A new study has found that the level of regret reported by transgender individuals following gender-affirming surgery is less than 1%, which is significantly lower than the regret associated with having children, getting a tattoo, or undergoing plastic surgery.
Regret is negative emotion characterized by feelings of disappointment, sadness, or remorse over a past action or choice, often accompanied by a desire to make a different choice. In the medical setting, regret can follow a decision to pursue treatment, and, in recent years, a lot has been made of the regret that transgender individuals feel after undergoing gender-affirming surgery (GAS).
New research by the University of Wisconsin’s School of Medicine and Public Health has examined rates of regret among patients who’ve had GAS as compared with regret by those who’ve had plastic and other surgeries and those who’ve made other major life decisions.
“Importantly, this systematic review does not seek to equate the decision to undergo gender affirming surgery to other elective surgeries or decisions, but instead aims to provide a framework to understand feelings of regret through a broader life experience,” said the researchers.
The purpose of GAS is to align a person’s physical characteristics with their gender identity. The types of operations that fall under GAS include facial surgery, “top” or chest surgery, and “bottom” or genital reconfiguration surgery. Undertaking this type of surgery is a choice that some individuals make as part of their gender affirmation journey, alongside hormone therapy and transitioning socially. However, some politicians, activists, and pundits argue that many transgender people who undergo this type of surgery come to regret it. It’s often used as a basis for restricting access to gender-affirming care. But is the argument a sound one?
The majority of the studies included in the researchers’ review focused on patients’ regret after plastic surgeries, including breast reconstruction (recreating the breasts after surgical removal), breast removal surgery (mastectomy), breast augmentation (breast implants), and body contouring (removal and tightening of excess skin). Regret was either reported as a percentage of total respondents, a numerical score on the Decision Regret Scale, or assessed qualitatively. The percentage of patients reporting regret following breast reconstruction ranged from zero to 47.1%, 5.1% to 9.1% after breast augmentation, and 10.82% to 33.3% after body contouring.
The researchers also examined previous research on regret following elective surgical procedures. A 2016 study of 837 women aged 25 to 45 who underwent tubal sterilization (a.k.a. tubal ligation, a surgical procedure that prevents pregnancy by cutting or blocking the fallopian tubes) found that 28% reported regret. In a 2020 UK study that explored rates of regret in 106 men following radical prostatectomy (removal of the entire prostate and surrounding tissue to treat prostate cancer), 30% reported “high regret” after surgery. For these men, regret was associated with lower sexual function scores.
The researchers also looked at regret following non-surgical major life decisions. When, in 2013, the Gallup Organization asked Americans over 45 with children how many children they’d like to have if they could “do it over again,” 7% of respondents chose "no children." Regret after getting tattooed was 16.2% according to a 2015 study conducted in New Orleans.
And what of regret following GAS? According to a retrospective Dutch study that followed transwomen and transmen from 1972 to 2015, 0.6% and 0.3%, respectively, reported feeling regret after GAS. Those behind that study divided the reasons for participants’ regret into three categories: true regret, or regretting having the surgery; social regret, which involved loss of contact with loved ones or being fired from a job because of the surgery; the third category included participants who reported feeling non-binary and no longer satisfied with their surgical result.
A systematic review and meta-analysis in 2021 assessed 27 studies, totaling 7,928 transgender individuals who’d undergone GAS, and found that 1% expressed regret. The most common reason for post-op regret was “difficulty/dissatisfaction in life with the new gender role.” Another common reason was the failure of surgery to achieve an individual’s aesthetic goals. A 2023 study by the University of Michigan found that after a gender-affirming mastectomy, 139 participants reported a Decision Regret Scale score of zero more than three years after the surgery.
“This systematic review highlights that regret following gender-affirming surgery is remarkably low, below 1%, compared to various elective surgeries and important life decisions,” said the researchers. “The findings challenge the restrictive narrative based on regret as a reason to limit access to gender-affirming services.”
The researchers said that the low rate of regret after GAS might be attributable, at least partially, to the stringent prerequisites that patients have to complete before being scheduled for surgery, which include the support of a mental health professional.
The researchers recognize that regret reported after any surgery is likely to be underestimated as patients don’t seek additional care, are lost to follow-up, don’t share their dissatisfaction with their surgeons, or go elsewhere for additional care. An additional consideration is that for individuals in the transgender community, any expression of regret might be weaponized against that community.
Discussions between patients and their surgeons regarding regret should be part of the preoperative process for all patients, the researchers said.
“Postoperative regret should be included in all discussions with patients in the informed consent process, not just in gender affirmation surgery,” they said. “The multifactorial nature of regret inclusive of gender identity, social and sexual relationships, goals and expectations of the surgery, and potential complications should be embraced as part of the decision-making process so patients can make the best decision for themselves.”
The study was published in The American Journal of Surgery.
