS.¹  However, most research in this area has been focused on adults. In this issue of Pediatrics, Mehringer et al²  elicit transmasculine youth’s descriptions of their experiences with chest dysphoria and MCS. Youth described improvements in mental health and quality of life after MCS. However, despite standards of care within transgender health considering MCS medically necessary,³  Mehringer et al²  identify important systemic barriers that often prevent transmasculine youth from accessing care. Although barriers to gender-affirming care remain widespread for transgender adults,⁴  barriers are particularly pronounced for youth. As youth in this study describe, lack of access to MCS prolongs unnecessary distress and difficulties in functioning.

As Mehringer et al²  note, many youth have insurance that will not cover MCS and cannot afford to pay out of pocket. Insurance companies commonly use coverage guidelines that are not consistent with the field’s standards of care. Although standards of care do not recommend a specific age for considering MCS, many insurance companies will deny medical coverage for youth aged <18. Historically, some providers have recommended transmasculine individuals receive testosterone therapy for 1 year before surgery. Although this recommendation is no longer considered best practice, it is still a requirement for covering MCS under some insurance plans.⁵  These insurance coverage difficulties and high out-of-pocket costs are also common with puberty suppression and hormone therapy for transgender youth.⁶ 

Barriers to care also exist on social, institutional, and cultural levels. Many transgender youth lack supportive parents, which often prevents them from accessing gender-affirming medical care altogether.⁷  Within the health care system, lack of available training needed to obtain the skill and techniques necessary to provide MCS (eg, incision, nipple placement, nipple sizing) contributes to a scarcity of providers. Although not successful to date, legislation to limit access to all gender-affirming medical care for youth aged <18 has been proposed in >12 states.²  Together, these barriers are manifestations of larger social stigma and transphobia that must be addressed. Transmasculine youth of color and youth from lower socioeconomic backgrounds are disproportionately impacted. In addition to structural practices that decrease access and quality of care for many people of color, Black youth tend to start breast development earlier than white youth,⁸  meaning they may experience more breast growth before obtaining MCS.

In addition to advocating for youth’s access to MCS on a systemic level, providers can collaboratively assist youth in navigating insurance, preparing for surgery, and developing coping skills to manage chest dysphoria. This requires attunement to the diverse experiences transmasculine people have in relation to MCS. Although many transmasculine youth who are accessing hormone therapy desire MCS, not all do. Some youth desire MCS but not hormone therapy, and individuals who identify with other genders, such as agender and nonbinary, may also desire MCS.⁹  Goals and expectations surrounding outcomes vary both within and across these groups. Additionally, 2 common surgical approaches, double mastectomy and periareolar surgery, use different techniques and may be associated with unique experiences (eg, aftercare and recovery process and patient satisfaction).

Attunement to the diversity and nuance of transgender youth’s experiences of their physical gender embodiment is also critical to providing gender-affirming care.¹⁰  Youth in the study conducted by Mehringer et al²  described internal (eg, distress, hopelessness) as well as situational (eg, limiting activities) and interpersonal (eg, avoiding interactions) manifestations of chest dysphoria. In addition to access to care, structural factors such as antidiscrimination policies and ability to legally change one’s name and gender marker may also impact dysphoria.¹¹  Although often obscured by an overfocus on dysphoria, authors within the field highlight how experiences of gender euphoria and resiliency are equally as important.¹²  Providers should keep in mind that, although many transmasculine youth experience chest dysphoria, this is only one part of their overall experience. More holistic conceptualizations of physical embodiment are needed that better reflect the full spectrum of lived experiences.

When referring to transgender people, writers should be cautious of using shorthand such as “pre- and post-MCS.” For a period, the terms “pre- and post-op transsexual” were commonly used. This convention was problematic because it violated privacy and conveyed a message that surgery defined the transgender person. Additionally, the specific terms used by Mehringer et al²  and this commentary may not reflect those used by individual youth. In general, language is actively evolving along with best practices in gender-affirming care. Maintaining cultural competency requires humility and regular engagement in continuing education that centers the experiences of transgender people from their own perspectives.