An act of desperation: self-attempted gender-affirming mastectomy

Gender-affirming surgery utilises surgical intervention to affirm a person’s identity. In Aotearoa New Zealand, there is an overwhelming unmet need for masculinising chest reconstruction for transgender men. Transgender people, who identify differently to the sex assigned to them at birth, can have significant distress known as gender dysphoria. There are multiple avenues of gender affirmation; however, gender-affirming surgery remains the most challenging to access.¹

Case report

Patient Z, an 18-year-old female-to-male transgender patient, presented to the emergency department after attempting a partial left mastectomy at home. He had a background of gender dysphoria on testosterone treatment and was awaiting gender-affirmation surgery. However, due to the long wait times of referral in the public healthcare system, an inability to afford a private consultation and the significant psychological stress of having breasts at an upcoming pool party he planned to complete a bilateral self-mastectomy at home. He had demonstrated premeditation by watching a “how to” video on YouTube, preparing appropriate equipment, marking the incision and considering analgesia and haemostasis. He sought medical attention several hours through his self-attempted left mastectomy due to concerns of damaging a nerve. He was reviewed by the acute mental health team and was deemed to have capacity to consent, with no active mood disorder, psychosis or suicidality. After discussing the risks, including irreversibility, poor cosmetic outcome/asymmetry and loss of both nipples, he proceeded to have a completion left mastectomy and symmetrising right mastectomy. The operation was uncomplicated and the patient was discharged home day 1 post-operatively. At clinic 4 weeks post-operatively, his bilateral mastectomy scars had healed well and he reported improvement in self-esteem and self-confidence and his ability to complete school work, and was looking forward to enrolling at university.

View Figure 1–2.

Discussion

Gender dysphoria causes significant distress for transgender people.² It is well documented that transgender people experience higher levels of discrimination, bullying and violence compared to the general public.¹ Additionally, a study reviewed patients prior to gender-affirming surgery and identified a significant proportion of patients with undiagnosed anxiety and depression.³ While not all transgender people want gender-affirmation surgery, individuals that do should be able to access this service and express their authentic gender.

In Aotearoa New Zealand, limited access to gender-affirming surgery due to resources is an increasing issue. Currently, there is only one surgeon performing gender-affirmation operations.⁴ Additionally, the publicly funded gender-affirming surgery eligibility assessment is a lengthy process that requires a multidisciplinary approach.² Regardless, many patients who meet the eligibility criteria are declined due to the lack of resource and financial capacity, or are wait-listed on a decade-long wait list.^5,6 A recent report estimated that only 13% have had access to this service via the public system.¹ This is a significant under-service and likely an under-representation of the unmet need due to poor documentation and lack of information of how to access services. 

Cost is another barrier to this service, with insurance companies excluding gender-affirmation surgery, resulting in patients needing to either self-fund or fundraise.⁷ In extreme cases, transgender men may even perform a self-mastectomy. Previous cases of self-amputation of breast tissue have been described in literature. However, these patients demonstrated an active psychiatric disorder and acute triggers that likely initiated self-mutilation.^8,9 Patient Z did not have a psychiatric disorder and had been considering gender-affirming surgery for years. A lack of access to gender-affirming surgery led to this act of desperation.

Transgender people often need to self-advocate for care in the public health system, but with increasing demand and associated psychological and possible physical harm it is crucial for public services to be more accessible to an under-served population.