Reviewer ’s report  
 
Title: 'Doing hymen reconstruction': an analysis of perceptions and experiences of Flemish 
gynaecologists  
 
Version: 0 Date: 06 Jun 2017  
 
Reviewer: Verina Wild  
 
Reviewer's report:  
 
Thank you for the opportunity to review this paper. As there is so little evidence on hymen 
reconstruction, empirical studies are highly appreciated.  
In general the article is well structured and written and very clear. It addresses an important topic 
(hymen reconstruction) and provides much needed empirical evidence. T he title of the paper is 
precise.  
 
I have a few comments:  
Abstract:  
- The abstract mentions "the high prevalence of FGCS". This is not explained in more detail in 
the paper. If this is mentioned in the abstract it would be good to show or point to some 
numbers on "the high prevalence of FGCS".  
 
- The abstract mentions that "most patients did not return" to a follow -up. However, on page 
15 it says that the majority of respondents were able to perform a follow up consultation. > 
Change abstract?  
 
- p 2, lin e 42: "normal" replace with "regular"? (> Otherwise explain, what is "normal"?)  
 
- p 2, line 55: Although the response rate... > This sentence see ms redundant to me, or rather a 
conclusion (if at all.).  
 
- p 3, line 3: The abstract mentions that more qualit ative research is necessary. In my opinion 
that is the most important finding of the entire study, but it is not repeated in the main text. 
Please also expand on this in the conclusion of the main text (see also my comments below).  
 
  
Background:  
- p 4, l 20ff: This is a very brief overview only, and I understand that much more information 
cannot be given. But there are some very good papers on hymen reconstruction that describe 
the complexity of the procedure. Maybe look into bibliographies from van Moorst  et al 2012 
(Eur J Contracept) or Wild et al 2015 (Soc Sci Med), but since then more relevant papers 
showing the complexity of the surgery have been published too. Some more references to 
show an understanding of the complexity of the surgery would be good  (and would also help 
to put the limitation of survey results into perspective > see my comments below).  
 
- p 4, l 55: First mentioning of an author (here: Amy) with first name?  
 
- Include a short paragraph that ethics and policy of hymen reconstruction st ill reveal many 
open questions, and that this study will focus on providing much needed empirical facts (as 
there are so few). Ethics & policy can then be a later step and are not the focus of this paper.  
 
Methods:  
- How were the physicians contacted?  
 
- Which questionnaire was used in a previous KAP -survey on FGM? These questions? Or this 
type of method? FGM is something very different from hymen reconstruction - it is a bit 
irritating that FGM is mentioned a few times in this paper without explaining wh y the 
reference is made so often. Do the authors think there is some kind of connection between 
these two practices? If so, please explain. Otherwise: Delete?  
 
Results:  
- Is it possible to retrieve data from the VVOG, so that it can be shown whether the 
demographics of this study are representative for the demographics in the VVOG?  
 
- p7, first paragraph: This is very interesting data (how many received medical training)  
 
- p7, line 37: Subsection heading missing? ("Personal comments")  
 
- p8: Here are paragr aphs which I find most problematic. First, the term "attitude" does not 
seem to fit to some questions (Example: Sufficient medical knowledge is not an attitude; the 
woman is in danger... is not an attitude). Second, such substantial questions are being ask ed 
here (e.g. "the woman has the right to decide on her own body, my personal opinion does not 
matter") that almost do not fit into a survey format, but would surely do into a qualitative 
project. I am not sure they can even deliver any valid data, as ther e are multiple ways to 
interpret the questions, and also a multitude of ways to interpret the answers. In the reporting 
I would recommend to be very careful, and to point to the fact, that these are mere first 
trends, and that the most important result is that a follow up qualitative study would be 
necessary to understand what is really at stake. The authors cite for example the result for the 
question "the surgery violates the right to physical integrity..." > The fact that the 
respondents answer so hetero genously could also be seen as irritation among the responders 
who might not have been in a position to answer this accurately, due to the survey format. 
What does it really tell us about the question and its potential replies? The authors also report 
on the questions that some patients might be in danger of becoming a victim of honor 
violence. This invokes the association with physical violence (or was even intended to invoke 
this only?), but no to bleed during the wedding night must not necessarily mean t hat "honor 
violence" will follow. Many other forms of social or psychological harm can follow, but 
maybe this is not captured in the question of "honor violence". Again, my recommendation is 
to be very careful with any sort of reporting or interpretation, as I find the questions too 
broad and unspecific to really find out relevant detail.  
 
- p9, reimbursement: This is again a very useful information. I cannot find the question in the 
attached survey though. It might be a good idea to publish the entire surv ey.   
 
- p10: No woman reported aesthetic reasons: That again is a very useful information. Again, I 
cannot find these questions (reported on page 10) in the attached survey, but it would be 
interesting to see them.  
 
- p11, line 3: Only 18 repondents received a request discussed alternative options: Again, very 
interesting information.  
 
- p11, line 60: Information on complications is again very useful, and very rarely discussed in 
the literature. Maybe mention in the i nterpretation section that the true number of 
complications is unknown.  
 
Discussion:  
- My main recommendation is to carefully look through the survey and its results and try to 
divide them into A) actual "facts" (while being careful here too and putting the limits of a 
survey into perspective) and B) issues of ethical or policy relevance, such as values, rights, 
principles (see especially page 8 of the paper). It is really difficult or even impossible to 
come to any normative / policy conclusions based on  the survey responses. In this case I 
would recommend to be very modest and rather to systematically collect the issues that 
deserve further qualitative or other research, or further ethical / normative discussion.  
 
- p 12, l 22: Many seem to be trained we ll enough, but it is also mentioned that HR is not 
integrated in a structured way into curricula: It would be worth pointing this inconsistency 
out (to be explored for further research).  
 
- The results that A) 'policy and guidance is needed' and B) 'more t raining is needed' cannot be 
drawn from this brief survey. These are highly complex questions, and should not be 
formulated so easily - and based on the survey results. These recommendations could be 
framed as issues that need further research and discussi on in order to come to appropriate 
conclusions, or should at least be heavily based upon results of other papers.  
 
- Sentences such as: (p 13, l 12): "In order for women to make an informed decision..." do not 
show that the complexity of the topic is truly  captured in this paper. Even the notion of an 
"informed decision" is contestable; let alone the possibility to make one. Rephrasing with 
more modest terms such as: It can be assumed that.../ It could be helpful to...Could make it 
work. "Should have autono my" (line 40) is also a difficult phrase - what does that actually 
mean? And to deduce a normative conclusion from that is just too quick.  
 
- p 14, line 17: inherent bio -politics are mentioned > reference?  
 
- p 14, line 22 -27: Explain this better? (> assoc iation between surgery and specific identities / 
FGCS as act that supports patriarchy).  
 
- p 14, l 34: Little is know about women's perspectives (> maybe cite some of the very few 
interview studies with women?)  
 
- p 14, l 49/50: Reimbursement of HR: Interes ting issue here on the Belgian state, maybe 
expand a little?  
 
- p 17, first paragraph: Here again is an example of policy recommendations which cannot be 
made on the basis of the survey > I recommend to rephrase as issues for further research.  
 
Conclusion:   
Here my main recommendation from above applies too.  
 
  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statisti cal review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
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3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
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holds  or has applied for patents relating to the content of the manuscript?  
 
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