Preference of FTM Transgenders for Partial Gender Affirming Surgery: Does the Answer Lie in Improved Quality of Life and Bodily Satisfaction with Masculinising Top Surgery? A Descriptive Survey Study

Abstract

Background:

For individuals with gender dysphoria, discomfort with their biological sex characteristics often leads to broader body image concerns. Masculinising top surgery, a popular gender affirming surgery, modifies an individual’s body to align with gender identity and expression by alleviating social, physical and psychological problems. The aim of our study is to assess patient satisfaction and quality of life (QOL) after top surgery and explore reasons for partial treatment request.

Methods:

In this prospective survey study of 10 female-to-male (FTM) transgenders who underwent top surgery, the questionnaires developed using validated survey tools such as Breast Questionnaires (BREAST-Q) and the Body Uneasiness Test-A (BUT-A) were distributed to the respondents one week before and six months post-surgery. The information on treatment requests and the motives behind the partial treatment requests was explored.

Results:

Ten patients (mean age 24.4 years) underwent top surgery as their initial gender affirming procedure. At six months, BREAST-Q scores improved significantly, with comfort in clothing increasing from 0.5 to 3.6 and comfort during sexual activity from 0.4 to 3.2, while self-confidence rose from 0.5 to 2.9. BUT-A scores showed marked reductions in body image concerns (4.3–0.2) and body dissatisfaction (3.8–0.3). Postoperatively, 60% opted for partial treatment due to improved QOL and sexual well-being.

Conclusion:

With the growing recognition and acceptance of transsexuality, there is an urgent need for a validated instrument to assess patients’ bodily satisfaction and QOL after masculinising top surgery. The partial treatment request and the underlying motive being improved QOL and sexual well-being further strengthens the role of top surgery.

List of Abbreviation

FTM: Female-to-male

TS: Transsexuals

QOL: Quality of life

DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Introduction

Body image encompasses one’s thoughts, feelings and behaviours toward their physical appearance, forming a complex psychological experience. ¹ For individuals with gender dysphoria, discomfort with their biological sex characteristics often leads to broader body image concerns extending beyond genitalia. ²

The American Psychiatric Association clarifies that being gender nonconforming is not inherently a mental health issue, as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Instead, gender dysphoria requires significant emotional distress to be considered a clinical concern. ³ Transgender identity should be viewed as a neutral aspect of human diversity, devoid of negative or pathological connotations. ⁴

Studies have demonstrated a high prevalence of mental health problems among transgender individuals. The chronic stress from societal stigma and discrimination leads to internalised transphobia and mental health issues. ⁵ Although there are specialised centres providing multidisciplinary care for gender dysphoric individuals, in many countries, there are countries in which such forms of care are not available. Therefore, the question remains as to how far these most recent high standards of care for transsexual (TS) individuals can be interpreted and applied in culturally diverse countries with more traditional values.^6,7

Gender affirming surgery modifies an individual’s body to align with their gender identity and expression, alleviating gender dysphoria. ⁴ While not all transmasculine individuals seek or need surgery, it is a standard-of- care treatment when aligned with patient goals. Options available are: a. Chest wall masculinisation (top surgery) b. hysterectomy c. phalloplasty d. metoidioplasty. ⁸

Masculinising top surgery is a popular gender affirming surgery among TS individuals. Often, it’s the first and only surgery they pursue as it alleviates the social, physical and psychological problems contributed by the distress over the presence of breasts. Also helps relieve binding-related issues. Treatment plans are tailored to each patient’s needs.^9–11

Despite its importance, little research has explored the standalone effects and goals of masculinising top surgery on transmasculine patients, which is subjective: To alleviate gender dysphoria symptoms, improve mental health, quality of life (QOL) and sexual confidence. On the other hand, existing literature focuses on the objective goals, the surgical techniques, aesthetic results and complication rates.

This study aims to fill the research gap by examining the personal, subjective experiences of transmasculine patients undergoing masculinising top surgery. Evaluating QOL pre- and post-surgery requires objective, evidence-based research, rather than individual physician perspectives. ¹²

The objective of the study is twofold: The primary objective is to measure the QOL improvement and improved bodily satisfaction from pre-operative to six months post-operative period, with assessment perfo- rmed through the Breast Questionnaires (BREAST-Q) instrument and the Body Uneasiness Test-A (BUT-A). The secondary objective explores the motives underlying the partial treatment request. To ascertain whether the motive for partial treatment requirement lies in improved QOL and bodily satisfaction. ¹³

While BREAST-Q and BUT-A have not been specifically validated for transgender populations, they provide a comprehensive assessment of body image, well-being and QOL factors.

Methods

After obtaining approval from the ethical committee of the institute, the eligible individuals who were assigned female at birth, identified as transmasculine, aged 18–30 years, who underwent chest wall reconstruction performed by the same surgeon between July 2023 and December 2024 were enrolled for the study. The participation of the respondents was voluntary and optional. The survey was distributed one week before surgery and repeated at six months post-surgery. The survey contained demographic questionnaires, selected questions adapted from the BREAST-Q questionnaire and the BUT-A, as well as applicants’ information on treatment request and motives for partial treatment.

Due to the lack of validated tools specific to transgender patients, especially for top surgery satisfaction, we adapted the BREAST-Q Breast reduction/Mastopexy module to assess changes in physical, psychosocial and sexual well-being. Modified instruments remain pivotal in transgender health research.

The BREAST-Q scores were scored on a five-point Likert scale, with the highest digit being the most positive result and zero the most negative. It was grouped into three categories for data analysis: ‘Satisfied’, ‘neutral’ or ‘dissatisfied’. In modified BREAST-Q scores, survey responses were summarised in percentages and mean scores to compare preoperative and postoperative data for 10 questions pertaining to our study. ¹⁴

Originally developed for assessing body image in eating disorder patients, the BUT-A^15,16 has since been utilised in several populations, including transgender individuals. The survey structure comprises 34 questions on body image, which is scored on a six-point Likert scale (0 = ‘never’, 5 = ‘always’) with higher scores indicating greater body uneasiness. For the purpose of our study, we identified eight questions for which the scores were interpreted under various domains, including: Compulsive self- monitoring, body image concerns, self-avoidance, avoidance for others, body dissatisfaction, depersonalisation, detachment and sexual dissatisfaction.

Chart analysis was performed for participants completing both preoperative and postoperative surveys. Statistical analysis using percentages, mean scores and standard deviations was calculated using Microsoft Excel.

At six months postoperative time, treatment requests were collected and classified as those requiring full treatment and those requiring partial treatment. As per our categorisation, anyone who did not want genital surgery was considered as requesting partial treatment.

Applicants requesting partial treatment were asked about their motivations and the reasons were categorised into: Concerns about genital surgery risks/outcomes, no genital dysphoria or unnecessary surgery (including satisfactory genital function), age (too old for certain interventions), improved QOL and sexual well-being.

These categories provide insight into the diverse motivations behind partial treatment requests.

Results

The cohort included 10 eligible patients with a mean age of 25.4 years (range 18–30). All were unmarried and 80% had at least some college education. Records confirmed top surgery as the first transition-related procedure for all patients. All the patients had received mental health counselling for gender dysphoria before surgery. Nine out of 10 patients had received/were receiving cross-sex hormone therapy before surgery.

On comparing the preoperative and six-month postoperative BREAST-Q results demonstrated statistically significant improvement in physical, sexual and psychosexual well-being and also improved breast satisfaction.

Following top surgery, the subject’s QOL and sexual confidence improved significantly, with patients showing substantial gains in self-esteem and body image (70%–100%), emotional well-being (60%), sexual confidence and satisfaction (60%–100%) Figure 1.

Figure 1.

Improvement in QOL and Sexual Life.^13–15

Mean BREAST-Q postoperative scores showed statistically significant gains across all domains Figure 2 with it rising markedly from exceedingly low preoperative values. Thus, reflecting better comfort in clothing, higher self-confidence and improved sexual well-being.

BUT-A scores improved significantly postoperatively, Figure 3, with reduced body image concerns, self-monitoring behaviours, depersonalisation and social avoidance.

Of the 10 applicants, six requested partial treatment and two requested full treatment. Two were not decided on the type of treatment desired Figure 4. The partial treatment requests were driven by improved QOL and sexual well-being in 60%, whereas in 40%, concerns about genital surgery risks or outcomes were the reason Table 1.

Figure 2.

Mean BREAST-Q Scores at Six Months Postoperatively Showed Significant Improvement Across All Domains Compared with Preoperative Values.^13–15

Figure 3.

Mean BUT-A Scores at Six Months Postoperatively Showed Significant Improvement Across All Domains Compared with Preoperative Values.^13–15

Figure 4.

Treatment request.^13–15

Table 1.

The Frequency and Percentage (%) of Motives for Partial Treatment.^13–15

Motives for Partial Treatment	Total	%
Concerns about genital surgery risks/ outcomes	1	40
No genital dysphoria	0	0
Age (too old for certain intervention)	0	0
Improved QOL and sexual well-being	2	60
Total	3	100

Discussion

Top surgery is vital for many female-to-male (FTM) individuals to align their physical appearance with their gender identity, enabling confident social interaction. Results of this prospective study indicate improved QOL, reflected by better physical, sexual and psychosocial well-being and decreased body image concerns, avoidance behaviours, compulsive self-monitoring and depersonalisation. Despite its importance, there is a significant gap in research examining the specific impact of masculinising top surgery, standalone, on patient-reported QOL and sexual confidence. Only a few studies have isolated the effects of this procedure from other gender affirming interventions.

This study had survey questions related to limitations, as these were not validated, though expert- and patient-informed. Currently, no validated patient-reported outcome instruments exist for gender affirming surgery. The BREAST-Q, while not tailored to FTM individuals, provides a robust framework for assessing well-being. Application of the tool showed significant gains in body image and QOL following chest masculinisation, although it was not originally designed for FTM individuals and has limited cultural sensitivity. Our findings validate the BREAST-Q’s utility in evaluating outcomes for this patient group.

The BUT-A survey, tailored for eating disorders, has crossover applicability in measuring body image issues integral to transgender body dysphoria. Through our study, we elucidated a drastic improvement in body image concerns, which was documented by a significant change in the idea of living with the appearance they have. There was also a significant decrease in bodily dissatisfaction, a decrease in the feeling of detachment and estrangement towards the body. The compulsive need for self-monitoring decreased significantly. All this highlights a crucial connection between improved well-being and reduced self-harm/suicide attempts in the transgender population.

Since our study elucidated a remarkable difference in the treatment request among the study population, as 60% opted for the partial treatment, we attempted to obtain insight into the underlying motives. Based on the responses and the experience, four categories were made. The current study showed that out of the patients who requested partial treatment, the underlying motive was improved QOL and sexual well-being after the top surgery, leading to not going further for the genital surgery. However, this relationship needs to be explored in further studies with a larger sample size.

Overall, our study was limited by a small cohort size. Although the survey questionnaire was designed using the validated survey scoring systems, it was not validated as a patient-reported outcome instrument in gender affirming surgery. The study did not consider the hormonal therapy timing, its duration or the complications of surgery. Also, the study is limited by a relatively short follow-up of six months, which may not capture long-term perspectives.

Despite this, our findings align with existing literature showing greater satisfaction and improvements in multiple QOL measures, psychosocial well-being and sexual satisfaction after top surgery, with benefits that were both clinically and statistically significant at six months.

Conclusions

Patient satisfaction is a key indicator of a successful surgery. The dominant narrative on surgical advancements and complications largely excludes patient voices, highlighting the need for more patient-centred research. Our patient-reported outcome provides unquestionable evidence that there are statistically significant changes in patient-reported QOL, sexual confidence, psychosocial well-being and self-esteem following top surgery. Our results are exceptionally positive, exceeding typical outcomes for most plastic surgery procedures and providing valuable insights into the benefits of chest wall masculinisation. To establish medical necessity for gender affirming procedures, future research should develop standardised outcome metrics. With the growing recognition and acceptance of transsexualism there is an urgent need to develop a standardised and validated instrument to assess patient satisfaction and QOL after surgery. The partial treatment request by the majority and the underlying motive of improved QOL and sexual well-being further strengthen the role of top surgery.