The teenager made a deep cut right around his left breast before going to a hospital emergency department. Photo / 123RF
WARNING: Graphic content
A New Zealand high schooler attempted to cut off his own breast in an “act of desperation” after years on a stretched public health system wait list for gender-affirming surgery, according to a report in the New Zealand Medical Journal today.
The 18-year-old female-to-male
Photos showed a deep cut around his entire left breast, which was later surgically removed along with the teen’s untouched right breast, the report’s authors wrote.
Surgery went well and the teen was discharged a day later, with his scars well healed and his self-esteem and confidence up at a post-operation appointment a month later, Wellington Regional Hospital doctors Mairarangi Haimona, Sue Hui Ong and Scott Diamond wrote.
“He reported improvement in self-esteem and self-confidence and his ability to complete school work, and was looking forward to enrolling at university.”
Assessment by the acute mental health team after the teen’s emergency department admission found he didn’t have a psychiatric disorder and wasn’t suicidal, they wrote.
“[He] had been considering gender-affirming surgery for years. A lack of access to gender-affirming surgery led to this act of desperation.”
The teenager, who had a background of gender dysphoria, was on testosterone treatment and was awaiting gender-affirmation surgery, had watched a “how to” video on YouTube, prepared appropriate equipment, marked the incision and considered pain relief and bleeding, Haimona, Ong and Diamond wrote.
“Due to the long wait times of referral in the public healthcare system, an inability to afford a private consultation and the significant psychological stress of having breasts at an upcoming pool party he planned to complete a bilateral (double) self-mastectomy at home.”
Gender dysphoria is significant distress when gender identity differs from sex assigned at birth or sex-related physical characteristics.
Not all transgender people wanted gender-affirmation surgery, but those who did should be able to get it, and limited access to the surgery in New Zealand was an increasing issue, the doctors wrote.
Only one surgeon did gender-affirmation genital operations in New Zealand, and there were barriers to accessing publicly funded surgery.
“Many patients who meet the eligibility criteria are declined due to the lack of resource and financial capacity, or are waitlisted on a decade-long wait list.”
Insurance companies also excluded the surgery from their policies, Haimona, Ong and Diamond wrote.
Other gender-affirming surgery, which as well as breast or chest surgery can include facial feminisation or masculinisation and voice surgery, was performed by a variety of specialists, including general gynaecologists, urologists, plastic and reconstructive surgeons or general breast surgeons.
There had been previous cases of self-amputation of breast tissue but those patients had demonstrated an active psychiatric disorder and acute triggers - unlike this teen, they wrote.
“Transgender people often need to self-advocate for care in the public health system, but with increasing demand and associated psychological and possible physical harm it’s crucial for public services to be more accessible to an under-served population.”
Home surgeries, as Gender Minorities Aotearoa executive director Te Ahi Wi-Hongi described them, are done “absolutely out of desperation”.
Wi-Hongi spoke to someone yesterday considering cutting their testicles off.
“Nobody wants to do [self-surgery], and people know they’re probably not going to have good outcomes, but it’s an absolute absence of options for most. In almost every part of New Zealand trans men can’t get a mastectomy … even if they get accepted on the [waiting] list, then they get moved off.”
These actions, which also affected people waiting for gender-affirming genital surgery, made the service look like it was “working and meeting [waiting list] targets”.
“Obviously nobody says to a patient, ‘sorry, there isn’t enough money to do your surgery’ … they get told there’s a limited number of surgeries and you don’t need it as much as others … we think everybody should be able to get the health care they need.”
People weren’t being removed from gender-affirming surgery wait lists to meet targets, Health New Zealand Te Whatu Ora’s Duncan Bliss said.
Some historical patients had been removed from the genital surgery waitlist as they didn’t meet the clinical criteria for consideration for surgery, said the director of the programmes delivery unit for hospital and specialist services.
“Some elective services employ a physical wellbeing criteria for access, which generally includes body mass index, smoking cessation, and psychological preparedness. These considerations and assessments are consistent with the current pathways of accessing Gags [gender affirming (genital) surgery] and plastic and reconstructive services.”
Once on the wait list, preparation time for surgery could be lengthy as patients may require weight loss, co-morbidities to be addressed, readiness assessment and/or hair removal before surgery, Bliss said.
“All patients are considered and assessed on an individual basis. If a person doesn’t meet the required criteria, they’ll not be able to progress to surgery.”
Each regional area had its own pathways for gender-affirming surgeries, and people should contact their GP to discuss options.
Gender-affirming surgery was complex, so it was important patients were fully prepared “so the best outcome can be reached”, Bliss said.
“We do recognise wait times for gender-affirming care are lengthy and we’re committed to addressing this.”
Health NZ gave him the same assurance, Associate Health Minister Matt Doocey said.
It wasn’t appropriate to comment on individual cases, but he acknowledged waiting for surgery could be difficult for patients and their whānau.
“I’d urge anyone who is waiting for surgery, and is concerned about their wellbeing, to reach out to their trusted healthcare provider.”
Wi-Hongi said it cost more than $15,000 to have a double mastectomy done privately, although prices varied by surgeon and theatre fees were up since Covid-19.
Genital reconstruction surgery costs varied, but could be done in Thailand for $30,000.
Wi-Hongi’s advice to anyone considering “home surgery” was “hang in there”.
“It might seem right now it’s completely hopeless, but we went from a 40-year waiting list for genital reconstruction surgery to 10 years or less when in 2019 the Government made changes [announcing $3 million funding for genital gender-affirming surgery].”
Home surgeries could also be deadly, or not work because - in the case of genital self-surgery - people were taken to hospital and patched up.
Some had managed to save for the surgery or be gifted it by family. Others had turned to sex work to raise the money, Wi-Hongi said.
“There are lots of options that people shouldn’t have to take. But that’s what happens when the health system doesn’t work.”
Cherie Howie is an Auckland-based reporter who joined the Herald in 2011. She has been a journalist for more than 20 years and specialises in general news and features.
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