Mastectomy
Mastectomy in the context of gender care — often called 'top surgery' — is the surgical removal of healthy breasts in biological females, with the aim of creating a male-looking chest. The procedure is requested by trans men and non-binary people, and increasingly by minor girls as well. It is fully irreversible.
Techniques
For smaller breasts a periareolar or 'keyhole' technique is used, with smaller scars around the areola. For larger breasts the 'double incision' technique is standard: two horizontal incisions under each breast, in which the entire breast tissue is removed and the nipples are replaced as free skin grafts. With this technique the blood supply to the nipple is completely interrupted; the nipple re-attaches as a skin graft does.
What is lost, permanently
The procedure fully removes the mammary gland tissue. The consequences are permanent and include:
- Inability to breastfeed. After mastectomy no future child can ever be breastfed. For minors making this decision before they can possibly grasp a wish to have children, this is a loss that is placed permanently beyond reach.
- Nipple sensation: with the double-incision technique with free transplantation of the nipple, the erogenous and tactile sensation of the nipple is in most cases permanently lost or strongly reduced. With other techniques too, sensation can decrease.
- Skin sensation: numbness or altered sensation of the chest skin is common and partly permanent.
- Cosmetic consequences: visible horizontal scars below the chest (double incision), dog-ear effects, asymmetry, contour irregularities, hyper- or hypopigmentation, and in a proportion of cases loss of transplanted nipple tissue through necrosis.
- Complications: haematoma, seroma, infection, delayed wound healing, wound dehiscence problems, hypertrophic scars or keloid formation.
Mastectomy in minors
In the Netherlands mastectomy is also performed on minors, sometimes from age 16, in some international clinics even younger. That is a fundamental issue. A 14- or 16-year-old girl:
- cannot realistically grasp the impact of lasting loss of breastfeeding capacity on future motherhood;
- is in a life phase in which her own identity, sexuality and body image are still very much in development;
- often has comorbid problems — autistic traits, eating disorders, social anxiety, trauma — that remain under-illuminated in a quick medical pathway;
- moreover, in most cases has not gone through a long-stable, persistent dysphoria since early childhood — which the original Dutch Protocol still required as a criterion.
The Cass Review (2024) advised explicit restraint with surgery in minors, given the irreversibility and the lack of robust long-term research. Several European countries (UK, Sweden, Finland) have adopted this advice. In the Netherlands this restraint has been implemented to a limited extent.
Informed consent in minors is problematic
Informed consent presupposes that the patient understands and can weigh the nature, the consequences and the alternatives of a procedure. In minors this is structurally limited: the prefrontal cortex, involved in long-term weighing, is still developing until around 25. A teenager can rationally understand that breastfeeding becomes impossible; emotionally and biographically this loss only becomes real when there is one's own wish to have children — a phase that comes years later. Signing a document does not make the consent truly informed in an adult psychological sense.
Regret and detransition
Regret rates are reported as low in older studies, but those studies have major methodological shortcomings: short follow-up, high loss to follow-up, and target groups that are not representative of the current cohort (predominantly teenage girls after 2015). Stories of detransitioners who have had their breasts removed — often young women who later view it as an irreversible choice made in a phase of psychological distress — are increasing. See also Detransition.
Reimbursement in the Netherlands
Mastectomy as part of gender care is reimbursed from the basic insurance in recognised centres. Waiting times vary.