A critical assessment of online patient education materials for gender-affirming surgery: a systematic review and meta-analysis

Abstract

Introduction: Gender-affirming surgeries significantly improve the well-being of transgender and gender-diverse individuals. However, patients often rely on online patient education materials (OPEMs) to navigate surgical options, making readability, quality, and accessibility critical factors in informed decision-making.

Objective: The objective of this study is to evaluate the readability, quality, and accessibility of online patient education materials related to gender-affirming surgeries.

Methods: This systematic review analyzed nine studies evaluating 898 OPEMs related to gender-affirming surgeries and transgender voice care. Readability was assessed using Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Flesch Reading Ease Score (FRES), while quality was evaluated using DISCERN and the Patient Education Materials Assessment Tool. A meta-analysis synthesized readability scores, and qualitative trends were examined to assess readability-quality trade-offs.

Results: OPEMs consistently exceeded the recommended 6th-grade reading level, with a pooled FKGL mean of 12.49 (95% CI: 12.41-12.57), indicating high school to university-level complexity. SMOG scores averaged 11.89 (95% CI: 11.79-11.99), suggesting materials required at least some college education. FRES scores (mean: 37.49, 95% CI: 37.17-37.80) classified most materials as "difficult" to "very difficult" to read. Healthcare-affiliated websites had significantly higher FKGL scores than non-healthcare sources (P < 0.01). DISCERN scores were highly variable, with 68.33% of facial feminization materials rated poor or very poor. Physician-created TikTok content scored higher in reliability (P < 0.001) but had lower engagement than non-physician videos. Spanish-language materials were slightly more readable (SMOG 11.7 vs. 14.2 in English) but less available.

Conclusions: Most OPEMs for gender-affirming care fail to meet health literacy guidelines, limiting accessibility. To improve patient comprehension, materials should be simplified without sacrificing accuracy, incorporate multimedia tools, and undergo usability testing. Standardized, trans-affirming, and linguistically inclusive resources are essential for equitable access and informed decision-making.

Keywords: gender-affirming surgery; online health information; patient education materials; readability; systematic review.