PONE-D-23-40640Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity researchPLOS ONE

Dear Dr. HO,

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 Mar 29 2024 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: https://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,

Daniel Antwi-Amoabeng, MD, MSc

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. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. 

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

3. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process.

4. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well. 

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 

6. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The authors have tackled an important subject matter, and the work is worthy of publication in PLOS ONE once the reviewers’ comments are addressed.

[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: 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: Yes

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: I thank the authors for establishing this important cohort and describing in the associated manuscript.

In general it is well written and I think it fits with the journals overall scope, and in particular a benefit to society.

I have some specific comments which can be found in the attached annotated manuscript.

However, two broader comments to be addressed by the authors are:

1. Please can the authors describe in the methods to what degree have TGD community been involved in the design and conduct of the research, and how will they be involved in future cohort analysis and dissemination of results.

2. The different gender affirming surgeries have quite different rates of uptake which also vary within healthcare systems. This granularity is seldom published and would be valuable not only to scientists and physicians, but to policy makers. For this reason, describing the frequency of GAS in smaller categories e.g. hysterectomy BSO vs phallo/metoidio vs chest would be helpful.

I would recommend that the authors resubmit having addressed these comments.

Reviewer #2: I would like to thank the authors for the opportunity to review their manuscript. This study provides a blueprint for how to identify and describe TGD adults and their usage of gender-affirming care within a health care system based on ICD codes. While I am recommending revisions, my hope is that this article reaches publication given its importance.

Overall

I am curious about the decision to include BMI. I understand that many surgeons have BMI requirements for accessing surgeries, but it seemed like an add-on. There was no mention of BMI/weight in the lit review or the discussion, making me question its importance to your study. Research has shown the BMI to be an outdated measure, and further research has shown that the use of the BMI can be used to (1) gatekeep surgeries, and (2) contribute to weight stigma, particularly for folks in larger/fat bodies.

Abstract

Delete the word “have” in this sentence: “During this time frame, 2,995 adults have received gender-affirming hormone therapy (GAHT)…”

Introduction

Line 80: I recommend choosing a different word than “TGD experience”

The introduction/background is informative and grounds the reader for what’s coming next.

Methods

Line 117: “…and 22 were excluded as they did not meet the criteria for TGD.” This sentence confused me because it left me wondering what the criteria is for TGD. In line 119, you write something similar, except in parenthesis you include, “(all postmenopausal cis women on hormone replacement therapy).” Will you clarify prior to line 117 what the criteria are for TGD in this study? And if criteria aren’t met, will you specify why that is like you did in line 119? I’m also wondering if this could be an issue with phrasing (“criteria for TGD”).

Lines 112-125: I recommend re-writing this paragraph in a way that is more accessible to the reader. I found myself a bit lost reading this paragraph, particularly around the cohort being TGD-identified with 100% accuracy and then some folks not meeting criteria for TGD. In order for these methods to be replicated, I think there needs to be a bit more clarity.

I appreciate the way your team used the specific hormone therapy as categories to be more inclusive of nonbinary and TGD folks.

The statistical methods section makes sense and flows well.

Results

In your tables, I recommend removing the word Caucasian since it’s outdated.

The tables look great and really support the results section.

Discussion

Line 267: delete “an”

In the discussion, I think it could be worthwhile to note that although there are more known trans people, trans people have always existed and may not have felt comfortable/safe being as visible as they are today. Access to care is becoming more widespread and known, making it more likely for trans folks to engage with the health care system to access gender-affirming care. I think it’s important for readers to understand that there isn’t necessarily an increase in trans people, but there is an increase in trans visibility and trans people accessing care.

Conclusion

Lines 344-346: “In conclusion, the findings from this dataset underscore a significant alignment with national trends indicating a rapid increase in the number of TGD adults actively pursuing gender-affirming care.” I recommend re-writing this sentence. Unintentionally, by using language such as “rapid increase,” this may fuel arguments around social contagion and push the narrative that the number of TGD people is increasing rapidly, and the number of folks seeking gender-affirming care is rapidly increasing. It is clear that this is not your intention, but I immediately had this thought when reading this.

The closing sentence of the conclusion is great!

Again, thank you for the opportunity to review your manuscript. I can tell how intentional this work was conducted, and the thoughtfulness of the research team. I am recommending revisions to increase clarity and accessibility for readers.

**********

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: Yes: Dr Alison Berner

Reviewer #2: Yes: Brendon Holloway

**********

[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.

Attachments

Attachment

Submitted filename: PONE-D-23-40640_reviewer_comments.pdf

Attachment

Submitted filename: PONE-D-23-40640 Review.docx

Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity research

PONE-D-23-40640R1

Dear Dr. HO,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Daniel Antwi-Amoabeng, MD, Msc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for addressing the reviewers' comments. The work is accepted for publication in the revised form.

Reviewers' comments: