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

Sir:

Bustos et al¹ must be commended for asking an important question about regret after gender-affirmation surgery, the effort they expended to answer it, and transparency when publishing an erratum. Scientific work must be open to scrutiny that can confirm or refute findings. Could the authors please comment on the following:

Methods

• 1. Was there a prespecified, registered research protocol? None appears on the PROSPERO website‚² and a query passed on via the editor-in-chief has not elicited a clarification.

• 2. Why was the authors’ determination of the primary study design not added to study characteristics (Table 2), alongside confirming which of the various available NIH quality scales³ was used to score each study (Supplemental Digital Content 2)? Without “showing the workings,” others cannot confirm the credibility of the work.

• 3. Why were missing data rates (if available from primary papers using proper cohorts) not added to Table 2, given the impact they have on uncertainty?

• 4. Was a PRISMA checklist⁴ filled in before submission? The Methods claim that PRISMA guidelines were followed,⁵ and yet many of the required items are missing.

• 5. Was a statistician involved in the design or conduct of this work, and if so, why are they not named as an author?

Results

• 6. What was the determination of the level of bias for Nelson et al? It still appears to have been classified as “moderate” in the corrected Table 2 and yet “good” in SDC 2.

Quality of Studies

• 7. Given that they performed a quality assessment, why did the researchers not perform a subgroup analysis to examine the impact of high, moderate, and low risk of bias or construct a forest plot?

Declaration of Interest

• 8. It seems implausible that such an eminent team has never been involved in any remunerated work that relates to their expertise. Indeed, several offer these surgeries directly to patients in their public biographies‚ so they must have an interest, and financial at that, in the findings. This is a matter of fact, not a criticism, of experts. The authors have all completed an International Committee of Medical Journal Editors uniform disclosure form where, among other matters, authors are encouraged to use wide and inclusive definitions: “Disclosure represents a commitment to transparency and does not necessarily indicate a bias. If you are in doubt about whether to list a relationship/ activity/interest, it is preferable that you do so.”⁶ Could the authors confirm they stand by the statement that they “have no financial interest to declare in relation to the content of this article”?

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article. Her interests can be found at https://www.whopaysthisdoctor.org/doctor/58/active. Open access article processing charge is funded by the Society for Evidence Based Gender Medicine.