Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019–2020

Travis Salway; Stephen Juwono; Ben Klassen; Olivier Ferlatte; Aidan Ablona; Harlan Pruden; Jeffrey Morgan; Michael Kwag; Kiffer Card; Rod Knight; Nathan J. Lachowsky

doi:10.1371/journal.pone.0252539

Peer Review History

Original SubmissionDecember 9, 2020
24 Feb 2021 Decision Letter - Xiaozhao Yousef Yang, Editor PONE-D-20-38781 Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019-2020 PLOS ONE Dear Dr. Salway, 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 Apr 10 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. 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We will update your Data Availability statement on your behalf to reflect the information you provide. [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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No ****** 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 ****** 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 ****** 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: Overall, the authors explored an interesting subject which has great implications to policymaking. The organization and presentation of the manuscript are very clear. Below I listed my questions and comments for the authors. 1. I would like to see more discussions about the two previous research on CTP based in Canada. Information such as how samples were collected, sample sizes, mean age of respondents, and geographic locations of the respondents if such information is available. 2. In the introduction section, the authors may also want to briefly explain why some of their focuses matter—settings of CTP occurrence, age at initiation of CTP etc. Are variations in those variables associated with variations in risks for feelings of shame, anxiety, depression, problematic substance use, suicide ideation, and/or suicide attempts—those consequences mentioned in the first paragraph? Some more discussion on this question may better highlight the importance and contribution that this study may potentially make. 3. “In total, N=7,237 provided a response to the last question”. Does it mean that 7,237 respondents answered the very last question or all questions? If it is the former, then what is the last question? Why is the very last question so important that it is worth mentioning here? 4. In the primary outcome variable, what are those response categories? 5. “Analyses were descriptive (univariate) and bivariate; multivariable analyses were not consistent with the objectives of this study, i.e., to generate statistics that inform CTP policy and intervention, rather than to identify causal effects (i.e., controlling for relationships between covariates)”. Your data are not longitudinal and therefore even if you use multivariate analysis, the results cannot reveal causality. On the other hand, why can’t multivariate analyses be used for policy making purposes? Isn’t multivariate analysis more capable of providing evidence of robust relationship than a bivariate analysis? 6. “This study demonstrates that 1 in 10 sexual minority men in Canada have experienced conversion therapy practices”. This is a very bold statement as your sample may not be nationally representative. 7. “We found that experiences of CTP were more prevalent among the youngest survey participants, despite these men having come of age during a time when visibility and social acceptance of minority sexual orientations is greater than it was for previous generations”. Could it also be that because of the greater social acceptance in recent years, the younger are more likely to come out and thus make themselves an easier target for CTP? This is why I think multivariate analyses can do a better job on informing the public and policymakers about the actual correlates of the outcome variable of interest. 8. Reading table 1 and 2, the 95% C.I. s are fine but should caution the readers that interpreting those statistics should be based on the assumption that the sample is representative of the population of interest but the samples used in the study are not. The authors may want to raise this issue in the results section. 9. As for table 3, I was wondering does “duration of conversion effort” or “conversion effort attempts” vary by sexual and gender identity? ****** 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 [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.0252539.r001
Revision 1
19 Apr 2021 Author Response April 10, 2021 Dear Dr. Yang, On behalf of named co-authors, I am pleased to submit a revised manuscript, in which we attend to the helpful comments from you and the reviewer, as outlined below. We look forward to hearing from you about next steps. Sincerely, Travis Salway, travis_salway@sfu.ca Editor comments: 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 Response: Thank you. We have adjusted the formatting of the manuscript to correspond to the PLoS ONE style requirements outlined in these links. We were unable to find instructions for file naming, but have replaced each file name with the first author’s last name + “Revised manuscript marked”, “Revised manuscript clean”, and “Response to reviewers.” 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. Response: We have added this detail to the manuscript (p7, lines 137-138). 3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions . In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. Response: We have revised the ‘Data Availability’ statement as follows: “The University of Victoria's Human Research Ethics Board has only approved storage of our data on secure university servers because the data contain potentially sensitive information about study participants. Data are available upon request through secure university servers only. Any requests to access the data can be made to University of Victoria's Human Research Ethics Board (250-472-4545 or ethics@uvic.ca). For further information about SexNow data access, including aggregated survey statistics, visit: https://www.cbrc.net/ourstats” Reviewer comments: Reviewer #1: Overall, the authors explored an interesting subject which has great implications to policymaking. The organization and presentation of the manuscript are very clear. Below I listed my questions and comments for the authors. 1. I would like to see more discussions about the two previous research on CTP based in Canada. Information such as how samples were collected, sample sizes, mean age of respondents, and geographic locations of the respondents if such information is available. Response: We have added these details about SexNow 2011 and TransPulse 2019 to the Introduction (p4, lines 80-83). 2. In the introduction section, the authors may also want to briefly explain why some of their focuses matter—settings of CTP occurrence, age at initiation of CTP etc. Are variations in those variables associated with variations in risks for feelings of shame, anxiety, depression, problematic substance use, suicide ideation, and/or suicide attempts—those consequences mentioned in the first paragraph? Some more discussion on this question may better highlight the importance and contribution that this study may potentially make. Response: Thank you for pointing out this gap in our rationale. Empirical data regarding these parameters are important when designing legislative approaches (e.g., bans) or educational campaigns to prevent CTP exposure. We have added this explanation to the corresponding section of the Introduction (pp4-5, lines 89-92). 3. “In total, N=7,237 provided a response to the last question”. Does it mean that 7,237 respondents answered the very last question or all questions? If it is the former, then what is the last question? Why is the very last question so important that it is worth mentioning here? Response: This means that 7,237 respondents completed the entire survey, although some may have skipped questions along the way. We have revised this sentence for clarity (p7, line 140). We believe this detail is useful for readers interested in knowing the number of participants who stopped answering survey the survey between the first and last question. 4. In the primary outcome variable, what are those response categories? Response: We have added the response categories to this part of the Methods section, for further clarity (p7, lines 145-149). 5. “Analyses were descriptive (univariate) and bivariate; multivariable analyses were not consistent with the objectives of this study, i.e., to generate statistics that inform CTP policy and intervention, rather than to identify causal effects (i.e., controlling for relationships between covariates)”. Your data are not longitudinal and therefore even if you use multivariate analysis, the results cannot reveal causality. On the other hand, why can’t multivariate analyses be used for policy making purposes? Isn’t multivariate analysis more capable of providing evidence of robust relationship than a bivariate analysis? Response: Thank you for this suggestion. We have now analyzed multivariable models for both of the outcomes and added these results to a new table (now labeled Table 3). Corresponding methods statements have been added (p10, lines 206-210), and the multivariable/adjusted relative risks are interpreted in a new sub-section of Results (pp11-12, lines 237-254). 6. “This study demonstrates that 1 in 10 sexual minority men in Canada have experienced conversion therapy practices”. This is a very bold statement as your sample may not be nationally representative. Response: We agree that this estimate should be interpreted with caution, given the non-probabilistic sampling methods used. We have revised this sentence (p13, lines 280-281) as follows: “This study demonstrates that 1 in 10 sexual minority men non-randomly sampled in a Canadian community-based survey have experienced conversion therapy practices.” 7. “We found that experiences of CTP were more prevalent among the youngest survey participants, despite these men having come of age during a time when visibility and social acceptance of minority sexual orientations is greater than it was for previous generations”. Could it also be that because of the greater social acceptance in recent years, the younger are more likely to come out and thus make themselves an easier target for CTP? This is why I think multivariate analyses can do a better job on informing the public and policymakers about the actual correlates of the outcome variable of interest. Response: Thank you for this suggestion. We agree that this is a convincing explanation for the greater prevalence of CTP in the youngest age group, and we have added this suggested interpretation to the Discussion section (p13, lines 287-292), including an acknowledgment that the association between young age and CTP exposure was reduced with adjustment, notably including adjustment for outness. 8. Reading table 1 and 2, the 95% C.I. s are fine but should caution the readers that interpreting those statistics should be based on the assumption that the sample is representative of the population of interest but the samples used in the study are not. The authors may want to raise this issue in the results section. Response: We have added a statement acknowledging that our sample does not meet the assumption of randomness and CIs should therefore be interpreted with caution (p9, lines 194-196). 9. As for table 3, I was wondering does “duration of conversion effort” or “conversion effort attempts” vary by sexual and gender identity? Response: Thank you for this suggestion. We have analyzed these two variables by sexual orientation and gender identity and added the results to the corresponding section of the manuscript (p12, lines 264-267). Attachments Attachment Submitted filename: Salway_ResponseToReviewers_20210410.docx https://doi.org/10.1371/journal.pone.0252539.r002
18 May 2021 Decision Letter - Xiaozhao Yousef Yang, Editor Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019-2020 PONE-D-20-38781R1 Dear Dr. Salway, 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, Xiaozhao Yousef Yang, 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: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) ****** 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: (No Response) ****** 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: (No Response) ****** 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: (No Response) ****** 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.0252539.r003
Formally Accepted
24 May 2021 Acceptance Letter - Xiaozhao Yousef Yang, Editor PONE-D-20-38781R1 Experiences with sexual orientation and gender identity conversion therapy practices among sexual minority men in Canada, 2019-2020 Dear Dr. Salway: 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 Dr. Xiaozhao Yousef Yang Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0252539.r004

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