Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this interesting manuscript.  Overall, the manuscript is well written with very few grammatical errors. There is a paucity of research on this topic and I do believe that this manuscript may be of value to expand this research.  More specific feedback by section of the manuscript can be found below.

Keywords: I wonder if there is a better way to express "muscular sculpture"?  Perhaps "contouring" instead?  I also wonder about "GAHT" as an acronym within the keywords section.  Is GAHT commonly used as a keyword?  

Introduction:

• Within this section, the authors talk about chest affirmation surgery being "the definitive step" in transition.  This is not the case for all transmasculine or non-binary people.  Perhaps there can be something added within this section that speaks to the fact that everyone's transition process can look different and what people want in terms of their own transition (including which order) can be unique.
• The first sentence of the last paragraph in this section doesn't make sense.  I believe there may be a word or two missing in this sentence.
• The last sentence includes "psychological investigation" of the patient before and after surgery as something that the authors are encouraging.  Given the many years when psychiatrists and psychologists were acting as "gatekeepers" for trans-identified people as they tried to access various forms of transition, I don't think that the terminology "psychological investigation" is appropriate to use here.  Perhaps this can be phrased in such a way that it is less potentially stigmatizing and won't be perceived as continued "gatekeeping".

Methods:

• "These keywords were paired with keywords related to surgery procedure and psychological impact:..." - "surgery" should be changed to "surgical" in this sentence.
• "The full texts of the selected articles were revised, and incongruities..." - "revised" should be changed to "reviewed" in this sentence.
• "Special attention...varied body habits and breast volumes,..." - "habits" should be changed to "habitus" in this sentence

Case Report:

• In the 4th paragraph of this section, the authors talk about a diagnosis of gender incongruence being established by the psychiatrist in accordance with the DSM-5 criteria.  In the DSM-5, the diagnosis listed is "gender dysphoria", not "gender incongruence".  Gender incongruence is the listed diagnosis in the ICD-11.  Which of these did the psychiatrist use to establish the diagnosis for this patient?
• "The request for these interventions was interpreted not as symptomatic behavior, but rather..." - Symptomatic of what?  Symptomatic of gender dysphoria?  Many, but not all people with gender dysphoria desire gender-affirming surgery/surgeries - This is typical and is not "symptomatic" per se - the use of this word is potentially stigmatizing.  I wonder about removing this sentence entirely from the manuscript.
• The authors refer to a "cup size 5C" - this is not a standard bra size measurement in most parts of the world.  The authors should consider interpreting this bra size into North American and UK sizing - I believe this would be equivalent to 40C.
• For the BUT and MC-SDS, the authors should consider including the "norms" for these scales such that the results could be more easily interpreted for this particular case by a reader.
• Under the explantion of the BUT, the authors state "It is plausible that the body is undergoing a process of re-elaboration...." - A bit more explanation of what the authors mean by "re-elaboration" would be helpful.

Review of the Literature

• "Although hypertrophic scarring...quality of life in transgender and non-binary individuals."; Authors should consider replacing "transgender" with "transmasculine" in this sentence
• "These results are corroborated by recent meta-analyses, which affirm that gender-affirming surgeries..." - Authors should consider replacing "affirm" with "confirm" in this sentence
• "A recent single-institution longitudinal study conducted in USA evaluated..." - an "a" should be added before "USA" in this sentence
• "Participants reported high satisfaction with surgical outcomes and recovery, often contributing to suicidal ideation." - I don't think this is what the authors were meaning to say here.  I believe they are trying to say that this contributes to lowering the risk of suicidal ideation (the opposite of what is currently stated in this sentence).

Discussion

"It is important to monitor whether this tendency evolves toward authenticity or becomes a form of masking." - I'm not sure what the authors meant by this sentence.  I suggest that this idea be explored more deeply or that this sentence be omitted.

Conclusions

• The first sentence of the conclusion is rather awkwardly worded and needs to be revised for clarity.
• "These findings support the view that surgical gender-affirming procedures, more than hormonal reassignment therapies, are essential components of transgender health care,..." - I would caution the authors against stating this assertion in this manner.  Transgender and non-binary people's transition processes and trajectories vary and are quite unique and individual.  Not everyone wants gender-affirming surgery/surgeries to be a part of their transition process and some people put greater value on other parts of their transition process (eg. hormonal treatment, social transition, etc.).  I also would caution against the use of the term "hormonal reassignment therapies", but rather use terms such as "hormone therapies".

 

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article entitled “Psychological Correlates after Gender-Affirming Mastectomy: Insights from a Case Report and Review of the Literature” presents a relevant and well-founded contribution to the fields of medicine, health psychology, and gender studies. The proposal to combine a clinical case analysis with a review of recent literature on the psychological ramifications of gender-affirming mastectomy demonstrates remarkable methodological rigor and ethical sensitivity in the face of a topic that is still marked by gaps in the scientific landscape.

The article is very well written and methodologically sound, therefore, I suggest that it be published in the journal Sexes.

Below are some minor suggestions for improving the study:

1. The statement in lines 65-69 needs a reference to support it.

2. I suggest that in the introduction, the authors present at least two or three case reports, or collections of cases similar to those proposed in the present study, and clearly present how this study differs in terms of originality and relevance.

3. In line 112, the authors refer to the incongruence between sex at birth and gender identity as having caused significant suffering since adolescence. I consider it relevant to present in detail the ways in which this suffering is expressed, as well as the likely psychosocial and functional impairments associated with it.

4. The text between lines 131 and 139 is excellent. I congratulate the authors on the writing of the text.

5. On page 135, please explain the most relevant signs and symptoms that suggested the hypothesis of a moderate depressive episode in the patient's past.

6. I also suggest adding a paragraph in the results about the patient's relationship with the healthcare team throughout the process, as well as some data on the patient's adherence to the different stages of healthcare.

7. I suggest that the authors remove the text from lines 267-269. The DFH is not intended to be a diagnostic tool. For the purpose for which it was developed—to capture aspects of the patient's subjectivity based on projections of unconscious content in the drawings—it is an excellent tool and fulfills its function.

8. I consider it important to add the theoretical framework for interpreting the drawings. I imagine it to be psychodynamic.

9. In Table 2, I suggest adding the cut-off points for the instruments and the subscales, if any.

10. The interpretation of the DFH was very good. Please add information about the credentials of the professional who performed the analysis and the theoretical framework used.

11. In line 344, please add the %, with confidence interval, to clarify “extremely low.”

Once again, I congratulate the authors on their excellent work.

Best regards.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf