PONE-D-20-21733

Experiences of violence and mental health outcomes among Asian American transgender adults in the United States

PLOS ONE

Dear Dr. Becerra,

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.

There are a number of methodological issues to be addressed, including:

1. Please specify the number of participants included in your sample for analysis - this currently only to be provided as 7.89%

2. Please add more information on how the survey was delivered (online? face to face?), how were participants recruited? What was the eligibility criteria (who was targeted)? 

3. I have some issues with how the outcomes were defined; the  authors state that the outcome variables include dichotomized versions of suicidal ideation, suicidal thoughts, and serious psychological distress - however, only suicide thoughts are reported on (not ideation) - how do thoughts and ideation differ in this study (they usually mean the same thing)? This requires further clarification. Moreover, what instruments were used to ask participants about suicidal ideation and attempts? Were they scales, were they validated? If they were scales, I would query why the authors recoded them into dichotomous variables when a continuous score would have been clinically more significant. If authors did recode scales into dichotomous variables, how was the decision made as to what constitutes a 'yes' answer and what is a 'no' answer? Much more detail is needed. 

4. I similarly question the authors decision to create over simplistic 'yes/no' variables to assess experience of violence, when there appears to be rich data on different types of violence; there is literature to support that different types of violence have different impacts on mental health, and it would be a genuine value add of this study to examine the experience of different types of violence on suicide outcomes in this transgender population. I would strongly suggest some re analysis to provide a more nuanced understanding of the effects of types of violence on suicidal thoughts and attempts. 

Please submit your revised manuscript by Dec 20 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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We look forward to receiving your revised manuscript.

Kind regards,

Michelle Tye, Ph.D.

Academic Editor

PLOS ONE

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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

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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 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

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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

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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: Experiences of violence and mental health outcomes among Asian American transgender adults in the United States

I agree that Asian American transgender individuals are an understudied population, in general, and in the context of negative mental health outcomes including suicidal ideation, suicidal thoughts, and serious psychological distress (SPD). This is novel and important work. This was a secondary data analysis of restricted-use national data.

Abstract

• Methods: can you identify how you subsetted to Asian Americans? How was this assessed in the 2015 USTS? Who is included in this ethnic group?

• Methods/Results: Improve notation for aOR and 95% CI for consistency. For example, define the format first/once in the methods then use it consistently in the results. For example:

o Methods: Adjusted odds ratio and 95% confidence interval (aOR; 95% CI) for each outcome will be adjusted for age, marital status, citizenship status, education level, employment status, and poverty level.

o Results: Experience of harassment/abuse during bathroom use had increased odds of suicidal attempts (1.81; 1.41, 2.31).

Manuscript

• Line 59-60: Does the literature refer to diagnosed cases or self-report?

• Can you speak to stigma for seeking mental health services and care?

• Line 70-71: same question as above. Does the literature refer to diagnosed cases or self-report?

• Line 96: Is the paragraph starting on this line refer to Asian Americans or transgender people nationally

• Line 155 and 164: Why is “OR” in caps?

• Line 185: Improve the statement for alpha or significance level. It is not clear what you are denoting. Perhaps you can say that “the significance level of .05 was used” or “A p-value less than 0.05 will determine a statistically significant difference”. You use other significance levels in the tables. You should mention these here as well.

• Methods/Results: as indicated for the abstract, improve notation for aOR and 95% CI for consistency. For example, define the format first/once in the methods then use it consistently in the results.

• Results: you are referring to “significantly higher “rates. Did you conduct one-tail or two tailed statistical tests? Your method section does not indicate the bivariate tests used.

• Results: Be consistent with rounding for percentages reported though this section including tables.

• Results: In tables, improve title and include sample sizes in the title or somewhere in the table. Distinguish headers from variables. Perhaps consider moving the asterisks denoting significant findings.

• Table 2: you have a symbol in front of “~U.S. Citizen” that you did not define at the footer of the table.

• Conclusion: this section lacks detail particularly to what the results indicate. what type of clinicians are your referring to? What type of assessments are your referring to?

• IRB approval: IRB review is mentioned in the acknowledgement section but not in the methods.

Reviewer #2: The manuscript, “Experiences of violence and mental health outcomes among Asian American transgender adults in the United States,” describes a study examining experiences of Asian American transgender adults in terms of violence and mental health using the 2015 US Transgender Survey. Key findings included high rates of minority stress (discrimination and abuse) as well as negative mental health outcomes, such as suicide ideation and distress. Authors highlight the need for reducing exposure to negative outcomes and greater use of trauma informed care approaches in healthcare settings. Several strengths of this study include novel topic and potential for future research. Despite several strengths, there are a number of research and conceptual issues that if addressed, would significantly improve the manuscript. These are explained below in no particular order.

1. It would be beneficial to readers to learn more about potential research on mental health of Asian American transgender and additional gender minority populations. For instance, several articles should be considered:

Ching TH, Lee SY, Chen J, So RP, Williams MT. A model of intersectional stress and trauma in Asian American sexual and gender minorities. Psychology of violence. 2018 Nov;8(6):657.

Operario D, Nemoto T. Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women. AIDS Education & Prevention. 2005 Oct 1;17(5):430-43.

Snow A, Cerel J, Loeffler DN, Flaherty C. Barriers to mental health care for transgender and gender-nonconforming adults: a systematic literature review. Health & social work. 2019 Aug 2;44(3):149-55.

Howard SD, Lee KL, Nathan AG, Wenger HC, Chin MH, Cook SC. Healthcare experiences of transgender people of color. Journal of general internal medicine. 2019 Oct 1;34(10):2068-74.

2. Methods: Consider providing Cronbach alpha for the Kessler-6 scale for study sample.

3. Table 2 needs a more descriptive/detailed title.

4. It appears that chi-square tests were run to test potential associations. If this represents potential prevalence by factors that are weighted, authors might consider putting the 95% Confidence Intervals

5. For logistic regression, authors may want to present findings in terms of prevalence ratios.

6. Did authors consider testing any interactions with demographics (age, education level, employment, poverty) as it appears these could represent intersectionality. Also may want to consider differences by gender identity (e.g., non-binary vs. gender male/female identifying groups).

7. It appears that additional limitations of the 2015 USTS survey were not mentioned. Authors should consider additional concerns in terms of non-probability sample. See the following for additional limitations:

Henderson, E.R., Blosnich, J.R., Herman, J.L. and Meyer, I.H., 2019. Considerations on sampling in transgender health disparities research. LGBT health, 6(6), pp.267-270.

8. The discussion needs further development, such as other studies in cisgender sexual minorities and cisgender Asian Americans with regards to experiencing abuse and risk of suicide/mental health distress.

9. Discussion should touch how healthcare needs and tailoring of trauma-informed care that considers intersectionality, such as identifying as both Asian American and a gender minority.

10. It might be helpful to readers to further tease of unique cultural concerns for Asian American gender minorities as well as details on how research can be more inclusive of these communities. It might be helpful to expand on any findings in terms of care and needed research on immigration/acculturation and gender minorities.

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Reviewer #1: No

Reviewer #2: Yes: Jason Flatt

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Attachments

Attachment

Submitted filename: PONE-D-20-21733.docx

PONE-D-20-21733R1

Experiences of violence and mental health outcomes among Asian American transgender adults in the United States

PLOS ONE

Dear Dr. Becerra,

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.

==============================

The authors have adequately addressed the first set of revisions, there are some additional queries below that need to be addressed, and which should significantly strengthen the manuscript. 

==============================

Please submit your revised manuscript by Feb 25 2021 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.

Please include the following items when submitting your revised manuscript:

• 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Michelle Tye, Ph.D.

Academic Editor

PLOS ONE

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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: (No Response)

**********

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: I Don't Know

**********

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: I agree that Asian American transgender individuals are an understudied population, in general, and in the context of negative mental health outcomes including suicidal ideation, suicidal thoughts, and serious psychological distress (SPD). This is novel and important work. This was a secondary data analysis of restricted-use national data.

Abstract

• Methods: Can you identify how you subsetted to Asian Americans? How was this assessed in the 2015 USTS? Who is included in this ethnic group?

• Methods/Results: Improve notation for aOR and 95% CI for consistency. For example, define the format first/once in the methods then use it consistently in the results. For example:

o Methods: Adjusted odds ratio and 95% confidence interval (aOR; 95% CI) for each outcome will be adjusted for age, marital status, citizenship status, education level, employment status, and poverty level.

o Results: Experience of harassment/abuse during bathroom use had increased odds of suicidal attempts (aOR: 1.81; 95% CI: 1.41, 2.31).

Manuscript

• Line 59-60: Does the literature refer to diagnosed cases or self-report?

• Can you speak to stigma for seeking mental health services and care?

• Line 70-72: same question as above. Does the literature refer to diagnosed cases or self-report?

• Line 155 and 157: Why is “OR” in caps? Perhaps consider listing the measures without stating the entire question asked, separated with semicolons. For example, instead of “In the past year, did anyone verbally harass you for any reason?”, you can indicate “verbal harassment for any reason in past year”.

• Line 211: Improve the statement for alpha or significance level. It is not clear what you are denoting. Perhaps you can say that “The significance level of .05 was used” or “A p-value less than 0.05 determined a statistically significant difference”. You use other significance levels in the tables. You should mention these here as well.

• Methods/Results: as indicated for the abstract, improve notation for aOR and 95% CI for consistency. For example, define the format first/once in the methods then use it consistently in the results.

• Results: you are referring to “significantly higher “rates. Did you conduct one-tail or two tailed statistical tests? Your method section does not indicate the bivariate tests used (Line 200).

• Results: Be consistent with rounding for percentages reported though this section including tables.

• Results: In tables, improve title and include sample sizes in the title or somewhere in the table. Distinguish headers from variables. Perhaps consider moving the asterisks denoting significant findings.

• Tables: Consider justifying to the right for the numeric columns.

• Table 2: You have a symbol in front of “~U.S. Citizen” that you did not define at the footer of the table.

• Conclusion: this section lacks detail particularly to what the results indicate. What type of clinicians are your referring to? What type of assessments are your referring to?

**********

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

[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.

Experiences of violence and mental health outcomes among Asian American transgender adults in the United States

PONE-D-20-21733R2

Dear Dr. Becerra,

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.

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Kind regards,

Michelle Tye, Ph.D.

Academic Editor

PLOS ONE

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