PONE-D-24-34499A systematic review of the research evidence of the impact of intersectionality on service engagement and recovery across different groups of women, trans women, and non-binary individuals experiencing homelessness and housing exclusionPLOS ONE

Dear Dr. Hess,

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 Jan 11 2025 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,

Lakshminarayana Chekuri, MD, PhD

Academic Editor

PLOS ONE

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When submitting your revision, we need you to address these additional requirements.

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2. Thank you for stating the following financial disclosure: 

 This work was supported through doctoral funding from the National Institute for Health and Care Research (NIHR) School for Social Care Research 

Please state what role the funders took in the study.  If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" 

If this statement is not correct you must amend it as needed. 

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

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This work was supported through doctoral funding from the National Institute for Health and Care Research (NIHR) School for Social Care Research. Special thanks to the first author’s doctoral advisory group for valuable feedback and reflections. We also thank the KCL clinical support librarians for their help developing the search strategy.

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 This work was supported through doctoral funding from the National Institute for Health and Care Research (NIHR) School for Social Care Research

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. As required by our policy on Data Availability, please ensure your manuscript or supplementary information includes the following: 

A numbered table of all studies identified in the literature search, including those that were excluded from the analyses.  

For every excluded study, the table should list the reason(s) for exclusion.  

If any of the included studies are unpublished, include a link (URL) to the primary source or detailed information about how the content can be accessed. 

A table of all data extracted from the primary research sources for the systematic review and/or meta-analysis. The table must include the following information for each study: 

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Confirmation that the study was eligible to be included in the review.  

All data extracted from each study for the reported systematic review and/or meta-analysis that would be needed to replicate your analyses. 

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Additional Editor Comments :

Thank you for your scholarly contribution to the topic area of Homelessness. I'd also like to thank the authors for choosing PLOS ONE to publish your findings from this study. Comments from reviewers are provided below. Please review these comments and I suggest address them and resubmit your manuscript. Your timely response would help this study be published and will make it accessible to interested readers across the world. I look forward to reviewing your revised manuscript. I wish you good luck with your future endeavors.

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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

Reviewer #3: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: Yes

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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: Yes

Reviewer #2: No

Reviewer #3: 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

Reviewer #3: 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: Thanks so much for the opportunity to read this review. I commend the authors on the extensiveness of their search, and their thorough analysis and reporting on this important topic. My general comments have to do with the methodology, namely with the outcomes measured and included settings.

INCONSISTENCY IN OUTCOMES & SETTINGS

Reading through the abstract, introduction, and materials and methods, the following outcomes seem to be mentioned at different times:

1. Impact of intersectionality on homelessness trajectories, recovery and engagement with services (Abstract background)

2. Impact of intersectionality on engagement with services and recovery (Abstract methods)

3. Impact of intersectionality on homelessness trajectories, recovery, and engagement with specific services (Aims of this paper; matches abstract background)

4. How help was sought, offered and received (Aims of this paper – Lines 37-38)

5. How services address intersectionality (Aims of this paper; Lines 41-42)

6. How intersectionality impacts recovery and support trajectories (Aims of this paper; Lines 42-43)

7. Access to support / Experiences of service access and help-seeking (Materials and methods; Lines 71-72)

8. Impact of intersectionality on experience of recovery and help-seeking (Inclusion and exclusion criteria; Lines 82-84)

9. Self-help and service support around homelessness or multiple needs (Inclusion and exclusion criteria; Lines 88-90).

I recognise that there’s overlap between each of these outcomes. However, the nuanced differences between them and the number of times they are expressed differently results in that by the time we begin to read the results, it’s not very clear what will be reported. As well, whereas ‘intersectionality’ is well defined, terms like ‘recovery’ and ‘support trajectories’ are not clear. Does recovery relate to recovery from homelessness? Is recovery from substance use disorder and mental illness included in your definition? This is made further complicated by the fact that themes are not reported to match the research question, but rather emerged through a type of inductive thematic analysis. This is fine – I think – but it would be helpful to more explicitly state how each of these themes tie back into an original, more clearly-defined research questions.

My understanding of the review question becomes even more convoluted when I look at the SR’s pre-registration where the main outcomes are again different to what is reported in the manuscript.

I also noticed some inconsistencies with the target setting. In Lines 43-46, the authors mention, “Refuges and day centres, community mental health support, primary care, social care, drug and alcohol services, local authority housing services and other statutory and voluntary agencies, and self-help initiatives.”

There is no emphasis on low-threshold criteria here, as there is further on in the text (Lines 123-129). As well, the criminal justice system comes up in the results but was not mentioned in the methods as part of the included services/settings.

Does criminal justice fall under the “other statutory and voluntary agencies” mentioned in Lines 43-46?

In sum, where the target population is clear, the target outcomes and included interventions (i.e., support services in question) are not which detracts from the meaning we can glean from results and their implications.

OTHER COMMENTS

If possible, I would recommend stating both race and ethnicity (rather than just race) in the target population to ensure that Ethnic groups who experience high rates of homelessness such as Travellers are not excluded.

Typo line 41: The review address

Lines 239 – 242: Who is part of this advisory group? This seems to have popped out of nowhere!

Line 253: Worded as if the (n=32) refers to individual women rather than included studies.

Line 276-277: I’m a bit confused by the sentence, “Poverty/class and religion were discussed only in relation to other variables when seeking help and support.”

Type line 367 – Solution(s) not solution

Typo line 376 – and delay(s)

The quote on Lines 409-411 lacks some context. Is the participant saying that they didn’t get to do the nice fluffy stuff? Is the participant homeless herself or a healthcare provider speaking about the situation?

The review set out to assess the impact of different intersectional dimensions on women’s, trans women’s, and non-binary individuals’ with – potentially – additional protected characteristics on women’s homelessness trajectories, recovery, and engagement with services. Perhaps in part due to some of the methodological confusions I have outlined, I still feel that there is a lack of clarity of how specific identities contribute to these specific elements (e.g., homelessness trajectory, recovery, service engagement and access). I think this murkiness can be resolved by (1) more clearly defining the research question and objectives, (2) more clearly demonstrating how each section of the results answers that research question, and (3) by adding implications/recommendations relevant to specific intersectional identity groups based on your review findings (e.g., how, specifically, can we better support women, trans women, and non-binary individuals of racial and ethnic minority status, of particular ages, sexual orientations, who are pregnant, and/or who have a disability).

Reviewer #2: Greetings esteemed authors. On one hand, I applaud any attempt to increase the visibility of transgender people and non-binary people, and I feel the manuscript I reviewed contains numerous attempts to do so, so I applaud that effort as a transgender person. On the other hand, I don't think the inclusion of nonbinary people is justified by the research corpus you examined. There are many points in the paper where you invoke the population of interest -- "women, transgender women and nonbinary people" -- where none of the cited research comes from the ~5 articles that explicitly mention nonbinary. It is not appropriate to point to a collection of research articles that make no mention of nonbinary people and imply that it has something to say about nonbinary people. Every place where nonbinary people are invoked in this draft, you need to scrutinize the specific articles you are referring to, and remove "nonbinary" from your description of any literature that doesn't explicitly include nonbinary participants.

Of course, there are a handful of subsections where you do cite the specific nonbinary-inclusive citations -- in those cases, it is justified to invoke that group, "women, transgender women and nonbinary people". However, I do think you need to provide some summary statistics about your literature pool -- how many articles include nonbinary people, how many total nonbinary people were considered in each study, or other indications to validate that your conclusions are being fairly ascribed to a group including nonbinary people.

I also think you've missed a very basic and important step in any research involving sexual orientation and gender identity (SOGI) -- you've not provided any operational definition of what "woman, transgender woman or nonbinary" means. Even after reading, I am not certain if you mean "nonbinary people who were assigned female at birth", "nonbinary people who were assigned male at birth", or both. To justify invoking nonbinary people as part of the population of interest explored in these papers, you need to be specific and consistent in your terminology usage, and you need to consider and discuss how the papers under consideration measured or judged gender.

Some evaluation of the quality of SOGI research methods used in each article would likely shrink your literature pool, as it's unfortunately too common for people to invoke nonbinary people in describing a sample, even when their data largely describe other groups.

Reviewer #3: The study aims to understand and summarize existing literature exploring the intersectionality of gender and race and other critical demographic variables on women, trans women, and non-binary individuals’ experience of homelessness, recovery, and engagement with specific services. The authors included research from qualitative, quantitative, and mixed-methods research to provide a more holistic view of the findings. Methods are robust, thorough, and appropriate for this study design. 52 studies from all over the world were included in the final review. They did a great job outlining results in extended detail. It was interesting to learn of the views toward voluntary services versus mainstream services (more exclusive and inaccessible). Findings are corroborated by previous research. Glaringly, intersectionality is not sufficiently addressed in most research, and most support groups also favor persons who fit normative assumptions of a certain group of people versus marginalized. The paper adds to the existing literature around the experience of homelessness and is befitting of publication without revision.

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Reviewer #1: No

Reviewer #2: Yes:  Evelyn Jolene Olansky

Reviewer #3: No

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PONE-D-24-34499R1A systematic review of the research evidence of the impact of intersectionality on service engagement across different groups of women, trans women, and non-binary individuals experiencing homelessness and housing exclusionPLOS ONE

Dear Dr. Hess,

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 22 2025 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,

Lakshminarayana Chekuri, MD, PhD

Academic Editor

PLOS ONE

Journal Requirements:

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:

Please review attached document.

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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)

Reviewer #2: 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

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: I Don't Know

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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

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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

Reviewer #2: 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: My main concerns during the first review related to unclear study aims / objectives and how this impacted the reader's ability to interpret the results. This revised version of the paper resolves those issues and, as a result, is much easier to read and understand. With the exception of a typo in the second line of the Abstract ('...half that of that'), I have no further requests for revisions. Well done on strengthening the paper as you have.

Reviewer #2: Thank you to the authors for providing more detail on the proportion of considered sources specific to transgender women and nonbinary individuals. I strongly agree with the authors that the visibility of trans and nonbinary people in research is important and worth protecting -- that said, if we allow such research to proliferate without requiring detailed substantiation and contextualization of the claims therein (chiefly that those claims stem from someone somewhere demonstrably talking to a queer person), then I do not believe these or any populations necessarily benefit. Thank you for further substantiating the extent to which your research corpus considered gender diversity.

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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: No

Reviewer #2: Yes:  Evelyn Jolene Olansky

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Attachments

Attachment

Submitted filename: Academic Editor comments 2-3-25.docx

PONE-D-24-34499R2A systematic narrative review of the research evidence of the impact of intersectionality on service engagement across different groups of women, trans women, and non-binary individuals experiencing homelessness and housing exclusionPLOS ONE

Dear Dr. Hess,

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 review attached document.

Please submit your revised manuscript by Apr 13 2025 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,

Lakshminarayana Chekuri, MD, PhD

Academic Editor

PLOS ONE

Journal Requirements:

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:

Please review attached document.

[Note: HTML markup is below. Please do not edit.]

[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: Academic Editor comments 2-24-25.docx

A systematic narrative review of the research evidence of the impact of intersectionality on service engagement and help-seeking across different groups of women, trans women, and non-binary individuals experiencing homelessness and housing exclusion

PONE-D-24-34499R3

Dear Dr. Hess,

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,

Lakshminarayana Chekuri, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: