Attitude and knowledge of healthcare providers towards female genital cosmetic surgery: A cross-sectional study

Zinat Ghanbari; Saeedeh Shirdel; Mohadese Dashtkoohi; Ideh Rokhzadi; Misa Naghdipour Mirsadeghi; Mahroo Rezaeinejad; Marjan Ghaemi

doi:10.1371/journal.pone.0343634

Peer Review History

Original SubmissionMarch 11, 2025
21 May 2025 Decision Letter - Federico Romano, Editor Dear Dr. Ghaemi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jul 04 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Federico Romano, M.D., Ph.D. Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf . 2. In the online submission form, you indicated that [The data supporting this study's findings are available from the corresponding author upon reasonable request.]. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. Additional Editor Comments: Dear Dr. Ghaemi, I have read your article, "Attitude and Knowledge of Healthcare Providers Toward Female Genital Cosmetic Surgery: A Cross-Sectional Study." It is appealing due to the complex topic it addresses. However, I must admit that a general revision of the English language is necessary to make the article more straightforward. I found many spelling mistakes that need to be corrected. There is a significant disparity in the specialties of the participants. This should be addressed as it could lead to a different evaluation of the results. Moreover, even if the objective of your article is to assess the knowledge of healthcare providers regarding FGCS, it is notable that only 27 participants admit to performing FGCS "several times". This must be emphasized in the article, and given the small number, it may be possible to focus on the results of these specific participants to assess whether any difference is present between those who perform this kind of surgery routinely and those who don't. I find that the "attitude to advertising" part is not clear: what do you mean by "advertising"? Could you be more specific? Please read carefully the attached reviewers' comments. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The authors present a very interesting manuscript regarding physicians' perspectives on FCGS from various specialties. The authors found the in general the physicians viewed FCGS in a positive light and would discuss short term complications associated with this surgery but without much thought on long-term complications. This is a very difficult topic to study and discuss so I applaud the authors on trying to advance the field on this topic. Were all these physicians from the same geographic area? Socioeconomic status? The sociodemographic information of the studied physicians should definitely be included. Obviously, this topic is viewed vastly differently in different religions/cultures/geographic locations/etc. Therefore, this information is paramount to present regarding the participants of this study. Furthermore, beyond just their specialty but the amount of training received specifically regarding FCGS should also be included in the study as this would inform the reader on how comfortable they would be discussing this topic. In addition, the number of previous FCGS procedures performed would be helpful to know and where their training regarding FCGS was performed. Was this only in regards to cis-females or were trans-females also included? This could also skew the physicians' perspectives on this issue. Reviewer #2: it is interesting to elaborate on the cultural aspects of a study made in a conservative religious environment and compare it to data in the literature. the conclusions and recommendations to the future need to be more clear ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0343634.r001
Revision 1
29 Jul 2025 Author Response Manuscript Title: Attitude and Knowledge of Healthcare Providers Toward Female Genital Cosmetic Surgery: A Cross-Sectional Study We would like to thank the Academic Editor and the reviewers for their thoughtful comments and suggestions, which have helped us substantially improve our manuscript. Below, we provide point-by-point responses to each comment. Revisions have been made accordingly in the revised manuscript. Editorial and Journal Requirements 1. English Language and Style Editor: A general revision of the English language is necessary to make the article more straightforward. I found many spelling mistakes that need to be corrected. Response: Thank you for your observation. We have thoroughly revised the manuscript for spelling, grammar, and clarity. The revised version improves flow and ensures consistency in scientific language, capitalization, tense, and punctuation. A clean and tracked version has been uploaded. 2. Disparity in Specialties There is a significant disparity in the specialties of the participants. This should be addressed as it could lead to a different evaluation of the results. Response: We agree. We have now explicitly acknowledged this as a limitation in the Discussion and Strengths and Limitations sections. We also clarified the composition of participant groups in the Results section. 3. Limited Number of FGCS Providers Only 27 participants admit to performing FGCS "several times". This must be emphasized... consider focusing on these participants for subgroup analysis. Response: We thank the editor for this insight. We now emphasize the limited number of providers who routinely perform FGCS in the Results, Discussion, and Conclusion sections. Due to sample size constraints, subgroup analysis was limited, but we added a note suggesting future research explore this in greater detail. 4. Clarify “Advertising” What do you mean by "advertising"? Could you be more specific? Response: We clarified this term in the Methods section. “Advertising” refers to public promotional activities such as online campaigns, clinic websites, and social media used by healthcare providers or clinics to promote FGCS services. 5. Ethics Statement Location Your ethics statement should only appear in the Methods section. Response: Corrected. The ethics statement now appears only in the Materials and Methods section. 6. Data Availability All data must be made freely available. Response: We have uploaded a de-identified version of the dataset as Supplementary File S1, in compliance with the journal’s data policy. We also updated the Data Availability Statement accordingly. Reviewer #1 Were all these physicians from the same geographic area? Socioeconomic status? Response: We have clarified that all participants were based in Iran, and the majority practiced in urban healthcare settings. Unfortunately, detailed socioeconomic data were not collected, and this limitation is now acknowledged in the limitation section. The sociodemographic information of the physicians should be included... Response: Thank you for your comment. Unfortunately, additional sociodemographic information for the physicians is not available in the dataset, as it was not collected during the study. Amount of training received and prior FGCS performed should be reported. Response: These details were already partially reported. We now enhance this reporting in the Discussion, clearly stating the percentage with formal training and number of procedures performed Was this study only about cis-females or did it include trans-females? Response: Thank you for this important point. We clarify in the Methods that the study focused solely on cisgender women. This clarification has been added explicitly. It is interesting to elaborate on the cultural aspects of a study made in a conservative religious environment and compare it to data in the literature. Response: We appreciate this suggestion. We now expanded the Discussion to reflect the cultural and religious context of Iran and how this may affect healthcare providers’ attitudes. We also compared findings to those in more liberal or secular societies where FGCS is perceived differently. Conclusions and recommendations to the future need to be clearer. Response: We revised the Conclusion and Future Directions sections to present clearer and more actionable recommendations, including calls for standardized training, ethical guidelines, and further subgroup analysis. We hope these revisions meet the editorial and reviewer expectations and respectfully request reconsideration for publication. Thank you again for the opportunity to revise our work. Sincerely, Dr. Marjan Ghaemi, on behalf of all authors Attachments Attachment Submitted filename: Response_FGCS.docx https://doi.org/10.1371/journal.pone.0343634.r002
26 Aug 2025 Decision Letter - Federico Romano, Editor Dear Dr. Ghaemi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by %DATE_RESVISION_DUE%. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Federico Romano, M.D., Ph.D. Academic Editor PLOS ONE Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: Thank you for reviewing the article. The reviewers’ comments have helped make the paper more comprehensible and have highlighted both its strengths and its limitations. However, some spelling errors remain that must be corrected before publication. Please pay particular attention to the correct use of capital letters where required. [Note: HTML markup is below. Please do not edit.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0343634.r003
Revision 2
9 Dec 2025 Author Response Dear Editor, Thank you I uploaded 3 files including response, highlighted file and clean file. Manuscript Title: Attitude and Knowledge of Healthcare Providers Toward Female Genital Cosmetic Surgery: A Cross-Sectional Study We would like to thank the Academic Editor and the reviewers for their thoughtful comments and suggestions, which have helped us substantially improve our manuscript. Below, we provide point-by-point responses to each comment. Revisions have been made accordingly in the revised manuscript. Editorial and Journal Requirements 1. English Language and Style Editor: A general revision of the English language is necessary to make the article more straightforward. I found many spelling mistakes that need to be corrected. Response: Thank you for your observation. We have thoroughly revised the manuscript for spelling, grammar, and clarity. The revised version improves flow and ensures consistency in scientific language, capitalization, tense, and punctuation. A clean and tracked version has been uploaded. 2. Disparity in Specialties There is a significant disparity in the specialties of the participants. This should be addressed as it could lead to a different evaluation of the results. Response: We agree. We have now explicitly acknowledged this as a limitation in the Discussion and Strengths and Limitations sections. We also clarified the composition of participant groups in the Results section. 3. Limited Number of FGCS Providers Only 27 participants admit to performing FGCS "several times". This must be emphasized... consider focusing on these participants for subgroup analysis. Response: We thank the editor for this insight. We now emphasize the limited number of providers who routinely perform FGCS in the Results, Discussion, and Conclusion sections. Due to sample size constraints, subgroup analysis was limited, but we added a note suggesting future research explore this in greater detail. 4. Clarify “Advertising” What do you mean by "advertising"? Could you be more specific? Response: We clarified this term in the Methods section. “Advertising” refers to public promotional activities such as online campaigns, clinic websites, and social media used by healthcare providers or clinics to promote FGCS services. 5. Ethics Statement Location Your ethics statement should only appear in the Methods section. Response: Corrected. The ethics statement now appears only in the Materials and Methods section. 6. Data Availability All data must be made freely available. Response: We have uploaded a de-identified version of the dataset as Supplementary File S1, in compliance with the journal’s data policy. We also updated the Data Availability Statement accordingly. Reviewer #1 Were all these physicians from the same geographic area? Socioeconomic status? Response: We have clarified that all participants were based in Iran, and the majority practiced in urban healthcare settings. Unfortunately, detailed socioeconomic data were not collected, and this limitation is now acknowledged in the limitation section. The sociodemographic information of the physicians should be included... Response: Thank you for your comment. Unfortunately, additional sociodemographic information for the physicians is not available in the dataset, as it was not collected during the study. Amount of training received and prior FGCS performed should be reported. Response: These details were already partially reported. We now enhance this reporting in the Discussion, clearly stating the percentage with formal training and number of procedures performed Was this study only about cis-females or did it include trans-females? Response: Thank you for this important point. We clarify in the Methods that the study focused solely on cisgender women. This clarification has been added explicitly. It is interesting to elaborate on the cultural aspects of a study made in a conservative religious environment and compare it to data in the literature. Response: We appreciate this suggestion. We now expanded the Discussion to reflect the cultural and religious context of Iran and how this may affect healthcare providers’ attitudes. We also compared findings to those in more liberal or secular societies where FGCS is perceived differently. Conclusions and recommendations to the future need to be clearer. Response: We revised the Conclusion and Future Directions sections to present clearer and more actionable recommendations, including calls for standardized training, ethical guidelines, and further subgroup analysis. We hope these revisions meet the editorial and reviewer expectations and respectfully request reconsideration for publication. Thank you again for the opportunity to revise our work. Sincerely, Dr. Marjan Ghaemi, on behalf of all authors Attachments Attachment Submitted filename: response.docx https://doi.org/10.1371/journal.pone.0343634.r004
9 Feb 2026 Decision Letter - Federico Romano, Editor Attitude and Knowledge of Healthcare Providers Towards Female Genital Cosmetic Surgery: A Cross-Sectional Study PONE-D-25-11323R2 Dear Dr. Ghaemi, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Federico Romano, M.D., Ph.D. Academic Editor PLOS One Additional Editor Comments (optional): Thank you for submitting the revised version of your manuscript. We appreciate your careful attention to the reviewers’ and editors’ comments. I believe the article may open discussion on this underexplored topic and that it warrants further investigation. Reviewers' comments: https://doi.org/10.1371/journal.pone.0343634.r005

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .