Examining the Impact of Breast Augmentation vs Hormone Therapy on Chest Femininity of Transgender Women

Abstract Background For transgender women, there is often the innate assumption that surgical breast augmentation will increase perceived chest femininity beyond hormone therapy alone. Objectives This study aimed to evaluate whether lay individuals found surgically augmented breasts more feminine than breast development from hormone replacement therapy alone in transgender patients. Methods We obtained preoperative (maximal breast growth on hormone therapy) and postoperative chest (after primary augmentation) images of 22 transgender patients, and age- and BMI-matched cisgender male (n = 17) and female (n = 21) control patients. Survey respondents (n = 271) rated each image on a scale of 1 (very feminine) to 5 (very masculine). Results were compared by survey respondent gender identity and sexual orientation. Results There was a significant difference in mean femininity score between all image types. Mean score for transgender patients fell by 0.478 points after surgery (P < .0001). Subgroup analysis looking at transgender participants revealed the same significance trend postoperatively. Transgender respondents also found no difference in femininity between female controls and postoperative transgender patients (P = .132). We also compared mean femininity scores across 4 self-identified respondent subgroups: cisgender and heterosexual, cisgender and lesbian, gay, or bisexual (LGB), transgender and heterosexual, and transgender and LGB. The cisgender and heterosexual subgroup rated the postoperative transgender patients more feminine than any of the other respondent subgroups (LGB P < .001, transgender and LGB P < .001, transgender only P = .018). Conclusions This study shows that breast augmentation significantly increased the perception of femininity. Furthermore, gender identity and sexual orientation are important in how lay persons perceive transgender patients. Level of Evidence: 4