Reply: Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence.

Sir,

We would like to thank Expósito-Campos and D’Angelo for their letter[1] in response to our systematic review.[2] The first remark in their letter criticizes the adequacy of the search strategy. On this matter, we followed the PRISMA guidelines and a comprehensive search strategy was designed and conducted by an experienced librarian and the study’s principal investigator using the PICO framework (participants, interventions, comparisons, outcomes). Additionally, a controlled vocabulary and defined keywords were used to search for relevant studies; this is exhibited in Supplemental Digital Content 1.[2] Regarding the inclusion of the study conducted by Jiang et al,[3] it was included because it complied with the selection criteria which was clearly stated in our methods section.[2] Certainly, the objective of the study in mention was “to review their experience performing gender-affirming vulvoplasty and to determine which factors influenced patient choice or surgeon recommendation of vulvoplasty, as well as to assess the patient’s satisfaction or regret with this choice.”[3] Therefore, based on authors’ discretion and agreement, it was concluded that the study referred to regret with the choice of undergoing the procedure.[4]

As it occurred with other studies, the cohort size did not represent the sample used in our systematic review, as some patients did not undergo gender-affirming surgery (GAS). For instance, in the study by Wiepjes et al,[5] we identified only those patients who underwent gonadectomy, which is considered part of the GAS spectrum. The calculations were as follows: [(adults transwomen, 75.3% × 3809 patients = 2868.1 patients) + (adults transmen, 83.8% × 1624 patients = 1360.9 patients) + (adolescents transwomen, 79.5% × 330 patients = 262.3 patients) + (adolescent transmen, 77.2% × 482 patients = 372.1 patients)].

Regarding the quality of included data in this review, Expósito-Campos and D’Angelo claimed there was “lack of controlled studies, incomplete follow-up, and lack of valid assessment measures.” It must be highlighted that a systematic review with meta-analysis is a type of secondary study in which the researchers use already published data in primary studies. Nonetheless, for the qualitative and quantitative synthesis, patients were not included if they did not undergo GAS, in an endeavor to minimize the risk of bias. Furthermore, as stated in the letter, we specified the limitations of our review and a thorough assessment of the risk of bias was conducted, so readers were provided with adequate tools to objectively evaluate the outcomes of included studies. In conclusion, we strongly believe that this study is of very high-quality and adds important and relevant information to the literature despite the observations stated in the letter.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.