Marital status differences in suicidality among transgender people

Hui Liu; Lindsey Wilkinson

doi:10.1371/journal.pone.0255494

Peer Review History

Original SubmissionFebruary 5, 2021
10 May 2021 Decision Letter - Vincenzo De Luca, Editor PONE-D-21-04050 Marital Status Differences in Suicidality among Transgender People PLOS ONE Dear Dr. Liu, 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 Jun 24 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. 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, Vincenzo De Luca 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. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ 3.Thank you for stating the following financial disclosure: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." At this time, please address the following queries: Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution. State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” If any authors received a salary from any of your funders, please state which authors and which funders. If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. [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 Reviewer #3: Yes Reviewer #4: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: I Don't Know ****** 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: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: 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 Reviewer #3: Yes Reviewer #4: 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: This intriguing study sheds light on marriage and partnership as moderators of suicidal ideation and attempt among a large sample of transgender people. The manuscript is well-organized, easy to follow, and an interesting read. My two primary comments are in relationship to the discussion, which while well-written, could be expanded upon. First, I would like to see some discussion on suicidal ideation versus suicide attempt, particularly among the transwomen group. Second, it would be useful to discuss both effect sizes (small, moderate, large) and significance in the discussion section. Minor comments: First paragraph of introduction: Please provide statistics for suicidal ideation and attempt for cisgender people in the US, as a basis for comparison with transgender people. In the description of covariates (p. 8) there are two places where (reference) is given. It seems as though the authors meant to insert references in these locations of the text. Reviewer #2: I am very much enjoying reading the author's manuscript. This study assessed how marital status modifies the risk of suicide among transgender people. Below are my comments. 1. What is the meaning of “MICE”? Please provide the full name. 2. Authors divided marital status into five groups. However, I believe that readers will would like to know why authors do this classification. 3.Please provide the 95%CI for the results from logistic regression. 4. Pleas provide the specific P values. 5. How to define a transgender person? Self-report? 6. Please specifically describe the standard survey weight. Reviewer #3: I appreciate the authors for taking up this important subject of research among transgender population. The introduction and the background of this topic is well justified and appropriate statistical analysis has been done. Discussion is also well written with good review of relevant literature. I have few queries and suggestions: 1)Since the data is from 2015 USTS ,how did the authors deal with the issue of consent from study participants to use their information in the current study? 2)participant's suicidal thought and attempt could be influenced by their personality, underlying stressful situations and comorbid psychiatric conditions 3)No information regarding whether their marital status(married or unmarried ) was perceived to be stressful or not. 4)Any information regarding the sexual orientation of the partners with whom the study population had been married or previously married. (it would be important to note because this factor may also influence the other protective factors in a married relationship status) 5) It would be also good to note the duration of married status and its relationship to suicidal ideation or attempt Reviewer #4: - Suicidality in my opinion is very softly assessed, mainly on the basis of questions with binary answers. This is a weakness the authors must acknowledge and explain in the manuscript. - It would be prudent to include definitions of transmen and transwomen to make it easy for novice readers in this field. - Though a few covariates have been rightly included, certain others such as cultural factors, co-morbid mental illness etc have not been included and this deserves mention in the limitations section. Overall i feel a more comprehensive assessment of sucidality in a more limited representative population is better suited to the research question at hand. ****** 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: No Reviewer #3: No Reviewer #4: Yes:** Kartik Singhai [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.0255494.r001
Revision 1
18 Jun 2021 Author Response RESPONSE MEMO We greatly appreciate the helpful comments and suggestions from the reviewers. In the following memo, we make a point-by-point response to detail how we incorporated comments made by each reviewer into the revised manuscript. The text in quotations are the direct quotes from the reviewers’ comments, which are followed by our response. Response to Reviewer 1 1. “First, I would like to see some discussion on suicidal ideation versus suicide attempt, particularly among the transwomen group.” We now discuss differences in results between suicidal ideation and attempt (pp. 15-16), emphasizing that our measure of attempt includes only ideators. We discuss the implications of this measurement of ideation and attempt, integrating the ideation-to-action theoretical framework, highlighting our contribution to this framework and indicating the need for future work to explore, separately, correlates of ideation and attempt among ideators. Differences in findings for ideation and attempt among transmen and transwomen further highlight the need for more understanding of the dynamic interplay of marriage timing and the timing of transition, a dynamic that likely affects the association between marital status and suicidality and likely varies among transmen and transwomen. 2. “Second, it would be useful to discuss both effect sizes (small, moderate, large) and significance in the discussion section.” We have added some discussion about effect sizes of marital status in the discussion section (p. 13). Specifically, we compared the sizes of marital status effects to other fundamental factors of social determinants such as race/ethnicity, education and sexual orientation and discussed the implications (p. 13). 3. “First paragraph of introduction: Please provide statistics for suicidal ideation and attempt for cisgender people in the US, as a basis for comparison with transgender people.” We have provided the relevant statistics for the general U.S. population (p. 3). 4. “In the description of covariates (p. 8) there are two places where (reference) is given. It seems as though the authors meant to insert references in these locations of the text.” We apologize for the confusion. The “reference” on page 8 was to indicate the reference group in the analysis. We have now clarified it (p. 8). Response to Reviewer 2 1. “What is the meaning of “MICE”? Please provide the full name.” We now spell out the full name of MICE, Multiple Imputation using Chained Equations (p. 7). 2. “Authors divided marital status into five groups. However, I believe that readers will would like to know why authors do this classification.” We now provide a justification for our approach to categorize marital status groups (p. 8). 3. “Please provide the 95%CI for the results from logistic regression.” We have now included 95% CIs in logistic regression results. 4. “Pleas provide the specific P values.” We have now added specific p-values to logistic regression results. 5. “How to define a transgender person? Self-report?” We now clarify that our transgender respondents are self-identified as transgender (p. 7). We provide a clear definition of transgender (i.e., assigned birth sex is different from current primary gender identity and/or respondent identifies primarily as transgender or transsexual) for the purpose of clarifying our study sample, although we understand defining the transgender population is challenging given that there is no universally agreed definition of the term, transgender. 6. “Please specifically describe the standard survey weight.” The standard survey weight incorporates a weight constructed using information from the American Community Survey to help adjust for hypothesized over-representation of whites and the 18-year-old group in the USTS sample. We now include this information on p. 10. Response to Reviewer 3 1) “Since the data is from 2015 USTS ,how did the authors deal with the issue of consent from study participants to use their information in the current study?” This study is a secondary data analysis of public dataset and no individual can be identified in the data. This study was approved by the Michigan State University institutional review board. 2) “participant's suicidal thought and attempt could be influenced by their personality, underlying stressful situations and comorbid psychiatric conditions.” Unfortunately, we don’t have these variables in our data. We acknowledge this limitation and discuss this point and call future research to explore these variables using other datasets (p. 15). 3) “No information regarding whether their marital status(married or unmarried ) was perceived to be stressful or not.” Our analysis is limited by our data, which does not provide information about whether their marital status was perceived to be stressful or not. We acknowledge this limitation and discuss this point and call future research to explore this possibility using other datasets (p. 17). 4) “Any information regarding the sexual orientation of the partners with whom the study population had been married or previously married. (it would be important to note because this factor may also influence the other protective factors in a married relationship status).” Unfortunately, we don’t have information regarding the sexual orientation of the partner. We acknowledge this limitation and call for more data collection in this field to include the partner’s information (p. 17). 5) “It would be also good to note the duration of married status and its relationship to suicidal ideation or attempt.” Unfortunately, we don’t have information about duration of marital status in our data. We acknowledge this limitation and discuss this point and call more data collections (pp. 17). Response to Reviewer 4 1. “Suicidality in my opinion is very softly assessed, mainly on the basis of questions with binary answers. This is a weakness the authors must acknowledge and explain in the manuscript.” While binary measures of suicide are limited in their ability to assess, for example, intensity of suicide ideation, the measures available in the USTS data are commonly used in empirical research on suicide using large national samples, allowing for comparisons across studies utilizing similar measures. While the binary measures provided in the USTS present weaknesses, we have taken advantage of the ability to measure past year suicide ideation among all transgender individuals as well as past year attempt among those with past year ideation, which better aligns with current understandings of suicidality. We add discussion and acknowledgement of the limitations of our measures for suicidality and call for collection of additional measures of suicidality among large-scale datasets surveying the transgender population (pp.15-17). Nevertheless, the 2015 U.S. Transgender Survey (USTS), conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, is so far the best dataset available to address our research questions. There are no nationally representative population-based data representing transgender Americans. 2. “It would be prudent to include definitions of transmen and transwomen to make it easy for novice readers in this field.” As suggested, we include definitions of transmen and transwomen on page 7. 3. “Though a few covariates have been rightly included, certain others such as cultural factors, co-morbid mental illness etc have not been included and this deserves mention in the limitations section.” Unfortunately, we don’t have these variables in our data. We acknowledge this limitation and discuss this point and call future research to explore these variables using other datasets (p. 17). 4. “Overall i feel a more comprehensive assessment of suicidality in a more limited representative population is better suited to the research question at hand.” We agree with the reviewer on the limitations of the measures and representativeness of the data. However, the 2015 U.S. Transgender Survey (USTS), conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, is so far the best dataset available to address our research questions. There are no nationally representative population-based data representing transgender Americans. Although the measures of suicidality are limited, they are generally consistent with other national suicide studies (e.g., The National Institute of Mental Health. Suicide. [cited 2020 September]. Available from: https://www.nimh.nih.gov/health/statistics/suicide.shtml). We also acknowledge such limitations in the paper (pp. 16-17). Given the paucity of research in this area using large datasets, we believe the strengthens and potential scientific and public significance of this study outweigh its limitations. We hope our effort in this line of research would inspire more future research and more data collection in this emerging field. Attachments Attachment Submitted filename: PLOS ONE response 6.11.21.docx https://doi.org/10.1371/journal.pone.0255494.r002
19 Jul 2021 Decision Letter - Vincenzo De Luca, Editor Marital Status Differences in Suicidality among Transgender People PONE-D-21-04050R1 Dear Dr. Liu, 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, Vincenzo De Luca 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 Reviewer #2: All comments have been addressed Reviewer #3: All comments have been addressed Reviewer #4: 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 Reviewer #2: Yes Reviewer #3: (No Response) Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: (No Response) Reviewer #4: Yes ****** 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 Reviewer #2: Yes Reviewer #3: (No Response) Reviewer #4: 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 Reviewer #2: Yes Reviewer #3: (No Response) Reviewer #4: 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: (No Response) Reviewer #2: Thank you for your revision. Only one issue need to be addressed. Please re-check all the tables and use "P<0.001" to replace "P=0.000" Reviewer #3: (No Response) Reviewer #4: (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 Reviewer #2: No Reviewer #3: Yes: Manoj Prithviraj Reviewer #4: Yes:** Kartik Singhai https://doi.org/10.1371/journal.pone.0255494.r003
Formally Accepted
25 Aug 2021 Acceptance Letter - Vincenzo De Luca, Editor PONE-D-21-04050R1 Marital Status Differences in Suicidality among Transgender People Dear Dr. Liu: 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. Vincenzo De Luca Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0255494.r004

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 .