Mastectomy

Mastectomy in the context of gender care—often referred to as “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, increasingly including underage girls. It is completely 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 beneath each breast, with all breast tissue removed and the nipples repositioned as free skin grafts. With this technique, the blood supply to the nipple is completely severed; the nipple reattaches in the same way as a skin graft.

What is permanently lost

The procedure completely removes the mammary gland tissue. The consequences are permanent and include:

• Inability to breastfeed. After a mastectomy, it will never be possible to breastfeed a child in the future. For minors who make this decision before they are even able to understand whether they may want children, this is a loss that is permanently placed beyond their reach.
• Nipple sensation: with the double-incision technique and free nipple grafting, erotic and tactile nipple sensation is permanently lost or greatly reduced in most cases. Sensation may also decrease with other techniques.
• Skin sensation: numbness or altered sensation in the skin of the chest is common and partly permanent.
• Cosmetic consequences: visible horizontal scars beneath the chest (double incision), protruding folds of skin at the ends of the scar (“dog ears”), asymmetry, contour irregularities, hyper- or hypopigmentation, and, in some cases, loss of transplanted nipple tissue due to necrosis.
• Complications: hematoma, seroma, infection, delayed wound healing, wound dehiscence, hypertrophic scarring, or keloid formation. An overview of the risks of complications is available at transgids.nl.

Mastectomy in minors

In the Netherlands, mastectomy is also performed on minors, sometimes from the age of 16, and at some international clinics at an even younger age. In Quebec, the procedure is available from age sixteen, and in Belgium, UZ Ghent came under fire when a daughter was referred for a mastectomy within a week. This is a fundamental issue. A 14- or 16-year-old girl:

• cannot realistically understand the impact of permanently losing the ability to breastfeed on future motherhood;
• is at a stage of life in which personal identity, sexuality, and body image are still developing rapidly;
• often has comorbid issues—autistic traits, eating disorders, social anxiety, or trauma—that remain underexplored in a rapid medical pathway;
• has, in most cases, not experienced long-term, stable, persistent dysphoria since early childhood—which was still a criterion under the original Dutch Protocol.

The Cass Review (2024) recommended explicit caution regarding surgery for minors, given its irreversibility and the lack of robust long-term research. Several European countries (the UK, Sweden, and Finland) have adopted this advice. In the Netherlands, this caution has been implemented only to a limited extent. Careful assessment and child-protection review are essential for an irreversible procedure such as this.

Informed consent in minors is problematic

Informed consent assumes that the patient understands and can weigh the nature, consequences, and alternatives of a procedure. In minors, this is structurally limited: the prefrontal cortex, which is involved in long-term decision-making, continues to develop until approximately age 25. A teenager may rationally understand that breastfeeding will no longer be possible; emotionally and biographically, that loss only becomes real if they later have a desire to have children—a stage that comes years later. Signing a document does not make consent genuinely informed in the psychological sense of an adult.

Regret and detransition

Rates of regret are reported as low in older studies, but those studies have major methodological shortcomings: short follow-up periods, high loss to follow-up, and populations that are not representative of the current cohort (predominantly teenage girls after 2015). Stories from detransitioners who have had their breasts removed—often young women who later view it as an irreversible choice made during a period of psychological distress—are becoming more common. See also Detransition.

Coverage in the Netherlands

Mastectomy as part of gender care is covered by basic health insurance at recognized centers. Waiting times vary.