When Sinead Watson had a double mastectomy in June 2017 at the age of 26, she was initially ‘quite euphoric.’ Although born female, she had been taking testosterone for two years and was using the name Sean. The mastectomy, or ‘top surgery’, was the last step on her transition.
‘I was so glad that I’d finally got it done – no more binders, no more being paranoid that I was a man with boobs – so I did feel really good about it,’ she says. After the surgery, however, she discovered she had no sensation at all in her chest area, something that continues to this day.
‘I realised after about five months my depression and self-hatred was still present, and that the surgery didn’t ‘cure’ me like I thought,’ she says. ‘The complete lack of sensation in my chest is unpleasant, and I realised in 2018 I regretted not only the surgery – I regretted transition as a whole because I still hated my body.’
Top surgery is on the rise among young women feeling unhappy with their female body, and social media sites such as Instagram and TikTok are awash with pictures of young women showing off their newly flat chest and scars – on Instagram, the hashtag #topsurgery has 262,735 posts. Even the computer game The Sims allows users to create characters with top surgery scars. Freedom of Information figures show that, in 2022, the Wales Gender Service made 172 referrals for top surgery.
Top surgery is on the rise among young women feeling unhappy with their female body
Some of the women who opt for double mastectomy as part of a gender reassignment process are very young: in the past six years, 51 teenagers aged 16 and 17 were referred from Scotland to hospitals in England to undergo further assessment for ‘specialist chest reconstruction’. In the US, top surgery is even bigger business, with girls as young as 13 able to have the operation.
While NHS England does not collate the number of top surgeries it carries out, many are performed privately, with numerous plastic surgeons advertising their services online. One such surgeon, Philip Rubin, told the Mail on Sunday last year that he now carries out 20 double mastectomies a month, up from one or two 10 years ago. Some young women choose to use crowdfunding platforms to raise the money to pay for the surgery, which typically costs about £8,000 to £10,000. A search on ‘top surgery UK’ on the GoFundMe platform brings up 1,145 results (without the UK search term, there are 45,758 results – this is an international phenomenon).
Rubin told the Mail that only one of his patients had regretted the surgery. Yet a growing number of women, like Watson, believe their top surgery was a mistake. A popular Reddit forum dedicated to de-transitioners (people who reverse their trans identity) has 44,000 members, though this includes people outside the UK. Some, like Watson, are speaking out about how they feel harmed by the surgery. Keira Bell, a de-transitioner who took a judicial review against the Tavistock Gender Identity Development Service (GIDS), the only NHS clinic in England for under-18s experiencing gender dysphoria, feels she was not properly advised before her surgery. Hannah Barnes’s book on GIDS, Time to Think, published in February, discusses the moving story of Harriet, a de-transitioner who regrets her top surgery and hormones and says that none of the possible reasons for her gender dysphoria, such as her autism and same-sex attraction, were properly explored by clinicians.
To anyone coming to this new, the trend seems extraordinary. So how did we get here? We know that more and more young people feel themselves to be trans or, the latest identity, non-binary. In the year to 2022, there were more than 3,500 referrals to GIDS a year, the majority of whom were girls. The clinic frequently put children on a medical pathway that started with puberty blockers and led to surgery. (GIDS also has a lengthy waiting list: rather than wait, some teenage girls turn to private doctors in a bid to get testosterone prescribed, often with minimal consultation.)
To anyone coming to this new, the trend seems extraordinary
Dr Az Hakeem, a consultant psychiatrist in private practice who provided exploratory therapy for people with gender dysphoria for 22 years, believes that trans and non-binary identities now form a fashionable subculture, magnified by social media sites such as Instagram and TikTok. Hakeem has found that, for many young women, identifying as a trans male is more palatable than coming out as lesbian:
‘When I ask these gender dysphoric girls who fancy girls whether they know any lesbians, they don’t, and any famous lesbians, they don’t. When you ask them about whether they know any trans men, they know loads of social influencers. Who wants to be a boring old lesbian when we can be this glamorous, muscular, hairy trans male?’
GIDS’s approach to patients with gender dysphoria has been that if a child or adult says they are trans, then the counsellor’s job is to endorse that, not to question it – something that horrifies Hakeem, who worked at the clinic in the early 2000s:
‘The word ‘affirmation’ sounds very positive, but what you’re doing is colluding with a false conclusion that a child’s come up with, that their body is wrong.’
Hakeem’s efforts to challenge the clinic’s orthodoxy were rebuffed: the prevailing view at GIDS, he says, was that homosexuality was ‘pathological’ and a heterosexual trans child was a better outcome than a gay one.
When a GIDS patient reaches 17 – the age at which they become eligible for referral for top surgery – they are typically transferred to one of seven adult clinics for gender dysphoria in England. Adults can also self-refer to these clinics. A referral for top surgery requires them to have displayed persistent, well-documented gender dysphoria. Patients need a letter of referral from only one professional (other types of gender reassignment surgery require letters from two professionals). Some NHS clinics also require the patient to have lived as the opposite sex for a year, and to have been taking hormones for six months before being referred for surgery.
The hospital didn’t warn her about the possible loss of sensation or inability to breastfeed, she says
Hakeem worries that young women opting for double mastectomy have unrealistic expectations:
‘They think they’re going to be men. But they’re not – they’re going to be women with no breasts. They’re never going to have a penis. And lots of them then get shocked when other people don’t really experience them as men. Because they’re being led into this false promise that they can be men and they can’t.’
Watson self-referred to the Sandyford adult clinic in 2015 when she was 24, at which point she had been wearing male clothing for more than a year. The previous year, she had been hospitalised in a psychiatric unit after a suicide attempt, but other than that had received no counselling. There was no attempt, she says, to explore her feelings of discomfort with her body:
‘They never asked me why I hated my breasts. If you had a young woman sitting in front of you saying she hated her breasts, wouldn’t you have questions?’
The hatred was the result, she says now, of having experienced sexual harassment from multiple men from the age of 14. By the time she went to the Sandyford, she was ‘depressed, self-harming, dealing with intrusive thoughts and developing a drinking problem.’
The testosterone hadn’t helped. ‘The masculinising changes that come with testosterone made me even more upset with my breasts,’ she says. ‘I wasn’t a cross-dressing woman any more, I was a woman with a beard and a manly voice.’ The hospital didn’t warn her about the possible loss of sensation or inability to breastfeed, she says.
Watson’s feelings of distress about her female body are characteristic of girls and young women who opt for top surgery. Yet, as Karleen Gribble, adjunct associate professor in the school of nursing and midwifery at Western Sydney university, says, it’s ‘incredibly common’ for teenage girls to dislike their breasts. Sue Evans, a former clinical nurse specialist at GIDS who blew the whistle on the clinic’s practice of referring children for puberty blockers without fully exploring the reasons for their distress, points out that adolescence ‘is a period of huge development, huge change and turmoil.’ With anorexic patients, she says, counsellors explore their feelings of hatred for their bodies. The same exploration model should be used with gender dysphoric patients, she argues.
What happens to those who, like Watson, regret their decision to have top surgery? Evans says there are very few places to turn:
‘When you realise the trans medicalisation hasn’t worked, when you realise that it wasn’t about the body, it’s about the mind, the support is non-existent, virtually, and then you get nothing. So the people who have been through a transition are in the black hole of NHS care where nobody is very interested in them.’
When Watson reached a point, in 2018, where she felt depressed and suicidal, she was referred by her GP to a counsellor who was unsympathetic: ‘They told me, ‘Why don’t you identify as non-binary? This doesn’t have to be the horrible tragedy you’re making it out to be.’ I never went back after that.’
The decision to remove both breasts can cause acute psychological distress once regret sets in. Gribble has this month co-authored a paper about a de-transitioned woman, now in her 30s, who, as a new mother, mourns the loss of her ability to breastfeed.
‘There’s not a good evidence base for chest masculinisation mastectomies being beneficial in even the medium term for adolescents,’ Gribble says. No medium-term or long-term research on outcomes has been carried out, she notes, and the shorter-term studies are of ‘poor quality.’
She finds it difficult to understand the seemingly cavalier approach with which some surgeons are performing operations that may have devastating consequences, citing one transgender doctor who said that if young women who have had mastectomies want breasts later in life, they can ‘go and get them’. As Evans points out: ‘You can have something that imitates a breast put back in, but you can’t recover the ability to breastfeed a child.’
Could it be that the end of top surgery as a cure for gender dysphoria is in sight? After recommendations from the paediatrician Dr Hilary Cass, whose 2022 interim review was highly critical of GIDS’s adoption of the affirmation model, the clinic is due to close in August, to be replaced by two regional clinics. Perhaps, if properly counselled, fewer young women will see double mastectomy as the solution to their problems. For Watson, however, who still struggles with her mental health, the damage is done:
‘I was not a mentally well young woman when I went to Sandyford, and they gave me powerful cross-sex hormones and surgery,’ she says. Hakeem believes that many doctors are afraid to speak out about their concerns publicly, but that at some point, the tide will turn, leading to lawsuits against the NHS:
‘You’re probably going to see a tsunami [of de-transitioners] at some point, but you can either wait for that tsunami to come and the world to realise they’ve made a catastrophic medical mistake, or some sensible people can stand by what they think.’
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