Trans and gender diverse people’s experiences of healthcare access in Australia: A qualitative study in people with complex needs

Bridget Gabrielle Haire; Eloise Brook; Rohanna Stoddart; Paul Simpson

doi:10.1371/journal.pone.0245889

Peer Review History

Original SubmissionOctober 14, 2020
13 Nov 2020 Decision Letter - Stefano Federici, Editor PONE-D-20-32368 Trans and gender diverse people’s experiences of healthcare access in Australia: a qualitative study in people with complex needs PLOS ONE Dear Dr. Haire, 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 Dec 28 2020 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. 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For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter. [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? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: 1) I dont know that the first sentence is correct in terms of being understudied: of all the research in the field, research on health and the impact of discrimination likely constitutes the bulk of research 2) The paper switches between writing out, for example, trans woman as two words, and combining them as one. Having it uniform as two words throughout would be preferable 3) Not sure that AMAB and AFAB are necessary in the table? 4) The following chapter might be of interest to the authors given the focus on complexity of care: Riggs, D.W., & Bartholomaeus, C. (2017). The disability and diagnosis nexus: Transgender men navigating mental health care services. In C. Loeser, V. Crowley & B. Pini (Eds.) Disability and masculinities: Corporeality, pedagogy, and the critique of otherness (pp. 67-84). London: Palgrave. 5) I think actual pseudonyms would be preferable to initials. Also, the method doesnt state if these initials are pseudonyms 6) The results sit on the side of a 'extract and comment' approach, which makes for a rather thin analysis of the data. Ideally, a little more detailed analysis of each extract would be undertaken: as per Braun and Clarke, a focus on latent as well as semantic meaning. This might mean reducing the number of extracts in each sub theme as at present they are rather long 7) Some of the themes or sub themes have specific titles when the extracts are actually quite broad. The mental health sub theme, for example, includes extracts that have seemingly little to do with mental health. Either the contents of the themes needs to be clarified, or a more indicative title used. Reducing the number of extracts as per 6 might also help with this. 8) The sub theme title 'attributes' is not descriptive (ie it doesnt describe the theme contents) Reviewer #2: This article contributes to a small but important body of knowledge about the health care needs of a hard to reach group. The authors acknowledge that it is a small sample and not representative in any sense, nevertheless the data collected is valuable in informing reform of the health system. The study is well designed and the methodology sound. The literature is adequate for the scale of the study. The research has clearly been carried out with a great deal of cultural sensitivity and so serves to demonstrate how data can be collected from those who are disenfranchised and so often not heard. The data is used to shape practical suggestions about health care provision in the future for those with complex needs. It makes a valuable contribution to the body of knowledge in relation to transgender people. ****** 6. PLOS authors have the option to publish the peer review history of their article (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: Yes:** Emeritus Professor Anne Mitchell [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.0245889.r001
Revision 1
4 Jan 2021 Author Response Thanks too the reviewers for their thoughtful and detailed recommendations. Reviewer #1 1) I don’t know that the first sentence is correct in terms of being understudied: of all the research in the field, research on health and the impact of discrimination likely constitutes the bulk of research We have changed the first sentence to: The global disease and health burden of trans and gender diverse (TGD) people are poorly understood, and the impacts of stigma, discrimination and violence are particularly serious. 2) The paper switches between writing out, for example, trans woman as two words, and combining them as one. Having it uniform as two words throughout would be preferable Thank you for this observation – we have identified all instances of the combining into one word, and changed to two words. 3) Not sure that AMAB and AFAB are necessary in the table? Our research team had been ambivalent about the inclusion of AMAB and AFAB, and we are very happy to take reviewer 1’s advice on this. These have now been removed (Table 1, pp8-10) 4) The following chapter might be of interest to the authors given the focus on complexity of care: Riggs, D.W., & Bartholomaeus, C. (2017). The disability and diagnosis nexus: Transgender men navigating mental health care services. In C. Loeser, V. Crowley & B. Pini (Eds.) Disability and masculinities: Corporeality, pedagogy, and the critique of otherness (pp. 67-84). London: Palgrave. Thank you for recommending this chapter. We have included a reference to it on page 4. This ‘gateway’ diagnosis is problematic not only because it is implicitly pathologizing, but because it may render a TGD person’s mental health issues invisible in contexts where accessing gender affirming treatment may take priority over full and frank discussion of mental health with a clinician.(10) We have also removed the word ‘comorbidities’ in the manuscript, in response to the critique of that term made in this chapter(see line 546). 5) I think actual pseudonyms would be preferable to initials. Also, the method doesn’t state if these initials are pseudonyms We have changed all initials to pseudonyms and noted this in the text (lines 166 and 180). 6) The results sit on the side of a 'extract and comment' approach, which makes for a rather thin analysis of the data. Ideally, a little more detailed analysis of each extract would be undertaken: as per Braun and Clarke, a focus on latent as well as semantic meaning. This might mean reducing the number of extracts in each sub theme as at present they are rather long We thank the reviewer for this comment and acknowledge that there is a descriptive emphasis in this study. The research team wants to keep the extracts in the results section relatively long so a sense of the voices of the participants can be discerned in the text. 7) Some of the themes or sub themes have specific titles when the extracts are actually quite broad. The mental health sub theme, for example, includes extracts that have seemingly little to do with mental health. Either the contents of the themes needs to be clarified, or a more indicative title used. Reducing the number of extracts as per 6 might also help with this. In the originally submitted version mental health was specifically addressed in the subtheme, Complexity in mental healthcare (lines 229-261). In response to the reviewer, we have renamed this subtheme ‘mental healthcare’. The issue of cost as a barrier to all forms of healthcare, including mental health, was then addressed under the theme ‘affording healthcare’ under the subtheme ‘economic hardship’. In this subtheme, the cost of mental healthcare is discussed alongside costs of dental healthcare and costs of prescription medication. We think that this is well justified because costs of healthcare was a significant issue for all participants, and this was not limited to mental health. Keeping this theme separate allows the reader to see the catastrophic impacts of delaying dental over time, with the example of Jen losing all her teeth and also bone mass due to her long term economic deprivation. 8) The sub theme title 'attributes' is not descriptive (ie it doesn’t describe the theme contents) We agree with the reviewer, and have changed the name of this subtheme to ‘positive qualities’. Reviewer #2 This article contributes to a small but important body of knowledge about the health care needs of a hard to reach group. The authors acknowledge that it is a small sample and not representative in any sense, nevertheless the data collected is valuable in informing reform of the health system. The study is well designed and the methodology sound. The literature is adequate for the scale of the study. The research has clearly been carried out with a great deal of cultural sensitivity and so serves to demonstrate how data can be collected from those who are disenfranchised and so often not heard. The data is used to shape practical suggestions about health care provision in the future for those with complex needs. It makes a valuable contribution to the body of knowledge in relation to transgender people. We thank the reviewer for her supportive comments. ________________________________________ Attachments Attachment Submitted filename: Response to reviewers trans paper.docx https://doi.org/10.1371/journal.pone.0245889.r002
11 Jan 2021 Decision Letter - Stefano Federici, Editor Trans and gender diverse people’s experiences of healthcare access in Australia: a qualitative study in people with complex needs PONE-D-20-32368R1 Dear Dr. Haire, 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 for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. 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, Stefano Federici, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors have made comprehensive changes to the manuscript, which is much improved as a result. I appreciate the points the authors made about the themes developed, and accept that there are differing ways of reporting a thematic analysis. ****** 7. PLOS authors have the option to publish the peer review history of their article (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 https://doi.org/10.1371/journal.pone.0245889.r003
Formally Accepted
14 Jan 2021 Acceptance Letter - Stefano Federici, Editor PONE-D-20-32368R1 Trans and gender diverse people’s experiences of healthcare access in Australia: a qualitative study in people with complex needs Dear Dr. Haire: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Prof. Stefano Federici Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0245889.r004

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