PONE-D-20-29954

Social conditions and mental health during COVID-19 lockdown among people who do not identify with the man/woman binomial in Spain

PLOS ONE

Dear Dr. Jacques Aviñó,

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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: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

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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: Dear editor,

Thank you for the opportunity to review the manuscript “Social conditions and mental health during COVID-19 lockdown among people who do not identify with the man/woman binomial in Spain”. It explores, as the title suggests, the social and health-related factors associated with mental health among people who do not identify with the man/woman binomial during COVID-19 lockdown. In the end, the authors conclude that people who did not identify with the man/woman binomial presented high proportions anxiety and depression during lockdown when compared to binary people. Although the manuscript brings to light an interesting and, commonly, neglected field of research, I do have two major concerns. Please, find them below:

1. Concerning the logistic models, I might have some suggestions:

a) The description of the models could improve. Precisely, the authors could make a bit more clear that the dependent variables were moderate/severe for anxiety and depression.

b) Sorry if I missed the information in the text but, why did the authors include 71 participants in the model if they had 72 participants initially? All the 72 participants fully complete the survey?

c) Another interesting analysis that can be easily done and might add some important topics in the discussion is to randomly select a matched sample for sociodemographic characteristics of 72 participants from the main database (n=7125) and (i) compare both groups regarding all mental health, and social and health-related factors. By doing so, it would be also possible to (ii) run the analysis in another way around, which means including being someone who does not identify with the man/woman binomial as an independent variable for moderate/severe anxiety and depression. Note that, although this might extrapolate the main aim of the study, it will fulfill a huge existing gap: How does the authors know if there is any specificity in this sample that should be taken into account and that it differs from the general population? In other words, how did the authors infer that it could have exacerbated pre-existing social inequities, such as adverse social, employment and economic conditions? For instance, by doing so, the authors would not need to hypothesized that “this could be explained due to the discrimination that non-binary people experience whenseeking employment”, but actually prove it. Additionally, how did the authors conclude that people who did not identify with the man/woman binomial presented high proportions of anxiety and depression during lockdown when compared to binary people, if the authors did not perform any group comparison, even being possible to do so? In my point of view, this is the most weak point of the present manuscript, because (a) it could have been done and (b) it would considerably increase the possible conclusions about the data. For instance, showing that not people who did not identify themselves with the man/woman binomial is a risk-factor, per se, independently of other variables; showing that even when compared to a matched sample people who did not identify themselves with the man/woman binomial indeed have more symptoms, etc. etc. In sum, the data analysis could have been far more complete.

d) Was any specific finding concerning the different items in the GAD7 or PHQ9? I am asking because another interesting finding could be to identify questionnaire items where people who do not identify with the man/woman binomial tend to report as more severe. Especially, if the authors are planning to use this data in qualitative future study, as they report. For instance, the authors could find that people who do not identify with the man/woman binomial report more self injuring thoughts. Again, another easy finding that could be extracted from the data and could considerably enrich the quality of the manuscript.

e) Which software was used for data analysis?

f) How does this information “All members of the research team are highly sensitive towards the different axes of social inequities, and the multiple power structures that impact the population unequally” adds something for the study? I mean, as a human science researcher, isn't it redundant to randomly state this in the method?

2. Concerning the survey:

a) Which software was used to run the online survey? How was the advertisement done? The authors provide any information about it. Was it through electronic media and a snowball sampling method, whereby the researcher invited the participants to share the survey with their contacts? There is far too little information on this regard.

b) How did the authors check for the reliability of the participants' answers? In online or extensive surveys, it might be useful to include some methods to decrease the odds of considering in the analysis someone that answered it randomly. For instance, including two similar questions in different moments to confirm if the answers will be also similar (sometimes it can be done by checking similar questions between and within questionnaires). Another strategy could be to check for mistakes or weird answers in basic questions such as age. Moreover, did the authors include a question asking whether the participant had already answered the survey? How much time, on average was necessary to complete the survey? Sometimes, this could also be used as a criteria to exclude non-reliable answers. For instance, if someone took much less than the mean time and its variance, it could indicate non-reliable answers.

3. Concerning the results and discussion:

a) In general, I think that both are adequate for the implemented method. Nevertheless, if the authors intend to address some of the major methodological concerns and considerably increase the quality of the study and the possible conclusions on the observed behaviour it will change both sections.

b) I would recommend reporting the results from Table 2 as a figure. It is a minor suggestion, but I think it turns more interesting for the reader. Don’t you?

c) The authors discussed that “this study contributes to the debate on the categorisation of sex-gender identities in health surveys and other registries, to question and challenge normative ways of classification”, however, they did not provide some options about how this could have been done or how to improve it in future studies. This is crucial, especially because the authors indeed add that “The research team will consider which could be the best way to frame questions around sex/gender for future surveys”. I mean, the main science goal is to learn from our own and others mistakes, right? How can I improve my research practice and reframe this question about gender/sex?

d) I did not find the fully available data.

Once more, thank you for the opportunity,

Best regards,

Reviewer #2: Line 51- Why is queer italicized?

Lines 65, 75-76- The terms sex-gender/sexual-gender is unclear. Please replace or define

Since sexual identity is generally used to refer to the sexual orientation that one identifies with, I don’t think this is a good term to use- I encourage you to find an alternative; I find the description of why you are not using the term gender identity unclear, please expand.

Line 116- Death of loved one

Lines 177-179- Without doing a significance test, I don’t think you can make the claim that non-binary people’s experiences are worse than men or women’s

I encourage another round of proofreading/copy editing

There is a lot of important work here, and I am so glad you are considering a vulnerable and under-researched population. I have concerns that your current methods do not allow you to say that non-binary people are experiencing greater mental health problems than their binary counterparts or that COVID is exacerbating these inequities. I would argue that associations between unemployment pre-COVID and depression/anxiety may suggest COVID is not exacerbating these symptoms but rather this problem was pre-existing. I encourage using a comparative analysis- perhaps an interaction of gender identity/predictor variable and mental health outcomes- using only variable that have shifted during COVID OR changing the framing to highlight particularly vulnerable subgroups of non-binary folks.

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Reviewer #1: No

Reviewer #2: Yes: Briana L McGeough

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Social conditions and mental health during COVID-19 lockdown among people who do not identify with the man/woman binomial in Spain

PONE-D-20-29954R1

Dear Dr. Avino,

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.

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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

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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: 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: No

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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: Dear Editor,

Thank you once more for the opportunity to review the manuscript “Social conditions and mental health during COVID-19 lockdown among people who do not identify with the man/woman binomial in Spain. The authors fully attended to all my concerns and did a great work by improving the data analysis, which had a substantial impact in the results and, consequently, to the overall picture and possible interpretations. The method was also improved concerning the data collection strategy, which was a major point before.

As a minor point, I would suggest the authors to say a word about “We analysed if there were any incoherent answers and did not find any”. I mean, how? Once more, this is not crucial.

Best regards,

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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: Yes: Bruno Kluwe-Schiavon