A 5-Year Analysis of Level of Evidence Ratings in Gender-Affirming Surgery Research

Abstract

Purpose:

This study assesses the level of evidence (LOE) of gender-affirming surgery (GAS) studies in peer-reviewed articles over a 5-year period and compares them with previous LOE studies in general plastic surgery and urology.

Methods:

A systematic review was conducted across 13 plastic surgery and urology journals. Articles published between 2017 and 2022 relating to original GAS research were assessed for LOE by two independent reviewers using the American Society of Plastic Surgeons LOE guidelines.

Results:

A total of 213 articles were reviewed. The LOE ratings were as follows: none were level 1, 7% were level 2, 20% were level 3, 58% were level 4, and 15% were level 5. The mean LOE rating for included articles was 3.82. This rating was compared with the previously reported mean LOE in Plastic and Reconstructive Surgery of 3.2. Case series (62%) were the most common study design, therapeutic studies (82%) were the most common study subtype, and genital masculinization (33%) was the most common topic. The overall number of GAS articles published increased from 2017 (N=7) to 2022 (N=56).

Conclusion:

LOE for GAS is consistent with that of non-GAS plastic surgery and urology publications. Criticism that LOE in GAS is low is unwarranted when compared with non-GAS interventions. Efforts to withhold medically necessary GAS based on published LOE should be interpreted cautiously and applied consistently with other areas of plastic and urological surgery.